1
|
Dong X, Wang K, Yang H, Cheng R, Li Y, Hou Y, Chang J, Yuan L. The Nomogram predicting the overall survival of patients with pancreatic cancer treated with radiotherapy: a study based on the SEER database and a Chinese cohort. Front Endocrinol (Lausanne) 2023; 14:1266318. [PMID: 37955009 PMCID: PMC10634587 DOI: 10.3389/fendo.2023.1266318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/06/2023] [Indexed: 11/14/2023] Open
Abstract
Objective Patients with pancreatic cancer (PC) have a poor prognosis. Radiotherapy (RT) is a standard palliative treatment in clinical practice, and there is no effective clinical prediction model to predict the prognosis of PC patients receiving radiotherapy. This study aimed to analyze PC's clinical characteristics, find the factors affecting PC patients' prognosis, and construct a visual Nomogram to predict overall survival (OS). Methods SEER*Stat software was used to collect clinical data from the Surveillance, Epidemiology, and End Results (SEER) database of 3570 patients treated with RT. At the same time, the relevant clinical data of 115 patients were collected from the Affiliated Cancer Hospital of Zhengzhou University. The SEER database data were randomly divided into the training and internal validation cohorts in a 7:3 ratio, with all patients at The Affiliated Cancer Hospital of Zhengzhou University as the external validation cohort. The lasso regression was used to screen the relevant variables. All non-zero variables were included in the multivariate analysis. Multivariate Cox proportional risk regression analysis was used to determine the independent prognostic factors. The Kaplan-Meier(K-M) method was used to plot the survival curves for different treatments (surgery, RT, chemotherapy, and combination therapy) and calculate the median OS. The Nomogram was constructed to predict the survival rates at 1, 3, and 5 years, and the time-dependent receiver operating characteristic curves (ROC) were plotted with the calculated curves. Calculate the area under the curve (AUC), the Bootstrap method was used to plot the calibration curve, and the clinical efficacy of the prediction model was evaluated using decision curve analysis (DCA). Results The median OS was 25.0, 18.0, 11.0, and 4.0 months in the surgery combined with chemoradiotherapy (SCRT), surgery combined with radiotherapy, chemoradiotherapy (CRT), and RT alone cohorts, respectively. Multivariate Cox regression analysis showed that age, N stage, M stage, chemotherapy, surgery, lymph node surgery, and Grade were independent prognostic factors for patients. Nomogram models were constructed to predict patients' OS. 1-, 3-, and 5-year Time-dependent ROC curves were plotted, and AUC values were calculated. The results suggested that the AUCs were 0.77, 0.79, and 0.79 for the training cohort, 0.79, 0.82, and 0.81 for the internal validation cohort, and 0.73, 0.93, and 0.88 for the external validation cohort. The calibration curves Show that the model prediction probability is in high agreement with the actual observation probability, and the DCA curve shows a high net return. Conclusion SCRT significantly improves the OS of PC patients. We developed and validated a Nomogram to predict the OS of PC patients receiving RT.
Collapse
Affiliation(s)
- Xiaotao Dong
- Department of Radiation Oncology, Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Kunlun Wang
- Department of Radiation Oncology, Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Hui Yang
- Department of Radiation Oncology, Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Ruilan Cheng
- Department of Hematology and Oncology, Shenzhen Children’s Hospital Affiliated to China Medical University, Shenzhen, China
| | - Yan Li
- Department of Radiation Oncology, Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Yanqi Hou
- Department of Radiation Oncology, Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Jiali Chang
- Department of Radiation Oncology, Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Ling Yuan
- Department of Radiation Oncology, Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, Henan, China
| |
Collapse
|
2
|
Comito T, Massaro M, Teriaca MA, Franzese C, Franceschini D, Navarria P, Clerici E, Di Cristina L, Bertolini A, Tomatis S, Reggiori G, Bresolin A, Bozzarelli S, Rimassa L, Bonifacio C, Carrara S, Santoro A, Zerbi A, Scorsetti M. Can STEreotactic Body Radiation Therapy (SBRT) Improve the Prognosis of Unresectable Locally Advanced Pancreatic Cancer? Long-Term Clinical Outcomes, Toxicity and Prognostic Factors on 142 Patients (STEP Study). Curr Oncol 2023; 30:7073-7088. [PMID: 37504373 PMCID: PMC10378012 DOI: 10.3390/curroncol30070513] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/17/2023] [Accepted: 07/21/2023] [Indexed: 07/29/2023] Open
Abstract
AIM The gold standard of care for pancreatic adenocarcinoma is the integrated treatment of surgery and chemotherapy (ChT), but about 50% of patients present with unresectable disease. Our study evaluated the efficacy in terms of local control, survival and safety of stereotactic body radiation therapy (SBRT) in locally advanced pancreatic cancer (LAPC). METHODS A retrospective study (STEP study) analyzed patients with LAPC treated with a dose of 45 Gy in 6 fractions. Local control (LC), distant progression free survival (DPFS), overall survival (OS) and toxicity were analyzed according to the Kaplan-Meier method. RESULTS A total of 142 patients were evaluated. Seventy-six patients (53.5%) received induction ChT before SBRT. The median follow-up was 11 months. One-, 2- and 3-year LC rate was 81.9%, 69.1% and 58.5%. Median DPFS was 6.03 months; 1- and 2-year DPFS rate was 19.9% and 4.5%. Median OS was 11.6 months and 1-, 2- and 3-year OS rates were 45.4%, 16.1%, and 9.8%. At univariate analysis, performed by the log-rank test, age < 70 years (p = 0.037), pre-SBRT ChT (p = 0.004) and post-SBRT ChT (p = 0.019) were associated with better OS. No patients experienced G3 toxicity. CONCLUSION SBRT represents an effective and safe therapeutic option in the multimodal treatment of patients with LAPC in terms of increased LC. When SBRT was sequentially integrated with ChT, the treatment proved to be promising in terms of OS as well.
Collapse
Affiliation(s)
- Tiziana Comito
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Maria Massaro
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Maria Ausilia Teriaca
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Ciro Franzese
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy
| | - Davide Franceschini
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Pierina Navarria
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Elena Clerici
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Luciana Di Cristina
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Anna Bertolini
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Stefano Tomatis
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Giacomo Reggiori
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Andrea Bresolin
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Silvia Bozzarelli
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Lorenza Rimassa
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Cristiana Bonifacio
- Department of Radiology, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Silvia Carrara
- Department of Gastroenterology, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Armando Santoro
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Alessandro Zerbi
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy
- Department of Pancreatic Surgery, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy
| |
Collapse
|
3
|
Sasaki M, Nakamura M, Ashida R, Nakata M, Yoshimura M, Mizowaki T. Assessing target localization accuracy across different soft-tissue matching protocols using end-exhalation breath-hold cone-beam computed tomography in patients with pancreatic cancer. JOURNAL OF RADIATION RESEARCH 2023:rrad048. [PMID: 37336503 DOI: 10.1093/jrr/rrad048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 03/23/2023] [Indexed: 06/21/2023]
Abstract
The purpose of this study was to retrospectively assess target localization accuracy across different soft-tissue matching protocols using cone-beam computed tomography (CBCT) in a large sample of patients with pancreatic cancer and to estimate the optimal margin size for each protocol. Fifty-four consecutive patients with pancreatic cancer who underwent 15-fraction volumetric modulated arc therapy under the end-exhalation breath-hold condition were enrolled. Two soft-tissue matching protocols were used according to the resectability classification, including gross tumor volume (GTV) matching for potentially resectable tumors and planning target volume (PTV) matching for borderline resectable or unresectable tumors. The tolerance of the target localization error in both matching protocols was set to 5 mm in any direction. The optimal margin size for each soft-tissue matching protocol was calculated from the systematic and random errors of the inter- and intrafraction positional variations using the van Herk formula. The inter- and intrafraction positional variations of PTV matching were smaller than those of GTV matching. The percentage of target localization errors exceeding 5 mm in the first CBCT scan of each fraction in the superior-inferior direction was 12.6 and 4.8% for GTV and PTV matching, respectively. The optimal margin sizes for GTV and PTV matching were 3.7 and 2.7, 5.4 and 4.1 and 3.9 and 3.0 mm in the anterior-posterior, superior-inferior and left-right directions, respectively. Target localization accuracy in PTV matching was higher than that in GTV matching. By setting the tolerance of the target localization error, treatment can be successful within the planned margin size.
Collapse
Affiliation(s)
- Makoto Sasaki
- Division of Clinical Radiology Service, Kyoto University Hospital, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan
| | - Mitsuhiro Nakamura
- Department of Information Technology and Medical Engineering, Human Health Sciences, Graduate School of Medicine, Kyoto University, 53 Kawaharacho, Shogoin, Sakyo-ku, Kyoto 606-8397, Japan
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto University, Kyoto 606-8507, Japan
| | - Ryo Ashida
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto University, Kyoto 606-8507, Japan
| | - Manabu Nakata
- Division of Clinical Radiology Service, Kyoto University Hospital, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan
| | - Michio Yoshimura
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto University, Kyoto 606-8507, Japan
| | - Takashi Mizowaki
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto University, Kyoto 606-8507, Japan
| |
Collapse
|
4
|
Basiliya K, Pang P, Honing J, di Pietro M, Varghese S, Gbegli E, Corbett G, Carroll NR, Godfrey EM. What can the Interventional Endoscopist Offer in the Management of Upper Gastrointestinal Malignancies? Clin Oncol (R Coll Radiol) 2023:S0936-6555(23)00183-8. [PMID: 37253647 DOI: 10.1016/j.clon.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 04/10/2023] [Accepted: 05/10/2023] [Indexed: 06/01/2023]
Abstract
The therapeutic possibilities of endoscopy have rapidly increased in the last decades and now allow organ-sparing treatment of early upper gastrointestinal malignancy as well as an increasing number of options for symptom palliation. This review contains an overview of the interventional endoscopic procedures in upper gastrointestinal malignancies. It describes endoscopic treatment of early oesophageal and gastric cancers, and the palliative options in managing dysphagia and gastric outlet obstruction. It also provides an overview of the therapeutic possibilities of biliary endoscopy, such as retrograde stenting and radiofrequency biliary ablation. Endoscopic ultrasound-guided therapeutic options are discussed, including biliary drainage, gastrojejunostomy and coeliac axis block. To aid in clinical decision making, the procedures are described in the context of their indication, efficacy, risks and limitations.
Collapse
Affiliation(s)
- K Basiliya
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK.
| | - P Pang
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - J Honing
- Early Cancer Institute, University of Cambridge, Cambridge, UK
| | - M di Pietro
- Early Cancer Institute, University of Cambridge, Cambridge, UK
| | - S Varghese
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - E Gbegli
- Department of Radiology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - G Corbett
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - N R Carroll
- Department of Radiology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - E M Godfrey
- Department of Radiology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| |
Collapse
|
5
|
Zheng R, Wang B, Liang F, Xu B. Systemic therapy‐based split‐course stereotactic body radiation therapy. PRECISION RADIATION ONCOLOGY 2022. [DOI: 10.1002/pro6.1176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Rong Zheng
- Department of Radiation Oncology Fujian Medical University Union Hospital Fuzhou Fujian China
- Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors (Fujian Medical University) Fuzhou Fujian China
- Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies) Fuzhou Fujian China
| | - Bisi Wang
- Department of Radiation Oncology Fujian Medical University Union Hospital Fuzhou Fujian China
| | - Feihong Liang
- Department of Radiation Oncology Fujian Medical University Union Hospital Fuzhou Fujian China
| | - Benhua Xu
- Department of Radiation Oncology Fujian Medical University Union Hospital Fuzhou Fujian China
- Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors (Fujian Medical University) Fuzhou Fujian China
- Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies) Fuzhou Fujian China
| |
Collapse
|
6
|
Nie D, Liu S, Cai S, Xing X, Xu F. The Effectiveness of Chemoradiotherapy in Elderly Patients with Pancreatic Cancer: A Population-Based Study Based on the SEER Database. Adv Ther 2022; 39:5043-5057. [PMID: 36044179 DOI: 10.1007/s12325-022-02297-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 08/05/2022] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Chemotherapy (CT) is the main treatment for patients with unresected pancreatic cancer (PC). Whether the addition of radiotherapy to chemotherapy improves the prognosis of elderly patients with unresected PC is unclear. The aim of our study was to compare the efficacy of chemoradiotherapy (CRT) with chemotherapy alone in elderly patients with unresected PC. METHODS The clinical data of elderly patients with unresected PC who received chemotherapy between 2004 and 2017 were determined from the Surveillance, Epidemiology, and End Results (SEER) database, and the patients were divided into CT and CRT groups. The primary outcome was overall survival (OS), and secondary endpoints were cancer-specific survival (CSS) and cancer-specific mortality (CSM). Propensity matching analysis (PSM) was used to balance the differences between the two groups. OS and CSS were assessed using Kaplan-Meier analysis, while CSM was assessed using a competing risk model. Subgroup analyses were also performed, and Cox regression was used to adjust for confounding factors. RESULTS A total of 17,814 patients were diagnosed with PC including 14,222 who received CT alone and 3592 who received CRT. The 1-year OS of the CT and CRT groups after PSM was 30.1% and 40.8%, and the 1-year CSS was 31.4% and 42.1%, respectively. Overall, the CRT group had better OS, CSS, and CSM rates than the CT group before and after PSM (P < 0.05). After adjustment for age, sex, race, histological grade, stage, and other factors, the CRT group still had a lower risk of death than the CT group, and subgroup analysis further revealed the survival benefit of CRT in each population. CONCLUSIONS CRT improves the outcome of patients with non-surgical PC over 65 years of age. But prospective studies are needed to validate our results.
Collapse
Affiliation(s)
- Duorui Nie
- Graduate School, Hunan University of Chinese Medicine, Changsha, China
| | - Siyu Liu
- Graduate School, Hunan University of Chinese Medicine, Changsha, China
| | - Si Cai
- Institute of Technology, China Pharmaceutical University, Nanjing, China
| | - Xiaoqi Xing
- College of Pharmacy, Hunan University of Chinese Medicine, Changsha, 410208, China
| | - Fei Xu
- College of Pharmacy, Hunan University of Chinese Medicine, Changsha, 410208, China. .,Hunan Engineering Technology Research Center for Bioactive Substance Discovery of Chinese Medicine, Changsha, China. .,Hunan Province Sino-US International Joint Research Center for Therapeutic Drugs of Senile Degenerative Diseases, Changsha, China.
| |
Collapse
|
7
|
Burkoň P, Trna J, Slávik M, Němeček R, Kazda T, Pospíšil P, Dastych M, Eid M, Novotný I, Procházka T, Vrzal M. Stereotactic Body Radiotherapy (SBRT) of Pancreatic Cancer-A Critical Review and Practical Consideration. Biomedicines 2022; 10:biomedicines10102480. [PMID: 36289742 PMCID: PMC9599229 DOI: 10.3390/biomedicines10102480] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/18/2022] [Accepted: 09/30/2022] [Indexed: 11/23/2022] Open
Abstract
Pancreatic cancer is the third leading cause of cancer death in the developed world and is predicted to become the second by 2030. A cure may be achieved only with surgical resection of an early diagnosed disease. Surgery for more advanced disease is challenging and can be contraindicated for many reasons. Neoadjuvant therapy may improve the probability of achieving R0 resection. It consists of systemic treatment followed by radiation therapy applied concurrently or sequentially with cytostatics. A novel approach to irradiation, stereotactic body radiotherapy (SBRT), has the potential to improve treatment results. SBRT can deliver higher doses of radiation to the tumor in only a few treatment fractions. It has attracted significant interest for pancreatic cancer patients, as it is completed quickly, requires less time away from full-dose chemotherapy, and is well-tolerated than conventional radiotherapy. In this review, we aim to provide the reader with a basic overview of current evidence for SBRT indications in the treatment of pancreatic tumors. In the second part of the review, we focus on practical information with respect to SBRT treatment plan preparation the performance of such therapy. Finally, we discuss future directions related to the use of magnetic resonance linear accelerators.
Collapse
Affiliation(s)
- Petr Burkoň
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 57 Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
| | - Jan Trna
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
- Department of Gastroenterology and Digestive Endoscopy, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 53 Brno, Czech Republic
- Department of Comprehensive Cancer Care, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 53 Brno, Czech Republic
- Correspondence: (J.T.); (M.S.)
| | - Marek Slávik
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 57 Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
- Correspondence: (J.T.); (M.S.)
| | - Radim Němeček
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
- Department of Comprehensive Cancer Care, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 53 Brno, Czech Republic
| | - Tomáš Kazda
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 57 Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
| | - Petr Pospíšil
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 57 Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
| | - Milan Dastych
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
- Department of Gastroenterology, University Hospital Brno, Jihlavska 340/20, 625 00 Brno, Czech Republic
| | - Michal Eid
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
- Department of Hematology, Oncology and Internal Medicine, University Hospital Brno, Jihlavska 340/20, 625 00 Brno, Czech Republic
| | - Ivo Novotný
- Department of Gastroenterology and Digestive Endoscopy, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 53 Brno, Czech Republic
| | - Tomáš Procházka
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 57 Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
| | - Miroslav Vrzal
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 57 Brno, Czech Republic
| |
Collapse
|
8
|
Shin H, Yu JI, Park HC, Yoo GS, Cho S, Park JO, Lee KT, Lee KH, Lee JK, Park JK, Heo JS, Han IW, Shin SH. The Feasibility of Stereotactic Body Proton Beam Therapy for Pancreatic Cancer. Cancers (Basel) 2022; 14:cancers14194556. [PMID: 36230475 PMCID: PMC9559584 DOI: 10.3390/cancers14194556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/15/2022] [Accepted: 09/15/2022] [Indexed: 11/16/2022] Open
Abstract
Background/Purpose: This study aimed to evaluate the clinical outcomes of stereotactic body proton beam therapy (SBPT) for pancreatic cancer. Methods: This retrospective study included 49 patients who underwent SBPT for pancreatic cancer between 2017 and 2020. Survival outcomes, bowel-related toxicities, and failure patterns were analysed. SBPT was performed after induction chemotherapy in 44 (89.8%) patients. The dose-fractionation scheme included 60 gray (Gy) relative biological effectiveness (RBE) in five fractions (n = 42, 85.7%) and 50 GyRBE in five fractions (n = 7, 14.3%). The median follow-up was 16.3 months (range, 1.8−45.0 months). Results: During follow-up, the best responses were complete response, partial response, and stable disease in four (8.2%), 13 (26.5%), and 31 (63.3%) patients, respectively. The 2-year overall survival, progression-free survival, and local control (LC) rates were 67.6%, 38.0%, and 73.0%, respectively. Grade ≥ 3 gastroduodenal (GD) toxicity occurred in three (6.1%) patients. Among them, one patient underwent endoscopic haemostasis. The other two patients received surgical management. They were followed up without disease progression for >30 months after SBPT. Overall, there was no significant dosimetric difference between the grade ≥ 2 and lower toxicity groups. Conclusions: SBPT provides relatively high LC rates with acceptable toxicities in pancreatic cancer.
Collapse
Affiliation(s)
- Hyunju Shin
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Jeong Il Yu
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
- Correspondence: (J.I.Y.); (H.C.P.)
| | - Hee Chul Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
- Correspondence: (J.I.Y.); (H.C.P.)
| | - Gyu Sang Yoo
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Sungkoo Cho
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Joon Oh Park
- Divisions of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Kyu Taek Lee
- Divisions of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Kwang Hyuck Lee
- Divisions of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Jong Kyun Lee
- Divisions of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Joo Kyung Park
- Divisions of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Jin Seok Heo
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - In Woong Han
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Sang Hyun Shin
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| |
Collapse
|
9
|
Oba A, Wu YHA, Colborn KL, Karam SD, Meguid C, Al-Musawi MH, Bao QR, Gleisner AL, Ahrendt S, Schulick RD, Del Chiaro M. Comparing neoadjuvant chemotherapy with or without radiation therapy for pancreatic ductal adenocarcinoma: National Cancer Database cohort analysis. Br J Surg 2022; 109:450-454. [PMID: 35136963 DOI: 10.1093/bjs/znac002] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 09/16/2021] [Accepted: 01/04/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Neoadjuvant treatment is important for improving the rate of R0 surgical resection and overall survival outcome in treating patients with pancreatic ductal adenocarcinoma (PDAC). However, the true efficacy of radiotherapy (RT) for neoadjuvant treatment of PDAC is uncertain. This retrospective study evaluated the treatment outcome of neoadjuvant RT in the treatment of PDAC. METHODS Collected from the National Cancer Database, information on patients with PDAC who underwent neoadjuvant chemotherapy (NAC) and pancreatectomy between 2010 to 2016 was used in this study. Short- and long-term outcomes were compared between patients who received neoadjuvant chemoradiotherapy (NACRT) and NAC. RESULTS The study included 6936 patients, of whom 3185 received NACRT and 3751 NAC. The groups showed no difference in overall survival (NACRT 16.1 months versus NAC 17.4 months; P = 0.054). NACRT is associated with more frequent margin negative resection (86.1 versus 80.0 per cent; P < 0.001) but a more unfavourable 90-day mortality than NAC (6.4 versus 3.6 per cent; P < 0.001). The odds of 90-day mortality were higher in the radiotherapy group (odds ratio 1.81; P < 0.001), even after adjusting for significant covariates. Patients who received NACRT received single-agent chemotherapy more often than those who received NAC (31.5 versus 10.7 per cent; P < 0.001). CONCLUSION This study failed to show a survival benefit for NACRT over NAC alone, despite its association with negative margin resection. The significantly higher mortality in NACRT warrants further investigation into its efficacy in the treatment of pancreatic cancer.
Collapse
Affiliation(s)
- Atsushi Oba
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Y H Andrew Wu
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Kathryn L Colborn
- Surgical Outcomes and Applied Research, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado, USA
| | - Sana D Karam
- Department of Radiation Oncology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Cheryl Meguid
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Mohammed H Al-Musawi
- Clinical Trials Office, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Quoc R Bao
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
- First Surgical Clinic, Department of Surgical, Gastroenterological and Oncological Science, University of Padua, Padua, Italy
| | - Ana L Gleisner
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
- University of Colorado Cancer Center, Denver, Colorado, USA
| | - Steven Ahrendt
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
- University of Colorado Cancer Center, Denver, Colorado, USA
| | - Richard D Schulick
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
- University of Colorado Cancer Center, Denver, Colorado, USA
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
- University of Colorado Cancer Center, Denver, Colorado, USA
| |
Collapse
|
10
|
Allam N, Jeffrey Zabel W, Demidov V, Jones B, Flueraru C, Taylor E, Alex Vitkin I. Longitudinal in-vivo quantification of tumour microvascular heterogeneity by optical coherence angiography in pre-clinical radiation therapy. Sci Rep 2022; 12:6140. [PMID: 35414078 PMCID: PMC9005734 DOI: 10.1038/s41598-022-09625-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/16/2022] [Indexed: 11/25/2022] Open
Abstract
Stereotactic body radiotherapy (SBRT) is an emerging cancer treatment due to its logistical and potential therapeutic benefits as compared to conventional radiotherapy. However, its mechanism of action is yet to be fully understood, likely involving the ablation of tumour microvasculature by higher doses per fraction used in SBRT. In this study, we hypothesized that longitudinal imaging and quantification of the vascular architecture may elucidate the relationship between the microvasculature and tumour response kinetics. Pancreatic human tumour xenografts were thus irradiated with single doses of \documentclass[12pt]{minimal}
\usepackage{amsmath}
\usepackage{wasysym}
\usepackage{amsfonts}
\usepackage{amssymb}
\usepackage{amsbsy}
\usepackage{mathrsfs}
\usepackage{upgreek}
\setlength{\oddsidemargin}{-69pt}
\begin{document}$$10$$\end{document}10, \documentclass[12pt]{minimal}
\usepackage{amsmath}
\usepackage{wasysym}
\usepackage{amsfonts}
\usepackage{amssymb}
\usepackage{amsbsy}
\usepackage{mathrsfs}
\usepackage{upgreek}
\setlength{\oddsidemargin}{-69pt}
\begin{document}$$20$$\end{document}20 and \documentclass[12pt]{minimal}
\usepackage{amsmath}
\usepackage{wasysym}
\usepackage{amsfonts}
\usepackage{amssymb}
\usepackage{amsbsy}
\usepackage{mathrsfs}
\usepackage{upgreek}
\setlength{\oddsidemargin}{-69pt}
\begin{document}$$30$$\end{document}30 Gy to simulate the first fraction of a SBRT protocol. Tumour microvascular changes were monitored with optical coherence angiography for up to \documentclass[12pt]{minimal}
\usepackage{amsmath}
\usepackage{wasysym}
\usepackage{amsfonts}
\usepackage{amssymb}
\usepackage{amsbsy}
\usepackage{mathrsfs}
\usepackage{upgreek}
\setlength{\oddsidemargin}{-69pt}
\begin{document}$$8$$\end{document}8 weeks following irradiation. The temporal kinetics of two microvascular architectural metrics were studied as a function of time and dose: the diffusion-limited fraction, representing poorly vascularized tissue \documentclass[12pt]{minimal}
\usepackage{amsmath}
\usepackage{wasysym}
\usepackage{amsfonts}
\usepackage{amssymb}
\usepackage{amsbsy}
\usepackage{mathrsfs}
\usepackage{upgreek}
\setlength{\oddsidemargin}{-69pt}
\begin{document}$$>150$$\end{document}>150 μm from the nearest detected vessel, and the vascular distribution convexity index, a measure of vessel aggregation at short distances. These biological metrics allowed for dose dependent temporal evaluation of tissue (re)vascularization and vessel aggregation after radiotherapy, showing promise for determining the SBRT dose–response relationship.
Collapse
Affiliation(s)
- Nader Allam
- Department of Medical Biophysics, University of Toronto, 101 College Street, Toronto, ON, M5G 1L7, Canada.
| | - W Jeffrey Zabel
- Department of Medical Biophysics, University of Toronto, 101 College Street, Toronto, ON, M5G 1L7, Canada
| | - Valentin Demidov
- Department of Medical Biophysics, University of Toronto, 101 College Street, Toronto, ON, M5G 1L7, Canada.,Geisel School of Medicine at Dartmouth, 1 Rope Ferry Rd, Hanover, NH, 03755, USA
| | - Blake Jones
- Department of Medical Biophysics, University of Toronto, 101 College Street, Toronto, ON, M5G 1L7, Canada
| | - Costel Flueraru
- National Research Council Canada, Information Communication Technology, 1200 Montreal Rd, Ottawa, ON, K1A 0R6, Canada
| | - Edward Taylor
- Radiation Medicine Program, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, ON, M5G 2M9, Canada.,Department of Radiation Oncology, University of Toronto, 149 College Street, Toronto, ON, M5T 1P5, Canada
| | - I Alex Vitkin
- Department of Medical Biophysics, University of Toronto, 101 College Street, Toronto, ON, M5G 1L7, Canada. .,Radiation Medicine Program, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, ON, M5G 2M9, Canada. .,Department of Radiation Oncology, University of Toronto, 149 College Street, Toronto, ON, M5T 1P5, Canada.
| |
Collapse
|
11
|
Michalet M, Bordeau K, Cantaloube M, Valdenaire S, Debuire P, Simeon S, Portales F, Draghici R, Ychou M, Assenat E, Dupuy M, Gourgou S, Colombo PE, Carrere S, Souche FR, Aillères N, Fenoglietto P, Azria D, Riou O. Stereotactic MR-Guided Radiotherapy for Pancreatic Tumors: Dosimetric Benefit of Adaptation and First Clinical Results in a Prospective Registry Study. Front Oncol 2022; 12:842402. [PMID: 35356227 PMCID: PMC8959839 DOI: 10.3389/fonc.2022.842402] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 01/31/2022] [Indexed: 01/05/2023] Open
Abstract
Introduction Stereotactic MR-guided adaptive radiotherapy (SMART) is an attractive modality of radiotherapy for pancreatic tumors. The objectives of this prospective registry study were to report the dosimetric benefits of daily adaptation of SMART and the first clinical results in pancreatic tumors. Materials and Methods All patients treated in our center with SMART for a pancreatic tumor were included. Patients were planned for five daily-adapted fractions on consecutive days. Endpoints were acute toxicities, late toxicities, impact of adaptive treatment on target volume coverage and organs at risk (OAR) sparing, local control (LC) rate, distant metastasis-free survival (DMFS), and overall survival (OS). Results Thirty consecutive patients were included between October 2019 and April 2021. The median dose prescription was 50 Gy. No patient presented grade > 2 acute toxicities. The most frequent grade 1–2 toxicities were asthenia (40%), abdominal pain (40%), and nausea (43%). Daily adaptation significantly improved planning target volume (PTV) and gross tumor volume (GTV) coverage and OAR sparing. With a median follow-up of 9.7 months, the median OS, 6-month OS, and 1-year OS were 14.1 months, 89% (95% CI: 70%–96%), and 75% (95% CI: 51%–88%), respectively, from SMART completion. LC at 6 months and 1 year was respectively 97% (95% CI: 79–99.5%) and 86% (95% CI: 61%–95%). There were no grade > 2 late toxicities. With a median follow-up of 10.64 months, locally advanced pancreatic cancer (LAPC) and borderline resectable pancreatic cancer (BRPC) patients (22 patients) had a median OS, 6-month OS, and 1-year OS from SMART completion of 14.1 months, 76% (95% CI: 51%–89%), and 70% (95% CI: 45%–85%), respectively. Nine patients underwent surgical resection (42.1% of patients with initial LAPC and 33.3% of patients with BRPC), with negative margins (R0). Resected patients had a significantly better OS as compared to unresected patients (p = 0.0219, hazard ratio (HR) = 5.78 (95% CI: 1.29–25.9)). Conclusion SMART for pancreatic tumors is feasible without limiting toxicities. Daily adaptation demonstrated a benefit for tumor coverage and OAR sparing. The severity of observed acute and late toxicities was low. OS and LC rates were promising. SMART achieved a high secondary resection rate in LAPC patients. Surgery after SMART seemed to be feasible and might increase OS in these patients.
Collapse
Affiliation(s)
- Morgan Michalet
- University Federation of Radiation Oncology of Mediterranean Occitanie, Montpellier Cancer Institute (ICM), Univ Montpellier, INSERM U1194 Institut de Recherche en Cancérologie de Montpellier (IRCM), Montpellier, France
| | - Karl Bordeau
- University Federation of Radiation Oncology of Mediterranean Occitanie, Montpellier Cancer Institute (ICM), Univ Montpellier, INSERM U1194 Institut de Recherche en Cancérologie de Montpellier (IRCM), Montpellier, France
| | - Marie Cantaloube
- University Federation of Radiation Oncology of Mediterranean Occitanie, Montpellier Cancer Institute (ICM), Univ Montpellier, INSERM U1194 Institut de Recherche en Cancérologie de Montpellier (IRCM), Montpellier, France
| | - Simon Valdenaire
- University Federation of Radiation Oncology of Mediterranean Occitanie, Montpellier Cancer Institute (ICM), Univ Montpellier, INSERM U1194 Institut de Recherche en Cancérologie de Montpellier (IRCM), Montpellier, France
| | - Pierre Debuire
- University Federation of Radiation Oncology of Mediterranean Occitanie, Montpellier Cancer Institute (ICM), Univ Montpellier, INSERM U1194 Institut de Recherche en Cancérologie de Montpellier (IRCM), Montpellier, France
| | - Sebastien Simeon
- University Federation of Radiation Oncology of Mediterranean Occitanie, Montpellier Cancer Institute (ICM), Univ Montpellier, INSERM U1194 Institut de Recherche en Cancérologie de Montpellier (IRCM), Montpellier, France
| | - Fabienne Portales
- Medical Oncology Department, Institut du Cancer de Montpellier (ICM), Montpellier Cancer Institute, Univ Montpellier, Montpellier, France
| | - Roxana Draghici
- University Federation of Radiation Oncology of Mediterranean Occitanie, Montpellier Cancer Institute (ICM), Univ Montpellier, INSERM U1194 Institut de Recherche en Cancérologie de Montpellier (IRCM), Montpellier, France
| | - Marc Ychou
- Medical Oncology Department, Institut du Cancer de Montpellier (ICM), Montpellier Cancer Institute, Univ Montpellier, Montpellier, France
| | - Eric Assenat
- Medical Oncology Department, Centre Hospitalier Universitaire (CHU) St Eloi, Montpellier, France
| | - Marie Dupuy
- Medical Oncology Department, Centre Hospitalier Universitaire (CHU) St Eloi, Montpellier, France
| | - Sophie Gourgou
- Biometrics Unit Institut du Cancer de Montpellier (ICM), Montpellier Cancer Institute, Univ Montpellier, Montpellier, France
| | - Pierre-Emmanuel Colombo
- Digestive Surgery Department, Institut du Cancer de Montpellier (ICM), Montpellier Cancer Institute, Univ Montpellier, Montpellier, France
| | - Sebastien Carrere
- Digestive Surgery Department, Institut du Cancer de Montpellier (ICM), Montpellier Cancer Institute, Univ Montpellier, Montpellier, France
| | - François-Regis Souche
- Surgical Department, Centre Hospitalier Universitaire (CHU) St Eloi, Montpellier, France
| | - Norbert Aillères
- University Federation of Radiation Oncology of Mediterranean Occitanie, Montpellier Cancer Institute (ICM), Univ Montpellier, INSERM U1194 Institut de Recherche en Cancérologie de Montpellier (IRCM), Montpellier, France
| | - Pascal Fenoglietto
- University Federation of Radiation Oncology of Mediterranean Occitanie, Montpellier Cancer Institute (ICM), Univ Montpellier, INSERM U1194 Institut de Recherche en Cancérologie de Montpellier (IRCM), Montpellier, France
| | - David Azria
- University Federation of Radiation Oncology of Mediterranean Occitanie, Montpellier Cancer Institute (ICM), Univ Montpellier, INSERM U1194 Institut de Recherche en Cancérologie de Montpellier (IRCM), Montpellier, France
| | - Olivier Riou
- University Federation of Radiation Oncology of Mediterranean Occitanie, Montpellier Cancer Institute (ICM), Univ Montpellier, INSERM U1194 Institut de Recherche en Cancérologie de Montpellier (IRCM), Montpellier, France
| |
Collapse
|
12
|
Macchia G, Nardangeli A, Laliscia C, Fodor A, Draghini L, Gentile PC, D’Agostino GR, Balcet V, Bonome P, Ferioli M, Autorino R, Vicenzi L, Raguso A, Borghesi S, Ippolito E, Di Cataldo V, Cilla S, Perrucci E, Campitelli M, Gambacorta MA, Deodato F, Scambia G, Ferrandina G. Stereotactic body radiotherapy in oligometastatic cervical cancer (MITO-RT2/RAD study): a collaboration of MITO, AIRO GYN, and MaNGO groups. Int J Gynecol Cancer 2022; 32:732-739. [DOI: 10.1136/ijgc-2021-003237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
ObjectiveThis retrospective, multicenter study analyzes the efficacy and safety of stereotactic body radiotherapy in a large cohort of patients with oligometastatic/persistent/recurrent cervical cancer.MethodsA standardized data collection from several radiotherapy centers that treated patients by stereotactic body radiotherapy between March 2006 and February 2021 was set up. Clinical and stereotactic body radiotherapy parameters were collected. Objective response rate was defined as a composite of complete and partial response, while clinical benefit included objective response rate plus stable disease. Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer and Common Terminology Criteria for Adverse Events scales were used to grade toxicities. The primary endpoints were the rate of complete response to stereotactic body radiotherapy, and the 2 year actuarial local control rate on a ‘per lesion’ basis. The secondary end points were progression-free survival and overall survival, as well as toxicity.ResultsA total of 83 patients with oligometastatic/persistent/recurrent cervical cancer bearing 125 lesions treated by stereotactic body radiotherapy at 15 different centers were selected for analysis. Of the sites of metastatic disease, lymph node metastases were most common (55.2%), followed by parenchyma lesions (44.8%). Median total dose was 35 Gy (range 10–60), in five fractions (range 1–10), with a median dose/fraction of 7 Gy (range 4–26). Complete, partial, and stable response were found in 73 (58.4%), 29 (23.2%), and 16 (12.8%) lesions, respectively, reaching 94.4% of the clinical benefit rate. Forty-six (55.4%) patients had a complete response. Patients achieving complete response on a ‘per lesion’ basis experienced a 2 year actuarial local control rate of 89.0% versus 22.1% in lesions not achieving complete response (p<0.001). The 2 year actuarial progression-free survival rate was 42.5% in patients with complete response versus 7.8% in patients with partial response or stable or progressive disease (p=0.001). The 2 year actuarial overall survival rate was 68.9% in patients with complete response versus 44.3% in patients with partial response or stable or progressive disease (p=0.015). Fifteen patients (18.1%) had mild acute toxicity, totaling 29 side events. Late toxicity was documented in four patients (4.8%) totaling seven adverse events.ConclusionOur analysis confirmed the efficacy of stereotactic body radiotherapy in oligometastatic/persistent/recurrent cervical cancer patients. The low toxicity profile encourages the wider use of stereotactic body radiotherapy in this setting.
Collapse
|
13
|
Spiliopoulos S, Zurlo MT, Casella A, Laera L, Surico G, Surgo A, Fiorentino A, de'Angelis N, Calbi R, Memeo R, Inchingolo R. Current status of non-surgical treatment of locally advanced pancreatic cancer. World J Gastrointest Oncol 2021; 13:2064-2075. [PMID: 35070042 PMCID: PMC8713317 DOI: 10.4251/wjgo.v13.i12.2064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/28/2021] [Accepted: 10/25/2021] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer is the 7th leading cause of death due to cancer in industrialized countries and the 11th most common cancer globally, with 458918 new cases (2.5% of all cancers) and 432242 deaths (4.5% of all cancer deaths) in 2018. Unfortunately, 80% to 90% of the patients present with unresectable disease, and the reported 5-year survival rate range between 10% and 25%, even after successful resection with tumor-free margins. Systemic chemotherapy, radiotherapy, and minimally invasive image-guided procedures that have emerged over the past years, are used for the management of non-operable PC. This review focuses on currently available non-surgical options of locally advanced pancreatic cancer.
Collapse
Affiliation(s)
- Stavros Spiliopoulos
- 2nd Radiology Department, Interventional Radiology Unit, National and Kapodistrian University of Athens, Athens 12461, Greece
| | - Maria Teresa Zurlo
- Interventional Radiology Unit, “F. Miulli” Regional General Hospital, Acquaviva delle Fonti 70021, Italy
| | - Annachiara Casella
- Unit of Hepato-Pancreatic-Biliary Surgery, “F. Miulli” Regional General Hospital, Acquaviva delle Fonti 70021, Italy
| | - Letizia Laera
- Department of Oncology, General Regional Hospital “F. Miulli”, Acquaviva delle Fonti 70021, Italy
| | - Giammarco Surico
- Department of Oncology, General Regional Hospital “F. Miulli”, Acquaviva delle Fonti 70021, Italy
| | - Alessia Surgo
- Department of Radiation Oncology, “F. Miulli” Regional General Hospital, Acquaviva delle Fonti 70021, Italy
| | - Alba Fiorentino
- Department of Radiation Oncology, “F. Miulli” Regional General Hospital, Acquaviva delle Fonti 70021, Italy
| | - Nicola de'Angelis
- Unit of Minimally Invasive and Robotic Digestive Surgery, “F. Miulli” Regional General Hospital, Acquaviva delle Fonti 70021, Italy
| | - Roberto Calbi
- Department of Radiology, General Regional Hospital “F. Miulli”, Acquaviva delle Fonti 70021, Italy
| | - Riccardo Memeo
- Unit of Hepato-Pancreatic-Biliary Surgery, “F. Miulli” Regional General Hospital, Acquaviva delle Fonti 70021, Italy
| | - Riccardo Inchingolo
- Interventional Radiology Unit, “F. Miulli” Regional General Hospital, Acquaviva delle Fonti 70021, Italy
| |
Collapse
|
14
|
Diao K, Nguyen TP, Moreno AC, Reddy JP, Garden AS, Wang CH, Tung S, Wang C, Wang XA, Rosenthal DI, Fuller CD, Gunn GB, Frank SJ, Morrison WH, Shah SJ, Lee A, Spiotto MT, Su SY, Ferrarotto R, Phan J. Stereotactic body ablative radiotherapy for reirradiation of small volume head and neck cancers is associated with prolonged survival: Large, single-institution, modern cohort study. Head Neck 2021; 43:3331-3344. [PMID: 34269492 PMCID: PMC8511054 DOI: 10.1002/hed.26820] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/18/2021] [Accepted: 07/09/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Recurrent head and neck cancer has poor prognosis. Stereotactic body radiotherapy (SBRT) may improve outcomes by delivering ablative radiation doses. METHODS We reviewed patients who received definitive-intent SBRT reirradiation at our institution from 2013 to 2020. Patterns of failure, overall survival (OS), and toxicities were analyzed. RESULTS One hundred and thirty-seven patients were evaluated. The median OS was 44.3 months. The median SBRT dose was 45 Gy and median target volume 16.9 cc. The 1-year local, regional, and distant control was 78%, 66%, and 83%, respectively. Systemic therapy improved regional (p = 0.004) and distant control (p = 0.04) in nonmetastatic patients. Grade 3+ toxicities were more common at mucosal sites (p = 0.001) and with concurrent systemic therapy (p = 0.02). CONCLUSIONS In a large cohort of SBRT reirradiation for recurrent, small volume head and neck cancers, a median OS of 44.3 months was observed. Systemic therapy improved regional and distant control. Toxicities were modulated by anatomic site and systemic therapy.
Collapse
Affiliation(s)
- Kevin Diao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Theresa P. Nguyen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Amy C. Moreno
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jay P. Reddy
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Adam S. Garden
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Catherine H. Wang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Samuel Tung
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Congjun Wang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Xin A. Wang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - David I. Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Clifton D. Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Gary B. Gunn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Steven J. Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - William H. Morrison
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Shalin J. Shah
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Anna Lee
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Michael T. Spiotto
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Shirley Y. Su
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Renata Ferrarotto
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jack Phan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| |
Collapse
|
15
|
Xu Y, Lu L, Luo J, Wang L, Zhang Q, Cao J, Jiao Y. Disulfiram Alone Functions as a Radiosensitizer for Pancreatic Cancer Both In Vitro and In Vivo. Front Oncol 2021; 11:683695. [PMID: 34631519 PMCID: PMC8494980 DOI: 10.3389/fonc.2021.683695] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 09/06/2021] [Indexed: 12/24/2022] Open
Abstract
The prognosis of pancreatic cancer remains very poor worldwide, partly due to the lack of specificity of early symptoms and innate resistance to chemo-/radiotherapy. Disulfiram (DSF), an anti-alcoholism drug widely used in the clinic, has been known for decades for its antitumor effects when simultaneously applied with copper ions, including pancreatic cancer. However, controversy still exists in the context of the antitumor effects of DSF alone in pancreatic cancer and related mechanisms, especially in its potential roles as a sensitizer for cancer radiotherapy. In the present study, we focused on whether and how DSF could facilitate ionizing radiation (IR) to eliminate pancreatic cancer. DSF alone significantly suppressed the survival of pancreatic cancer cells after exposure to IR, both in vitro and in vivo. Additionally, DSF treatment alone caused DNA double-strand breaks (DSBs) and further enhanced IR-induced DSBs in pancreatic cancer cells. In addition, DSF alone boosted IR-induced cell cycle G2/M phase arrest and apoptosis in pancreatic cancer exposed to IR. RNA sequencing and bioinformatics analysis results suggested that DSF could trigger cell adhesion molecule (CAM) signaling, which might be involved in its function in regulating the radiosensitivity of pancreatic cancer cells. In conclusion, we suggest that DSF alone may function as a radiosensitizer for pancreatic cancer, probably by regulating IR-induced DNA damage, cell cycle arrest and apoptosis, at least partially through the CAM signaling pathway.
Collapse
Affiliation(s)
- Ying Xu
- State Key Laboratory of Radiation Medicine and Protection, School of Radiation Medicine and Protection, Soochow University, Suzhou, China.,Collaborative Innovation Center of Radiological Medicine of Jiangsu Higher Education Institutions, Soochow University, Suzhou, China
| | - Lunjie Lu
- Department of Radiation Physics, Qingdao Central Hospital, Qingdao, China
| | - Judong Luo
- Department of Oncology, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, China
| | - Lili Wang
- Department of Radiotherapy, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Qi Zhang
- State Key Laboratory of Radiation Medicine and Protection, School of Radiation Medicine and Protection, Soochow University, Suzhou, China.,Collaborative Innovation Center of Radiological Medicine of Jiangsu Higher Education Institutions, Soochow University, Suzhou, China
| | - Jianping Cao
- State Key Laboratory of Radiation Medicine and Protection, School of Radiation Medicine and Protection, Soochow University, Suzhou, China.,Collaborative Innovation Center of Radiological Medicine of Jiangsu Higher Education Institutions, Soochow University, Suzhou, China
| | - Yang Jiao
- State Key Laboratory of Radiation Medicine and Protection, School of Radiation Medicine and Protection, Soochow University, Suzhou, China.,Collaborative Innovation Center of Radiological Medicine of Jiangsu Higher Education Institutions, Soochow University, Suzhou, China
| |
Collapse
|
16
|
Passardi A, Rapposelli IG, Scarpi E, Sullo FG, Bartolini G, Neri E, Ghigi G, Tontini L, Ercolani G, Monti M, Ruscelli S, Matteucci L, Valgiusti M, Frassineti GL, Romeo A. Multimodal Treatment with GEMOX Plus Helical Tomotherapy in Unresectable Locally Advanced Pancreatic Cancer: A Pooled Analysis of Two Phase 2 Studies. Biomolecules 2021; 11:biom11081200. [PMID: 34439866 PMCID: PMC8393939 DOI: 10.3390/biom11081200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/29/2021] [Accepted: 08/09/2021] [Indexed: 12/29/2022] Open
Abstract
In locally advanced pancreatic cancer (LAPC), the combination of chemotherapy and radiotherapy is a widely used treatment option. We performed a pooled analysis, including an exploratory analysis for prognostic and predictive factors, of two phase 2 trials including 73 patients with LAPC, treated with gemcitabine and oxaliplatin (GEMOX) and hypofractionated tomotherapy. With a median follow-up of 36 months (range 1–65), median progression-free (PFS) and overall survival (OS) were 10.2 (95% confidence interval [CI] 7.8–13.2) and 14.3 (95% CI 12.0–18.1) months, respectively. The overall resectability rate was 23.3% (95% CI 13.6–33.0), and the R0 resection rate was 13.7% (95% CI 5.8–21.6). In the multivariate analysis, ECOG performance status (PS) 0 and low levels of CA 19–9 were associated with improved OS and PFS. Concerning OS, log(CA19–9) resulted in a hazard ratio (HR) of 1.20 (95% CI 1.02–1.42), p = 0.027. For ECOG PS 0, HR was 1.00; for PS 1, HR was 2.69 (95% CI 1.46–4.96); for PS 2, HR was 4.18 (95% CI 0.90–19.46); p = 0.003. Low CA19–9 levels were also predictive for resection, with an odds ratio of 0.71 (95% CI 0.52–0.97), p = 0.034. In conclusion, GEMOX and hypofractionated radiotherapy is a treatment option in LAPC. Further studies are needed to identify differences in tumor biology, which may help to predict resectability and prognosis.
Collapse
Affiliation(s)
- Alessandro Passardi
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
| | - Ilario Giovanni Rapposelli
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
- Correspondence: ; Tel.: +39-0543-739100
| | - Emanuela Scarpi
- Unit of Biostatistics and Clinical Trials, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy;
| | - Francesco Giulio Sullo
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
| | - Giulia Bartolini
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
| | - Elisa Neri
- Radiotherapy Unit, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (E.N.); (G.G.); (L.T.); (A.R.)
| | - Giulia Ghigi
- Radiotherapy Unit, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (E.N.); (G.G.); (L.T.); (A.R.)
| | - Luca Tontini
- Radiotherapy Unit, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (E.N.); (G.G.); (L.T.); (A.R.)
| | - Giorgio Ercolani
- General and Oncologic Surgery Unit, Morgagni-Pierantoni Hospital, AUSL Romagna, 47121 Forlì, Italy;
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy
| | - Manlio Monti
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
| | - Silvia Ruscelli
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
| | - Laura Matteucci
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
| | - Martina Valgiusti
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
| | - Giovanni Luca Frassineti
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
| | - Antonino Romeo
- Radiotherapy Unit, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (E.N.); (G.G.); (L.T.); (A.R.)
| |
Collapse
|
17
|
Kim SH, Shin EJ. Endoscopic Ultrasound-Guided Fiducial Placement for Stereotactic Body Radiation Therapy in Pancreatic Malignancy. Clin Endosc 2021; 54:314-323. [PMID: 34082487 PMCID: PMC8182253 DOI: 10.5946/ce.2021.102] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/07/2021] [Indexed: 12/18/2022] Open
Abstract
Stereotactic body radiation therapy (SBRT) is an important treatment option for pancreatic cancer, which is known to be one of the malignancies with the worst prognosis. However, the high radiation doses delivered during SBRT may cause damage to adjacent radiosensitive organs. To minimize such damage, fiducial markers are used for localization during SBRT for pancreatic cancer. The development of endoscopic ultrasound (EUS) has enabled fiducial markers to be inserted into the pancreas using an EUS fine-needle aspiration (FNA) needle, unlike in the past when percutaneous placement was generally performed. For successful EUS-guided fiducial marker placement, it is necessary for the fiducial markers to be loaded within the EUS-FNA needles to have a low probability of complications and a low migration risk, and to be stably observed in SBRT imaging. A systematic review has shown that the technical success rate of EUS-guided fiducial marker placement is 96.27%, whereas the fiducial marker migration and adverse event rates are 4.33% and 4.85%, respectively. Nonetheless, standardized techniques for fiducial marker placement and the characteristics of optimal fiducial markers have not yet been established. This review will introduce the characteristics (e.g., materials and shapes) of fiducial markers used in fiducial marker placement for pancreatic cancer and will discuss conventional techniques along with their success rates, difficulties, and adverse events.
Collapse
Affiliation(s)
- Seong-Hun Kim
- Department of Internal Medicine, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Korea
| | - Eun Ji Shin
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|
18
|
Tonneau M, Lacornerie T, Mirabel X, Pasquier D. [Stereotactic body radiotherapy for locally advanced pancreatic cancer: A systemic review]. Cancer Radiother 2021; 25:283-295. [PMID: 33423968 DOI: 10.1016/j.canrad.2020.08.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 08/02/2020] [Accepted: 08/06/2020] [Indexed: 01/11/2023]
Abstract
Stereotactic body radiation therapy (SBRT) for locally advanced pancreatic cancer (LAPC) is an emerging treatment option. Most studies showed local control of approximately 75% with no evidence of improved overall survival. Gastrointestinal toxicities could be significant, ranging up to 22% for acute toxicities≥grade 3+ and 44% for late toxicities≥grade 3+. Currently, no standardized guidelines for treatment and management scheme. We conducted a systemic review of published prospective and retrospective trials to evaluate the efficacy, safety, technical data, and discuss future directions.
Collapse
Affiliation(s)
- M Tonneau
- Département universitaire de radiothérapie, centre Oscar-Lambret, université de Lille, 3, rue Combemale, 59020 Lille cedex, France.
| | - T Lacornerie
- Service de physique médicale, centre Oscar-Lambret, 3, rue Combemale, 59020 Lille cedex, France
| | - X Mirabel
- Département universitaire de radiothérapie, centre Oscar-Lambret, université de Lille, 3, rue Combemale, 59020 Lille cedex, France
| | - D Pasquier
- Département universitaire de radiothérapie, centre Oscar-Lambret, université de Lille, 3, rue Combemale, 59020 Lille cedex, France; Centre de recherche en informatique, signal et automatique de Lille, UMR CNRS 9189, université de Lille, M3, avenue Carl-Gauss, 59650 Villeneuve-d'Ascq, France
| |
Collapse
|
19
|
Maximizing Tumor Control and Limiting Complications With Stereotactic Body Radiation Therapy for Pancreatic Cancer. Int J Radiat Oncol Biol Phys 2020; 110:206-216. [PMID: 33358561 DOI: 10.1016/j.ijrobp.2020.11.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/04/2020] [Accepted: 11/05/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE Stereotactic body radiation therapy (SBRT) and stereotactic ablative body radiation therapy is being increasingly used for pancreatic cancer (PCa), particularly in patients with locally advanced and borderline resectable disease. A wide variety of dose fractionation schemes have been reported in the literature. This HyTEC review uses tumor control probability models to evaluate the comparative effectiveness of the various SBRT treatment regimens used in the treatment of patients with localized PCa. METHODS AND MATERIALS A PubMed search was performed to review the published literature on the use of hypofractionated SBRT (usually in 1-5 fractions) for PCa in various clinical scenarios (eg, preoperative [neoadjuvant], borderline resectable, and locally advanced PCa). The linear quadratic model with α/β= 10 Gy was used to address differences in fractionation. Logistic tumor control probability models were generated using maximum likelihood parameter fitting. RESULTS After converting to 3-fraction equivalent doses, the pooled reported data and associated models suggests that 1-year local control (LC) without surgery is ≈79% to 86% after the equivalent of 30 to 36 Gy in 3 fractions, showing a dose response in the range of 25 to 36 Gy, and decreasing to less than 70% 1-year LC at doses below 24 Gy in 3 fractions. The 33 Gy in 5 fraction regimen (Alliance A021501) corresponds to 28.2 Gy in 3 fractions, for which the HyTEC pooled model had 77% 1-year LC without surgery. Above an equivalent dose of 28 Gy in 3 fractions, with margin-negative resection the 1-year LC exceeded 90%. CONCLUSIONS Pooled analyses of reported tumor control probabilities for commonly used SBRT dose-fractionation schedules for PCa suggests a dose response. These findings should be viewed with caution given the challenges and limitations of this review. Additional data are needed to better understand the dose or fractionation-response of SBRT for PCa.
Collapse
|
20
|
Liauw SL, Ni L, Wu T, Arif F, Cloutier D, Posner MC, Kozloff M, Kindler HL. A prospective trial of stereotactic body radiation therapy for unresectable pancreatic cancer testing ablative doses. J Gastrointest Oncol 2020; 11:1399-1407. [PMID: 33457009 DOI: 10.21037/jgo-20-187] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background We explored the safety and efficacy of ablative doses of stereotactic body radiation therapy (SBRT) for unresectable pancreatic cancer. Methods This phase I/II trial included patients with unresectable pancreatic cancer previously treated with any number of cycles of induction chemotherapy. Patients were enrolled according to a 3+3 dose escalation design at 10, 12.5, and 15 Gy ×3, with subsequent patients at the maximally tolerated dose (MTD). Treatment was delivered to gross tumor delineated with MRI fusion using image-guidance to fiducial markers. Dose-limiting toxicity (DLT) was defined as grade 3+ toxicity within 30 days. Secondary endpoints included late gastrointestinal (GI) toxicity, freedom from local failure (FFLF), and survival. Results Fifteen patients received a median 10 cycles of chemotherapy. There were no DLTs, and the MTD was 15 Gy ×3. Thirty-day toxicity included grade 2 nausea (46%) and grade 2 diarrhea (7%). Median survival after SBRT was 12.8 months (23 months after diagnosis) and median relapse-free survival was 7 months. At 1-year, FFLF was 80%. Four patients had grade 3+ GI bleeding after 30 days (median 6 months). Grade 3+ GI bleeding was associated with tumor volume (P=0.01), heterogeneity of dose within the planning target volume (PTV) (V120, P=0.03), and duodenal dose (V26-30 Gy, P<0.2). Conclusions This aggressive SBRT regimen demonstrated limited 30-day morbidity, a moderate degree of local control, and a moderate risk for late GI bleeding. Further work is necessary to define the most appropriate hypofractionated radiation therapy (RT) regimen in the ablative dose range.
Collapse
Affiliation(s)
- Stanley L Liauw
- Department of Radiation Oncology, University of Chicago Medical Center, Chicago, IL, USA
| | - Lisa Ni
- Department of Radiation Oncology, University of Chicago Medical Center, Chicago, IL, USA
| | - Tianming Wu
- Department of Radiation Oncology, University of Chicago Medical Center, Chicago, IL, USA
| | - Fauzia Arif
- Department of Radiation Oncology, University of Chicago Medical Center, Chicago, IL, USA
| | - Denise Cloutier
- Department of Radiation Oncology, University of Chicago Medical Center, Chicago, IL, USA
| | - Mitchell C Posner
- Department of Surgical Oncology, University of Chicago Medical Center, Chicago, IL, USA
| | - Mark Kozloff
- Department of Medical Oncology, University of Chicago Medical Center, Chicago, IL, USA
| | - Hedy L Kindler
- Department of Medical Oncology, University of Chicago Medical Center, Chicago, IL, USA
| |
Collapse
|
21
|
Kerdsirichairat T, Shin EJ. Role of endoscopic ultrasonography guided fiducial marker placement in gastrointestinal cancer. Curr Opin Gastroenterol 2020; 36:402-408. [PMID: 32740001 DOI: 10.1097/mog.0000000000000662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Dose escalation radiation therapy such as those delivered by stereotactic body radiation therapy (SBRT) has shown to improve local disease control in multiple types of malignancies. This requires fiducial placement to improve accuracy of treatment and avoid adverse events to adjacent radiosensitive organs during respiration phases. The purpose of this review is to provide updates of recent high-quality articles related to endoscopic ultrasonography (EUS)-guided fiducial placement for gastrointestinal malignancies, particularly in pancreatic cancer, which is expected to be the second leading cause of cancer-related deaths in the USA within this decade. RECENT FINDINGS A recent systematic review and meta-analysis has shown that EUS-guided fiducial placement for gastrointestinal malignancies has excellent technical success and safety profile. Comparative studies of most commercially available fiducial types via a 22-gauge needle system showed that a 0.035 mm diameter and 10 mm long gold fiducial with coiled configuration, hollow core and external helical design might be favoured due to its most balanced performance of visibility, artifact and migration. SUMMARY A fine balance of performance characteristics of fiducials should be discussed with radiation oncologists to select a suitable and preferred type of fiducials. The comparative studies of other newly developed platinum fiducials and liquid fiducial are pending.
Collapse
Affiliation(s)
| | - Eun Ji Shin
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| |
Collapse
|
22
|
Bouchart C, Navez J, Closset J, Hendlisz A, Van Gestel D, Moretti L, Van Laethem JL. Novel strategies using modern radiotherapy to improve pancreatic cancer outcomes: toward a new standard? Ther Adv Med Oncol 2020; 12:1758835920936093. [PMID: 32684987 PMCID: PMC7343368 DOI: 10.1177/1758835920936093] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 05/22/2020] [Indexed: 12/11/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) remains one of the most aggressive solid tumours with an estimated 5-year overall survival rate of 7% for all stages combined. In this highly resistant disease that is located in the vicinity of many radiosensitive organs, the role of radiotherapy (RT) and indications for its use in this setting have been debated for a long time and are still under investigation. Although a survival benefit has yet to be clearly demonstrated for RT, it is the only technique, other than surgery, that has been demonstrated to lead to local control improvement. The adjuvant approach is now strongly challenged by neoadjuvant treatments that could spare patients with rapidly progressive systemic disease from unnecessary surgery and may increase free margin (R0) resection rates for those eligible for surgery. Recently developed dose-escalated RT treatments, designed either to maintain full-dose chemotherapy or to deliver a high biologically effective dose, particularly to areas of contact between the tumour and blood vessels, such as hypofractionated ablative RT (HFA-RT) or stereotactic body RT (SBRT), are progressively changing the treatment landscape. These modern strategies are currently being tested in prospective clinical trials with encouraging preliminary results, paving the way for more effective treatment combinations using novel targeted therapies. This review summarizes the current literature regarding the use of RT for the treatment of primary PDAC, describes the limitations of conventional RT, and discusses the emerging role of dose-escalated RT and heavy-particle RT.
Collapse
Affiliation(s)
- Christelle Bouchart
- Department of Radiation-Oncology, Institut Jules Bordet, Boulevard de Waterloo, 121, Brussels, 1000, Belgium
| | - Julie Navez
- Department of Hepato-Biliary-Pancreatic Surgery, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean Closset
- Department of Hepato-Biliary-Pancreatic Surgery, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Alain Hendlisz
- Department of Gastroenterology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Dirk Van Gestel
- Department of Radiation-Oncology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Luigi Moretti
- Department of Radiation-Oncology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Luc Van Laethem
- Department of Gastroenterology, Hepatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| |
Collapse
|
23
|
Abstract
OBJECTIVES Locally advanced pancreatic cancer (LAPC) is managed with multimodality therapy. We aim to evaluate the outcome of single-modality radiation therapy for LAPC. METHODS Locally advanced pancreatic cancer patients were identified between 2004 and 2013 using the National Cancer Database excluding patients who received chemotherapy or surgery. RESULTS A total of 6590 patients were included. The mean age was 73.5 (range, 28-90) years, 83.2% were white, and 54.4% were female. Tumors of 4 cm or greater (>T3 stage) accounted for 52.7%. The median radiation dose was 39.6 Gy. Stereotactic body radiation (SBRT) delivered to 64 patients and external-beam/intensity modulated radiotherapy in 416 patients. Radiation therapy was associated with improved overall survival (OS) compared with no treatment in univariate and multivariable analyses. The medians OS for patients who received SBRT, external-beam/intensity modulated radiotherapy, or no radiation were 8.6, 6.7, and 3.4 months, respectively (P < 0.001). There is a significant difference in 12-month OS for the SBRT cohort (31.9%; 95% confidence interval [CI], 20.9%-43.5%) compared with patients who received no radiation (15.1%; 95% CI, 14.2%-16.0%), and on multivariable analysis (hazard ratio, 0.50; 95% CI, 0.38-0.65; P < 0.001). CONCLUSIONS The current study suggests potential benefit for radiation therapy alone in comparison with no treatment in LAPC.
Collapse
|
24
|
Abi Jaoude J, Kouzy R, Nguyen ND, Lin D, Noticewala SS, Ludmir EB, Taniguchi CM. Radiation therapy for patients with locally advanced pancreatic cancer: Evolving techniques and treatment strategies. Curr Probl Cancer 2020; 44:100607. [PMID: 32471736 DOI: 10.1016/j.currproblcancer.2020.100607] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 05/04/2020] [Indexed: 12/11/2022]
Abstract
Despite ongoing efforts, patients with locally advanced pancreatic cancer (LAPC) continue to have a dismal prognosis. Such tumors are unresectable, and optimal treatment with chemotherapy and/or radiation therapy is still not established. While chemotherapy is conventionally aimed at preventing metastatic spread of disease, radiation therapy acts locally, improving local control which can potentially improve overall survival and most importantly quality of life. Here, we aim to review the primary literature assessing the role of diverse radiation therapy strategies for patients with LAPC. Many radiation regimens can be considered, and no standard treatment has demonstrated a clear improvement in clinical outcomes. We advise that the modality of choice be dependent on the availability of equipment, the dose and fractionation of treatment, as well as the dose received by normal tissue. Moreover, a candid discussion with the patient concerning treatment goals is equally as essential. Three notable strategies for LAPC are intensity-modulated radiation therapy, volumetric modulated arc therapy, and proton. These radiation modalities tend to have improved dose distribution to the target volumes, while minimizing the radiation dose to surrounding normal tissues. Stereotactic body radiation therapy can also be considered in LAPC patients in cases where the tumor does not invade the duodenum or other neighboring structures. Because of the high doses delivered by stereotactic body radiation therapy, proper respiratory and tumor motion management should be implemented to reduce collateral radiation dosing. Despite improved clinical outcomes with modern radiation modalities, evolving techniques, and more accurate planning, future studies remain essential to elucidate the optimal role for radiation therapy among patients with LAPC.
Collapse
Affiliation(s)
| | - Ramez Kouzy
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Daniel Lin
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Ethan B Ludmir
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | |
Collapse
|
25
|
Volume de-escalation in radiation therapy: state of the art and new perspectives. J Cancer Res Clin Oncol 2020; 146:909-924. [PMID: 32072318 DOI: 10.1007/s00432-020-03152-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 02/10/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE New RT techniques and data emerging from follow-up for several tumor sites suggest that treatment volume de-escalation may permit to minimize therapy-related side effects and/or obtain better clinical outcomes. Here, we summarize the main evidence about volume de-escalation in RT. METHOD The relevant literature from PubMed was reviewed in this article. The ClinicalTrials.gov database was searched for clinical trials related to the specific topic. RESULTS In Lymphoma, large-volume techniques (extended- and involved-field RT) are being successfully replaced by involved-site RT and involved-node RT. In head and neck carcinoma, spare a part of elective neck is controversial. In early breast cancer, partial breast irradiation has been established as a treatment option in low-risk patients. In pancreatic cancer stereotactic body radiotherapy may be used to dose escalation. Stereotactic radiosurgery should be the treatment choice for patients with oligometastatic brain disease and a life expectancy of more than 3 months, and it should be considered an alternative to WBRT for patients with multiple brain metastases. CONCLUSION Further clinical trials are necessary to improve the identification of suitable patient cohorts and the extent of possible volume de-escalation that does not compromise tumor control.
Collapse
|
26
|
Dell’Oro M, Short M, Wilson P, Bezak E. Clinical Limitations of Photon, Proton and Carbon Ion Therapy for Pancreatic Cancer. Cancers (Basel) 2020; 12:cancers12010163. [PMID: 31936565 PMCID: PMC7017270 DOI: 10.3390/cancers12010163] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 01/03/2020] [Accepted: 01/06/2020] [Indexed: 02/08/2023] Open
Abstract
Introduction: Despite improvements in radiation therapy, chemotherapy and surgical procedures over the last 30 years, pancreatic cancer 5-year survival rate remains at 9%. Reduced stroma permeability and heterogeneous blood supply to the tumour prevent chemoradiation from making a meaningful impact on overall survival. Hypoxia-activated prodrugs are the latest strategy to reintroduce oxygenation to radioresistant cells harbouring in pancreatic cancer. This paper reviews the current status of photon and particle radiation therapy for pancreatic cancer in combination with systemic therapies and hypoxia activators. Methods: The current effectiveness of management of pancreatic cancer was systematically evaluated from MEDLINE® database search in April 2019. Results: Limited published data suggest pancreatic cancer patients undergoing carbon ion therapy and proton therapy achieve a comparable median survival time (25.1 months and 25.6 months, respectively) and 1-year overall survival rate (84% and 77.8%). Inconsistencies in methodology, recording parameters and protocols have prevented the safety and technical aspects of particle therapy to be fully defined yet. Conclusion: There is an increasing requirement to tackle unmet clinical demands of pancreatic cancer, particularly the lack of synergistic therapies in the advancing space of radiation oncology.
Collapse
Affiliation(s)
- Mikaela Dell’Oro
- Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide SA 5001, Australia; (M.S.); (E.B.)
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide SA 5000, Australia;
- Correspondence: ; Tel.: +61-435214264
| | - Michala Short
- Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide SA 5001, Australia; (M.S.); (E.B.)
| | - Puthenparampil Wilson
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide SA 5000, Australia;
- School of Engineering, University of South Australia, Adelaide SA 5001, Australia
| | - Eva Bezak
- Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide SA 5001, Australia; (M.S.); (E.B.)
- Department of Physics, University of Adelaide, Adelaide SA 5005, Australia
| |
Collapse
|
27
|
Ye J, Mills BN, Zhao T, Han BJ, Murphy JD, Patel AP, Johnston CJ, Lord EM, Belt BA, Linehan DC, Gerber SA. Assessing the Magnitude of Immunogenic Cell Death Following Chemotherapy and Irradiation Reveals a New Strategy to Treat Pancreatic Cancer. Cancer Immunol Res 2020; 8:94-107. [PMID: 31719057 PMCID: PMC6946873 DOI: 10.1158/2326-6066.cir-19-0373] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 09/18/2019] [Accepted: 11/07/2019] [Indexed: 12/22/2022]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) continues to have a dismal prognosis, in part, due to ineffective treatment strategies. The efficacy of some chemotherapies and especially radiotherapy is mediated partially by the immune system. Therefore, we hypothesized that profiling the immune response following chemotherapy and/or irradiation can be used as a readout for treatment efficacy but also to help identify optimal therapeutic schedules for PDAC. Using murine models of PDAC, we demonstrated that concurrent administration of stereotactic body radiotherapy (SBRT) and a modified dose of FOLFIRINOX (mFX) resulted in superior tumor control when compared with single or sequential treatment groups. Importantly, this combined treatment schedule enhanced the magnitude of immunogenic cell death, which in turn amplified tumor antigen presentation by dendritic cells and intratumoral CD8+ T-cell infiltration. Concurrent therapy also resulted in systemic immunity contributing to the control of established metastases. These findings provide a rationale for pursuing concurrent treatment schedules of SBRT with mFX in PDAC.
Collapse
Affiliation(s)
- Jian Ye
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
- Center for Tumor Immunology Research, University of Rochester Medical Center, Rochester, New York
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - Bradley N Mills
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
- Center for Tumor Immunology Research, University of Rochester Medical Center, Rochester, New York
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - Tony Zhao
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
- Center for Tumor Immunology Research, University of Rochester Medical Center, Rochester, New York
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - Booyeon J Han
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
- Center for Tumor Immunology Research, University of Rochester Medical Center, Rochester, New York
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
- Department of Microbiology and Immunology, University of Rochester Medical Center, Rochester, New York
| | - Joseph D Murphy
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
- Center for Tumor Immunology Research, University of Rochester Medical Center, Rochester, New York
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
- Department of Microbiology and Immunology, University of Rochester Medical Center, Rochester, New York
| | - Ankit P Patel
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
- Center for Tumor Immunology Research, University of Rochester Medical Center, Rochester, New York
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - Carl J Johnston
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Edith M Lord
- Center for Tumor Immunology Research, University of Rochester Medical Center, Rochester, New York
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
- Department of Microbiology and Immunology, University of Rochester Medical Center, Rochester, New York
| | - Brian A Belt
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
- Center for Tumor Immunology Research, University of Rochester Medical Center, Rochester, New York
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - David C Linehan
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
- Center for Tumor Immunology Research, University of Rochester Medical Center, Rochester, New York
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - Scott A Gerber
- Department of Surgery, University of Rochester Medical Center, Rochester, New York.
- Center for Tumor Immunology Research, University of Rochester Medical Center, Rochester, New York
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
- Department of Microbiology and Immunology, University of Rochester Medical Center, Rochester, New York
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| |
Collapse
|
28
|
Neilsen BK, Lin C. Changing paradigm of radiation therapy for the treatment of pancreatic cancer. PRECISION RADIATION ONCOLOGY 2019. [DOI: 10.1002/pro6.1080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Beth K Neilsen
- Department of Radiation OncologyUniversity of Nebraska Medical Center Omaha Nebraska USA
| | - Chi Lin
- Department of Radiation OncologyUniversity of Nebraska Medical Center Omaha Nebraska USA
| |
Collapse
|
29
|
Oar A, Lee M, Le H, Hruby G, Dalfsen R, Pryor D, Lee D, Chu J, Holloway L, Briggs A, Barbour A, Chander S, Ng SP, Samra J, Shakeshaft J, Goldstein D, Nguyen N, Goodman KA, Chang DT, Kneebone A. Australasian Gastrointestinal Trials Group (AGITG) and Trans-Tasman Radiation Oncology Group (TROG) Guidelines for Pancreatic Stereotactic Body Radiation Therapy (SBRT). Pract Radiat Oncol 2019; 10:e136-e146. [PMID: 31761541 DOI: 10.1016/j.prro.2019.07.018] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 07/28/2019] [Accepted: 07/31/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Nonrandomized data exploring pancreas stereotactic body radiation therapy (SBRT) has demonstrated excellent local control rates and low toxicity. Before commencing a randomized trial investigating pancreas SBRT, standardization of prescription dose, dose constraints, simulation technique, and clinical target volume delineation are required. METHODS AND MATERIALS Specialists in radiation oncology, medical oncology, hepatobiliary surgery, and gastroenterology attended 2 consecutive Australasian Gastrointestinal Trials Group workshops in 2017 and 2018. Sample cases were discussed during workshop contact with specifically invited international speakers highly experienced in pancreas SBRT. Furthermore, sample cases were contoured and planned between workshop contact to finalize dose constraints and clinical target volume delineation. RESULTS Over 2 separate workshops, consensus was reached on dose and simulation technique. The working group recommended a dose prescription of 40 Gy in 5 fractions. Treatment delivery during end-expiratory breath hold with triple-phase contrast enhanced computed tomography was recommended. In addition, dose constraints, stepwise contouring guidelines, and an anatomic atlas for pancreatic SBRT were developed. CONCLUSIONS Pancreas SBRT is emerging as a promising treatment modality requiring prospective evaluation in randomized studies. This work attempts to standardize dose, simulation technique, and volume delineation to support the delivery of high quality SBRT in a multicenter study.
Collapse
Affiliation(s)
- Andrew Oar
- Icon Cancer Centre, Gold Coast University Hospital, Gold Coast; Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia.
| | - Mark Lee
- Icon Cancer Centre, Gold Coast University Hospital, Gold Coast
| | - Hien Le
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, Australia
| | - George Hruby
- Royal North Shore Hospital, Sydney, Australia; University of Sydney, Sydney, Australia
| | - Raymond Dalfsen
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, Australia
| | - David Pryor
- Princess Alexandra Hospital, Brisbane, Australia
| | | | - Julie Chu
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Lois Holloway
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia; South Western Clinical School, University of New South Wales, Sydney, Australia; Institute of Medical Physics, University of Sydney, Sydney, Australia; Centre for Medical Radiation Physics, University of Wollongong, Wollongong, Australia
| | - Adam Briggs
- Royal North Shore Hospital, Sydney, Australia
| | - Andrew Barbour
- Princess Alexandra Hospital, Brisbane, Australia; University of Queensland, Diamantina Institute, Translational Research Institute, Woolloongabba, Australia
| | - Sarat Chander
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Sweet Ping Ng
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Jas Samra
- Royal North Shore Hospital, Sydney, Australia; University of Sydney, Sydney, Australia
| | - John Shakeshaft
- Icon Cancer Centre, Gold Coast University Hospital, Gold Coast
| | - David Goldstein
- Department of Medical Oncology, Nelune Cancer Centre, Prince of Wales Hospital, Sydney, Australia; Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Nam Nguyen
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Discipline of Medicine, University of Adelaide, Adelaide, Australia
| | - Karyn A Goodman
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | | | - Andrew Kneebone
- Royal North Shore Hospital, Sydney, Australia; University of Sydney, Sydney, Australia
| |
Collapse
|
30
|
Dose Escalation in Stereotactic Body Radiation Therapy for Pancreatic Cancer: A Meta-Analysis. Am J Clin Oncol 2019; 42:46-55. [PMID: 29965809 DOI: 10.1097/coc.0000000000000472] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine whether increasing biologically effective dose (BED) with stereotactic body radiation therapy (SBRT) is associated with improved local control (LC) or toxicities in patients with locally advanced pancreatic cancer. METHODS A PICOS/PRISMA/MOOSE selection protocol was used to identify 15 studies across 12 institutions in 5 countries where patients received definitive SBRT for nonmetastatic disease. Biologically equivalent doses were calculated with an α/β of 10 (ie, BED10) for LC and acute toxicity and 3 (ie, BED3) for late toxicity. Fixed and random effects models were used to characterize LC and grade 3/4 toxicities by BED. RESULTS There were 508 patients included with a median follow-up time of 9.1 months. The median dose was 30 Gy, and the most common regimen was 30 Gy/5 fractions. There was no significant difference in LC rates at 1 year between the BED10<70 Gy versus ≥70 Gy groups, with an estimate of 0.60 (95% confidence interval [CI], 0.36-0.81) versus 0.83 (95% CI, 0.63-0.97), respectively. There was no significant difference in acute toxicity rates between the BED10<70 Gy versus ≥70 Gy groups, with an estimate of 0.02 (95% CI, 0.00-0.08) versus 0.05 (95% CI, 0.00-0.22), respectively. Given the dose distribution across studies, 3 intervals were used to characterize BED3. There were no significant differences in late toxicity among those receiving BED3<100, 100 to 200, or >200 Gy. CONCLUSIONS SBRT for pancreatic cancer results in LC rates of 60% to 83% and clinically significant toxicity of <7%. Increasing BED10 beyond 70 Gy was not associated with increased rates of 1-year LC or acute toxicity. Increasing BED3 beyond 100 Gy was not associated with increased rates of late toxicity.
Collapse
|
31
|
Shen ZT, Zhou H, Li AM, Ji XQ, Jiang CC, Yuan X, Li B, Zhu XX, Huang GC. Clinical outcomes and prognostic factors of stereotactic body radiation therapy combined with gemcitabine plus capecitabine for locally advanced unresectable pancreatic cancer. J Cancer Res Clin Oncol 2019; 146:417-428. [PMID: 31667573 DOI: 10.1007/s00432-019-03066-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 10/23/2019] [Indexed: 12/25/2022]
Abstract
PURPOSE This study aimed to evaluate the clinical outcomes, toxicity, and prognostic factors of SBRT combined with gemcitabine plus capecitabine (GEM-CAP) in treating locally advanced pancreatic cancer (LAPC). METHODS A total of 56 patients with LAPC treated with SBRT combined with GEM-CAP were reviewed from October 2010 to October 2016. The median total prescription dose at five fractions was 40 Gy (30-50 Gy). The patients were subjected to two cycles of GEM-CAP before SBRT. GEM-CAP chemotherapy was then offered for four cycles or until disease tolerance or progression. The primary endpoints included overall survival (OS) and progression-free survival (PFS). RESULTS The median OS and PFS from the date of diagnosis was 19 (95% CI 14.6-23.4) and 12 months (95% CI 8.34-15.66), respectively. The 1-year and 2-year survival rates were 82.1% and 35.7%, whereas the 1-year and 2-year PFS rates were 48.2% and 14.3%, respectively. The median carbohydrate antigen 19-9-determined PFS time was 11 months (95% CI 5.77-16.24). Multivariate analysis demonstrated that tumor diameter, lymph node metastasis, pre-treatment CA19-9 level, and post-treatment CA19-9 decline were independent prognostic factors (p < 0.05). Acute toxicity was minimal, with two cases (3.6%) experiencing grade 3 duodenal obstruction. No adverse events greater than grade 3 occurred. In late toxicity, three patients (5.4%) developed grade 3 gastrointestinal toxicity and two (3.6%) suffered from perforation caused by grade 4 radiation enteritis and intestinal fistula. CONCLUSIONS The combination of Cyberknife SBRT and GEM-CAP achieved excellent efficacy with acceptable toxicity for LAPC.
Collapse
Affiliation(s)
- Ze-Tian Shen
- Department of Radiation Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
| | - Han Zhou
- Department of Radiation Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
| | - Ao-Mei Li
- Department of Radiation Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
| | - Xiao-Qin Ji
- Department of Radiation Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
| | - Chang-Chen Jiang
- Department of Radiation Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
| | - Xi Yuan
- Department of Radiation Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
| | - Bing Li
- Department of Radiation Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
| | - Xi-Xu Zhu
- Department of Radiation Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China.
| | - Gui-Chun Huang
- Department of Medical Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China.
| |
Collapse
|
32
|
Macchia G, Lazzari R, Colombo N, Laliscia C, Capelli G, D'Agostino GR, Deodato F, Maranzano E, Ippolito E, Ronchi S, Paiar F, Scorsetti M, Cilla S, Ingargiola R, Huscher A, Cerrotta AM, Fodor A, Vicenzi L, Russo D, Borghesi S, Perrucci E, Pignata S, Aristei C, Morganti AG, Scambia G, Valentini V, Jereczek-Fossa BA, Ferrandina G. A Large, Multicenter, Retrospective Study on Efficacy and Safety of Stereotactic Body Radiotherapy (SBRT) in Oligometastatic Ovarian Cancer (MITO RT1 Study): A Collaboration of MITO, AIRO GYN, and MaNGO Groups. Oncologist 2019; 25:e311-e320. [PMID: 32043791 DOI: 10.1634/theoncologist.2019-0309] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 08/23/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Recent studies have reported improvement of outcomes (progression-free survival, overall survival, and prolongation of androgen deprivation treatment-free survival) with stereotactic body radiotherapy (SBRT) in non-small cell lung cancer and prostate cancer. The aim of this retrospective, multicenter study (MITO RT-01) was to define activity and safety of SBRT in a very large, real-world data set of patients with metastatic, persistent, and recurrent ovarian cancer (MPR-OC). MATERIALS AND METHODS The endpoints of the study were the rate of complete response (CR) to SBRT and the 24-month actuarial local control (LC) rate on "per-lesion" basis. The secondary endpoints were acute and late toxicities and the 24-month actuarial late toxicity-free survival. Objective response rate (ORR) included CR and partial response (PR). Clinical benefit (CB) included ORR and stable disease (SD). Toxicity was evaluated by the Radiation Therapy Oncology Group (RTOG) and the European Organization for Research and Treatment of Cancer (EORTC) and Common Terminology Criteria for Adverse Events (CTCAE) scales, according to center policy. Logistic and Cox regression were used for the uni- and multivariate analysis of factors predicting clinical CR and actuarial outcomes. RESULTS CR, PR, and SD were observed in 291 (65.2%), 106 (23.8%), and 33 (7.4%) lesions, giving a rate of CB of 96.4%. Patient aged ≤60 years, planning target volume (PTV) ≤18 cm3 , lymph node disease, and biologically effective dose α/β10 > 70 Gy were associated with higher chance of CR in the multivariate analysis. With a median follow-up of 22 months (range, 3-120), the 24-month actuarial LC rate was 81.9%. Achievement of CR and total dose >25 Gy were associated with better LC rate in the multivariate analysis. Mild toxicity was experienced in 54 (20.7%) patients; of 63 side effects, 48 were grade 1, and 15 were grade 2. The 24-month late toxicity-free survival rate was 95.1%. CONCLUSIONS This study confirms the activity and safety of SBRT in patients with MPR-OC and identifies clinical and treatment parameters able to predict CR and LC rate. IMPLICATIONS FOR PRACTICE This study aimed to define activity and safety of stereotactic body radiotherapy (SBRT) in a very large, real life data set of patients with metastatic, persistent, recurrent ovarian cancer (MPR-OC). Patient age <60 years, PTV <18 cm3 , lymph node disease, and biologically effective dose α/β10 >70 Gy were associated with higher chance of complete response (CR). Achievement of CR and total dose >25 Gy were associated with better local control (LC) rate. Mild toxicity was experienced in 20.7% of patients. In conclusion, this study confirms the activity and safety of SBRT in MPR-OC patients and identifies clinical and treatment parameters able to predict CR and LC rate.
Collapse
Affiliation(s)
- Gabriella Macchia
- Fondazione "Giovanni Paolo II," Unità Operativa di Radioterapia, Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Roberta Lazzari
- Division of Radiotherapy, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Nicoletta Colombo
- Division of Medical Gynecologic Oncology, IEO European Institute of Oncology, IRCCS and University of Milan-Bicocca, Milan, Italy
| | - Concetta Laliscia
- Department of Translational Medicine, Division of Radiation Oncology, University of Pisa, Pisa, Italy
| | - Giovanni Capelli
- Department of Human Sciences, Society and Health, University of Cassino and Southern Lazio, Cassino, Italy
| | - Giuseppe Roberto D'Agostino
- Department of Radiotherapy and Radiosurgery, Humanitas Clinical and Research Hospital, IRCSS, Rozzano, Milan, Italy
| | - Francesco Deodato
- Fondazione "Giovanni Paolo II," Unità Operativa di Radioterapia, Università Cattolica del Sacro Cuore, Campobasso, Italy
| | | | - Edy Ippolito
- Department of Radiation Oncology, Campus Bio-Medico University, Rome, Italy
| | - Sara Ronchi
- Division of Radiotherapy, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Fabiola Paiar
- Department of Translational Medicine, Division of Radiation Oncology, University of Pisa, Pisa, Italy
| | - Marta Scorsetti
- Department of Radiotherapy and Radiosurgery, Humanitas Clinical and Research Hospital, IRCSS, Rozzano, Milan, Italy
- Humanitas University, Department of Biomedical Sciences, Rozzano, Milano, Italy
| | - Savino Cilla
- Fondazione "Giovanni Paolo II," Unità Operativa di Fisica Medica, Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Rossana Ingargiola
- Division of Radiotherapy, IEO European Institute of Oncology, IRCCS, Milan, Italy
- Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Alessandra Huscher
- U.O. di Radioterapia Oncologica "Guido Berlucchi," Fondazione Poliambulanza, Brescia, Italy
| | - Anna Maria Cerrotta
- Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Andrei Fodor
- Department of Radiation Oncology, San Raffaele Scientific Institute, Milan, Italy
| | - Lisa Vicenzi
- Department of Oncology and Radiotherapy, Azienda Ospedaliera Universitaria Ospedali Riuniti, Ancona, Italy
| | | | - Simona Borghesi
- Radiotherapy Department, Azienda USL Toscana sud est, San Donato Hospital-Arezzo, Italy
| | - Elisabetta Perrucci
- Radiation Oncology Section, University of Perugia and Perugia General Hospital, Perugia, Italy
| | - Sandro Pignata
- Istituto Nazionale Tumori di Napoli, Fondazione Pascale IRCCS, Naples, Italy
| | - Cynthia Aristei
- Radiation Oncology Section, University of Perugia and Perugia General Hospital, Perugia, Italy
| | - Alessio Giuseppe Morganti
- Department of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Giovanni Scambia
- Fondazione Policlinico Universitario A. Gemelli, IRCCS, Unità Operativa Complessa Ginecologia Oncologica, Dipartimento per la Salute della Donna e del Bambino e della Salute Pubblica, Roma, Italy
- Università Cattolica del Sacro Cuore, Istituto di Ginecologia e Ostetricia, Roma, Italy
| | - Vincenzo Valentini
- Fondazione "Giovanni Paolo II," Unità Operativa di Radioterapia, Università Cattolica del Sacro Cuore, Campobasso, Italy
- Fondazione Policlinico Universitario A. Gemelli, IRCCS, Unità Operativa Complessa di Radioterapia, Dipartimento di Scienze Radiologiche, Radioterapiche ed Ematologiche, Roma, Italy
- Università Cattolica del Sacro Cuore, Istituto di Radiologia, Roma, Italy
| | - Barbara Alicja Jereczek-Fossa
- Division of Radiotherapy, IEO European Institute of Oncology, IRCCS, Milan, Italy
- Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Gabriella Ferrandina
- Fondazione Policlinico Universitario A. Gemelli, IRCCS, Unità Operativa Complessa Ginecologia Oncologica, Dipartimento per la Salute della Donna e del Bambino e della Salute Pubblica, Roma, Italy
- Università Cattolica del Sacro Cuore, Istituto di Ginecologia e Ostetricia, Roma, Italy
| |
Collapse
|
33
|
Jiang W, Haque W, Verma V, Butler EB, Teh BS. Neoadjuvant stereotactic body radiation therapy for nonmetastatic pancreatic adenocarcinoma. Acta Oncol 2019; 58:1259-1266. [PMID: 31237185 DOI: 10.1080/0284186x.2019.1631472] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 06/05/2019] [Indexed: 02/07/2023]
Abstract
Background: Neoadjuvant therapy is a strategy for resectable and borderline resectable pancreatic cancer, but a consensus approach regarding optimal management is undetermined. Neoadjuvant options include chemotherapy with/without radiotherapy. Stereotactic body radiation therapy (SBRT) is a novel radiation technique that may provide benefit over conventionally fractionated radiation therapy (CFRT) in the neoadjuvant setting. The purpose of the present study is to determine neoadjuvant treatment with SBRT to other neoadjuvant treatment options for patients with resectable pancreatic cancer. Material and methods: The National Cancer Database was queried (2004-2015) for patients with nonmetastatic pancreatic adenocarcinoma receiving neoadjuvant therapy followed by pancreatectomy. Patients were categorized based on the type of neoadjuvant treatment administered. Statistics included temporal trend assessment by annual percent change (APC), predictors for SBRT by multivariable logistic regression, Kaplan-Meier overall survival (OS) analysis without and with propensity matching, and Cox proportional hazards modeling for univariable OS analysis. Results: Of 5828 patients, 332 (5.7%), 3234 (55.5%) and 2262 (38.8%) received neoadjuvant chemo-SBRT, chemotherapy, and chemo-CFRT, respectively. SBRT utilization increased from 0% in 2004 to 9.5% in 2015, with a greater APC after 2010 (p < .001). SBRT was more likely to be utilized in patients with T3-4 and node-positive disease (p < .05 for all). The chemo-SBRT cohort was associated with a higher OS rate before and after propensity matching (p < .05 for both). The rate of R0 resection was higher in radiotherapy groups than the chemotherapy cohort (p < .001). Conclusions: Utilization of neoadjuvant SBRT for pancreatic cancer is increasing. In the neoadjuvant setting, chemo-SBRT may improve R0 resection and OS over chemotherapy and chemo-CFRT, although confirmatory prospective studies are needed for confirmation.
Collapse
Affiliation(s)
- Wei Jiang
- Department of Radiation Oncology, Houston Methodist Hospital , Houston , TX , USA
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College , Shenzhen , Guangdong , China
| | - Waqar Haque
- Department of Radiation Oncology, Houston Methodist Hospital , Houston , TX , USA
| | - Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital , Pittsburgh , PA , USA
| | - E Brian Butler
- Department of Radiation Oncology, Houston Methodist Hospital , Houston , TX , USA
| | - Bin S Teh
- Department of Radiation Oncology, Houston Methodist Hospital , Houston , TX , USA
| |
Collapse
|
34
|
Passardi A, Scarpi E, Neri E, Parisi E, Ghigi G, Ercolani G, Gardini A, La Barba G, Pagan F, Casadei-Gardini A, Valgiusti M, Ferroni F, Frassineti GL, Romeo A. Chemoradiotherapy (Gemox Plus Helical Tomotherapy) for Unresectable Locally Advanced Pancreatic Cancer: A Phase II Study. Cancers (Basel) 2019; 11:cancers11050663. [PMID: 31086093 PMCID: PMC6562444 DOI: 10.3390/cancers11050663] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 05/09/2019] [Accepted: 05/10/2019] [Indexed: 01/05/2023] Open
Abstract
The aim of the study was to evaluate the safety and efficacy of a new chemo-radiotherapy regimen for patients with locally advanced pancreatic cancer (LAPC). Patients were treated as follows: gemcitabine 1000 mg/m2 on day 1, and oxaliplatin 100 mg/m2 on day 2, every two weeks (GEMOX regimen) for 4 cycles, 15 days off, hypofractionated radiotherapy (35 Gy in 7 fractions in 9 consecutive days), 15 days off, 4 additional cycles of GEMOX, restaging. From April 2011 to August 2016, a total of 42 patients with non resectable LAPC were enrolled. Median age was 67 years (range 41-75). Radiotherapy was well tolerated and the most frequently encountered adverse events were mild to moderate nausea and vomiting, abdominal pain and fatigue. In total, 9 patients underwent surgical laparotomy (5 radical pancreatic resection 1 thermoablation and 3 explorative laparotomy), 1 patient became operable but refused surgery. The overall resectability rate was 25%, while the R0 resection rate was 12.5%. At a median follow-up of 50 months, the median progression-free survival and overall survival were 9.3 (95% CI 6.2-14.9) and 15.8 (95% CI 8.2-23.4) months, respectively. The results demonstrate the feasibility of a new chemo-radiotherapy regimen as a potential treatment for unresectable LAPC.
Collapse
Affiliation(s)
- Alessandro Passardi
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Via P. Maroncelli n. 40, 47014 Meldola, Italy.
| | - Emanuela Scarpi
- Unit of Biostatistics and Clinical Trials, IRST-IRCCS, Via P. Maroncelli n. 40, 47014 Meldola, Italy.
| | - Elisa Neri
- Radiotherapy Unit, IRST-IRCCS, Via P. Maroncelli n. 40, 47014 Meldola, Italy.
| | - Elisabetta Parisi
- Radiotherapy Unit, IRST-IRCCS, Via P. Maroncelli n. 40, 47014 Meldola, Italy.
| | - Giulia Ghigi
- Radiotherapy Unit, IRST-IRCCS, Via P. Maroncelli n. 40, 47014 Meldola, Italy.
| | - Giorgio Ercolani
- General and Oncologic Surgery Unit, Morgagni-Pierantoni Hospital, AUSL Romagna, Via C. Forlanini n. 34, 47121 Forlì, Italy.
- Department of Medical and Surgical Sciences, University of Bologna, Via Massarenti n. 9, 40138 Bologna, Italy.
| | - Andrea Gardini
- General and Oncologic Surgery Unit, Morgagni-Pierantoni Hospital, AUSL Romagna, Via C. Forlanini n. 34, 47121 Forlì, Italy.
| | - Giuliano La Barba
- General and Oncologic Surgery Unit, Morgagni-Pierantoni Hospital, AUSL Romagna, Via C. Forlanini n. 34, 47121 Forlì, Italy.
| | - Flavia Pagan
- Unit of Biostatistics and Clinical Trials, IRST-IRCCS, Via P. Maroncelli n. 40, 47014 Meldola, Italy.
| | - Andrea Casadei-Gardini
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Via P. Maroncelli n. 40, 47014 Meldola, Italy.
| | - Martina Valgiusti
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Via P. Maroncelli n. 40, 47014 Meldola, Italy.
| | - Fabio Ferroni
- Radiology Unit, IRST IRCCS, Via P. Maroncelli n. 40, 47014 Meldola, Italy.
| | - Giovanni Luca Frassineti
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Via P. Maroncelli n. 40, 47014 Meldola, Italy.
| | - Antonino Romeo
- Radiotherapy Unit, IRST-IRCCS, Via P. Maroncelli n. 40, 47014 Meldola, Italy.
| |
Collapse
|
35
|
Boldrini L, Cusumano D, Cellini F, Azario L, Mattiucci GC, Valentini V. Online adaptive magnetic resonance guided radiotherapy for pancreatic cancer: state of the art, pearls and pitfalls. Radiat Oncol 2019; 14:71. [PMID: 31036034 PMCID: PMC6489212 DOI: 10.1186/s13014-019-1275-3] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 04/11/2019] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Different studies have proved in recent years that hypofractionated radiotherapy (RT) improves overall survival of patients affected by locally advanced, unresectable, pancreatic cancer. The clinical management of these patients generally leads to poor results and is considered very challenging, due to different factors, heavily influencing treatment delivery and its outcomes. Firstly, the dose prescribed to the target is limited by the toxicity that the highly radio-sensitive organs at risk (OARs) surrounding the disease can develop. Treatment delivery is also complicated by the significant inter-fractional and intra-fractional variability of therapy volumes, mainly related to the presence of hollow organs and to the breathing cycle. The recent introduction of magnetic resonance guided radiotherapy (MRgRT) systems leads to the opportunity to control most of the aforementioned sources of uncertainty influencing RT treatment workflow in pancreatic cancer. MRgRT offers the possibility to accurately identify radiotherapy volumes, thanks to the high soft-tissue contrast provided by the Magnetic Resonance imaging (MRI), and to monitor the tumour and OARs positions during the treatment fraction using a high-temporal cine MRI. However, the main advantage offered by the MRgRT is the possibility to online adapt the RT treatment plan, changing the dose distribution while the patient is still on couch and successfully addressing most of the sources of variability. SHORT CONCLUSION Aim of this study is to present and discuss the state of the art, the main pitfalls and the innovative opportunities offered by online adaptive MRgRT in pancreatic cancer treatment.
Collapse
Affiliation(s)
- Luca Boldrini
- Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, UOC Radioterapia Oncologica, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Roma, Italia
| | - Davide Cusumano
- Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, UOC Fisica Sanitaria, Fondazione Policlinico Policlinico Universitario “A. Gemelli” IRCCS, Roma, Italia
| | - Francesco Cellini
- Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, UOC Radioterapia Oncologica, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Roma, Italia
| | - Luigi Azario
- Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, UOC Fisica Sanitaria, Fondazione Policlinico Policlinico Universitario “A. Gemelli” IRCCS, Roma, Italia
| | - Gian Carlo Mattiucci
- Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, UOC Radioterapia Oncologica, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Roma, Italia
| | - Vincenzo Valentini
- Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, UOC Radioterapia Oncologica, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Roma, Italia
| |
Collapse
|
36
|
Kim L, Nguyen N, Singhal N, Phan V, Iankov I, Le H. Application of stereotactic body radiotherapy in advanced pancreatic cancers in Australia. J Med Radiat Sci 2019; 66:54-61. [PMID: 30411540 PMCID: PMC6399188 DOI: 10.1002/jmrs.313] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 10/04/2018] [Accepted: 10/11/2018] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION The majority of pancreatic cancers present locally advanced and carry a high mortality rate. Treatment is challenging, with mixed data suggesting use of chemotherapy alone or in combination with radiotherapy. The use of radiotherapy has previously been limited due to lack of ability to deliver radiation to the tumour mass without causing significant toxicity to surrounding organs. Stereotactic body radiotherapy (SBRT) allows delivery of higher biologically equivalent dose in a shorter treatment duration. We sought to investigate the safety and application of this technique in our centre. METHOD We enrolled 27 patients from 2015, identified as locally advanced unresectable with histologically confirmed, non-metastatic, pancreatic adenocarcinoma. All patients had endoscopically inserted fiducial markers and where possible concurrent chemotherapy was administered. Dose schedules ranged from 25 to 42 Gy in 5 or 3 fractions. RESULTS With an overall median follow up of 9 months (range, 3-32.7), the median survival was 11.6 months. Of those alive at 1 year, the local control rate was 67%. Six patients had Grade 3 toxicity, and other six had Grade 2 toxicity. None had Grade 4 or above toxicity. The most common symptom recorded was fatigue. CONCLUSION SBRT for locally advanced pancreatic cancer is technically complex but feasible in a high volume centre. SBRT is unique, allowing safe delivery of high radiation dose resulting in good local control and decreases treatment time making it an attractive option for patients with unresectable pancreatic cancer.
Collapse
Affiliation(s)
- Laurence Kim
- Department of Radiation OncologyRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Nam Nguyen
- Department of GastroenterologyRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Nimit Singhal
- Department of Medical OncologyRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
- School of MedicineUniversity of AdelaideAdelaideSouth AustraliaAustralia
| | - Vinh‐An Phan
- Department of GastroenterologyRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Ivan Iankov
- Department of Radiation OncologyRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Hien Le
- Department of Radiation OncologyRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| |
Collapse
|
37
|
Lischalk JW, Burke A, Chew J, Elledge C, Gurka M, Marshall J, Pishvaian M, Collins S, Unger K. Five-Fraction Stereotactic Body Radiation Therapy (SBRT) and Chemotherapy for the Local Management of Metastatic Pancreatic Cancer. J Gastrointest Cancer 2018; 49:116-123. [PMID: 28044263 DOI: 10.1007/s12029-016-9909-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The majority of patients with pancreatic cancer are diagnosed with metastatic disease at presentation. Nevertheless, local progression is responsible for up to 30% of deaths and can lead to significant morbidity. As a consequence, further exploration of effective methods of local control and palliation is essential. Stereotactic body radiation therapy (SBRT) is a widely utilized technique for the treatment of localized pancreatic cancer. Here, we report our experience with SBRT and chemotherapy for the local treatment of the metastatic patient population. METHODS This single institution retrospective review analyzed 20 patients with pathologically diagnosed metastatic adenocarcinoma of the pancreas. All patients underwent fiducial placement under endoscopic ultrasound (EUS) guidance. SBRT was delivered in five fractions to a total dose of 25 to 30 Gy. Patients received concurrent (given within 1 week of the start of SBRT) or sequential chemotherapy. Local tumor control was evaluated using Response Evaluation Criteria in Solid Tumors. Toxicity was graded using Common Terminology Criteria for Adverse Events version 4.03. Local control and overall survival were reported using the Kaplan-Meier method. RESULTS Patient median age was 64 years, and the median pre-treatment Eastern Cooperative Oncology Group performance status was 1. All patients received chemotherapy and half of the patients (10 of 20) received concurrent chemotherapy with folinic acid, fluorouracil, and oxaliplatin or fluorouracil, leucovorin, irinotecan, and oxaliplatin. Nearly all patients (19 of 20) received post-SBRT chemotherapy. Median time from pathological diagnosis to SBRT was 3.9 months. The twelve-month local control and overall survival were 43 and 53%, respectively. However, in patients with planning target volume (PTV) targets smaller than the population median, the 12-month local control was 78%. Median time to local progression (17.8 vs. 3.0 months, p = 0.02) and overall survival (24.9 vs. 8.8, p = 0.001) were also significantly improved in this smaller PTV cohort. Though not statistically significant, there was a trend towards improvement in local control (17.8 vs. 4.3 months, p = 0.17) and overall survival (16.7 vs. 9.7 months, p = 0.087) for those who received concurrent versus sequential chemotherapy, respectively. Lastly, there were no reported grade 3-5 late toxicities. CONCLUSIONS As systemic therapies improve, the local management of pancreatic cancer will become increasingly important. Here, we report significantly improved local control with SBRT of smaller PTV tumors with concurrent chemotherapy. Five-fraction SBRT offers a quick and effective modality of local tumor control with minimal toxicity in the metastatic pancreatic cancer population.
Collapse
Affiliation(s)
- Jonathan W Lischalk
- Department of Radiation Medicine, Georgetown University Hospital, Lower Level Bles, 3800 Reservoir Road, NW, Washington, DC, 20007, USA.
| | - Aidan Burke
- Department of Radiation Medicine, Georgetown University Hospital, Lower Level Bles, 3800 Reservoir Road, NW, Washington, DC, 20007, USA
| | - Jessica Chew
- Georgetown University School of Medicine, Medical Dental Building, 3900 Reservoir Road, NW, Washington, DC, 20057, USA
| | - Christen Elledge
- Georgetown University School of Medicine, Medical Dental Building, 3900 Reservoir Road, NW, Washington, DC, 20057, USA
| | - Marie Gurka
- Department of Radiation Oncology, James Graham Brown Cancer, University of Louisville Hospital, 529 S. Jackson Street, Louisville, KY, 40202, USA
| | - John Marshall
- Lombardi Cancer Center Medical Oncology, Department of Medicine, Georgetown University Hospital, Pasquerilla Healthcare Center, 5th Floor, 3800 Reservoir Road, NW, Washington, DC, 20007, USA
| | - Michael Pishvaian
- Lombardi Cancer Center Medical Oncology, Department of Medicine, Georgetown University Hospital, Pasquerilla Healthcare Center, 5th Floor, 3800 Reservoir Road, NW, Washington, DC, 20007, USA
| | - Sean Collins
- Department of Radiation Medicine, Georgetown University Hospital, Lower Level Bles, 3800 Reservoir Road, NW, Washington, DC, 20007, USA
| | - Keith Unger
- Department of Radiation Medicine, Georgetown University Hospital, Lower Level Bles, 3800 Reservoir Road, NW, Washington, DC, 20007, USA
| |
Collapse
|
38
|
Ng SP, Koay EJ. Current and emerging radiotherapy strategies for pancreatic adenocarcinoma: stereotactic, intensity modulated and particle radiotherapy. ACTA ACUST UNITED AC 2018; 1. [PMID: 30198024 DOI: 10.21037/apc.2018.07.03] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The role of radiotherapy for locally advanced pancreatic cancer (LAPC) is unclear based on studies that used conventional doses and fractionation schedules. Modern radiotherapy techniques have not been studied in depth, however. We reviewed the literature on emerging methods of delivering higher doses of conformal radiotherapy using stereotactic body radiation, intensity modulated radiation, and particle beam radiation, highlighting clinical outcomes and toxicities. The literature review suggests low rates of acute and late toxicities when higher doses of radiation are given with careful attention to normal tissue dose constraints, including for stereotactic body radiotherapy (SBRT), escalated doses with intensity modulated radiation therapy (IMRT), and particle-based therapy. Retrospective evidence suggests prolonged survival for patients who receive biological equivalent doses above 70 Gy. Prospective trials that evaluate modern radiotherapy techniques are warranted for LAPC.
Collapse
Affiliation(s)
- Sweet Ping Ng
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eugene J Koay
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| |
Collapse
|
39
|
Chapman BC, Gleisner A, Rigg D, Meguid C, Goodman K, Brauer B, Gajdos C, Schulick RD, Edil BH, McCarter MD. Perioperative outcomes and survival following neoadjuvant stereotactic body radiation therapy (SBRT) versus intensity-modulated radiation therapy (IMRT) in pancreatic adenocarcinoma. J Surg Oncol 2018; 117:1073-1083. [PMID: 29448308 DOI: 10.1002/jso.25004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 01/09/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND OBJECTIVES To compare outcomes in patients receiving neoadjuvant stereotactic body radiation therapy (SBRT) with those receiving intensity-modulated radiation therapy (IMRT) for pancreatic adenocarcinoma. METHODS We analyzed patients receiving neoadjuvant SBRT for borderline resectable (BRPC) and locally advanced pancreatic cancer (LAPC) (2012-2016). Differences in baseline characteristics, perioperative outcomes, progression-free survival (PFS), and overall survival (OS) were compared. RESULTS Seventy-five (82.4%) patients received SBRT and 16 (17.6%) received IMRT. There were no differences in surgical resection rates in the SBRT (n = 38, 50.7%) and IMRT (n = 11, 68.8%) groups (P = 0.188). Among resected patients, there was no difference in postoperative outcomes or pathologic outcomes including lymph node status, margin status, lymphovascular and perineural invasion, or pathologic response to neoadjuvant treatment (P > 0.05). Among all patients, median PFS and OS were 9.9 and 23.5 months in the SBRT group, respectively, and 15.3 and 21.8 months in the IMRT group, respectively (P > 0.05). Similarly, there was no difference in PFS or OS between groups when stratified by BRPC, LAPC, and surgically resected patients (P > 0.05). CONCLUSIONS In the neoadjuvant setting, SBRT and IMRT appear to have similar rates of resection, perioperative outcomes, and survival outcomes, but additional studies with increased sample size and longer follow up are needed.
Collapse
Affiliation(s)
- Brandon C Chapman
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Ana Gleisner
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Devin Rigg
- University of Colorado School of Medicine, Aurora, CO
| | - Cheryl Meguid
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Karyn Goodman
- Division of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO
| | - Brian Brauer
- Division of Gasteroenterology, University of Colorado School of Medicine, Aurora, CO
| | - Csaba Gajdos
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Richard D Schulick
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Barish H Edil
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Martin D McCarter
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| |
Collapse
|
40
|
Ng SP, Herman JM. Stereotactic Radiotherapy and Particle Therapy for Pancreatic Cancer. Cancers (Basel) 2018; 10:cancers10030075. [PMID: 29547526 PMCID: PMC5876650 DOI: 10.3390/cancers10030075] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 03/10/2018] [Accepted: 03/14/2018] [Indexed: 01/19/2023] Open
Abstract
Pancreatic cancer is a devastating disease with poor survival outcomes. Recent studies have shown that the addition of radiotherapy to chemotherapy in the setting of locally advanced pancreatic cancer did not improve overall survival outcome. These studies commonly utilize conventional radiotherapy treatment fractionation and technique (typically 3-D conformal radiotherapy or intensity modulated radiotherapy). Although no clear benefit in overall survival was demonstrated in those studies, those who received radiotherapy did have a clear benefit in terms of local control. Therefore, there is increasing interest in exploring different techniques and/or modality of radiotherapy and dose/fractionation. Stereotactic radiotherapy, which employs a hypofractionated regimen, has the potential advantage of delivering a high dose of radiation to the tumor in a short period of time (typically over 5 days) with minimal dose to the surrounding normal structures. Particle therapy such as proton and carbon ion therapy are being explored as potential radiation modality that could cause greater biological damage to the tumor compared to photon treatment, with rapid dose falloff resulting in minimal to no dose to adjacent structures. This review will discuss the current literature and emerging roles of stereotactic radiotherapy and particle therapy in pancreatic cancer.
Collapse
Affiliation(s)
- Sweet Ping Ng
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA.
| | - Joseph M Herman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA.
| |
Collapse
|
41
|
Demonstration of Safety and Feasibility of Hydrogel Marking of the Pancreas-Duodenum Interface for Image Guided Radiation Therapy (IGRT) in a Porcine Model: Implications in IGRT for Pancreatic Cancer Patients. Int J Radiat Oncol Biol Phys 2018; 101:640-645. [PMID: 29680252 PMCID: PMC6064682 DOI: 10.1016/j.ijrobp.2018.02.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 02/02/2018] [Accepted: 02/12/2018] [Indexed: 12/03/2022]
Abstract
Purpose: To test the feasibility and safety of injecting a high-contrast hydrogel marker at the head of the pancreas (HOP) and duodenum interface and assesses the marker visibility on cone beam computed tomography (CBCT) to localize this important boundary during image guided radiation therapy in a porcine model. Methods and Materials: This was a 2-stage study. The feasibility/visibility stage evaluated the ability to place the hydrogel using endoscopic ultrasound guidance on 8 swine (4 euthanized at post-injection day 8, 4 euthanized at post-injection day 22) and assessed the quality of visibility of the marked location on CBCT in the longer-surviving group. The risk assessment stage evaluated the toxicity of targeted intrapancreatic injections (3 swine) and intramural duodenal wall injections (3 swine) to assess toxicity of a misplaced hydrogel injection. All swine underwent postmortem examination and histopathologic studies. Results: The HOP—duodenum interface was successfully marked using hydrogel in 6 of the 8 swine. Histopathologic examination of the 6 successful hydrogel injections showed mild/minimal (4 cases) or moderate (2 cases) reactive inflammation isolated to the injection site. Of the 4 swine survived to 22 days, 3 demonstrated successful hydrogel placement at the HOP—duodenum interface, and this marked location was clearly visible for positional guidance on CBCT. There was no evidence of pancreatitis or duodenal toxicity in the swine undergoing targeted intrapancreatic or intramural duodenum injections for the risk assessment stage. Conclusions We demonstrate the feasibility and safety of injecting a hydrogel marker to highlight the HOP—duodenum interface that has acceptable visibility on CBCT. This technique, translated to humans, enables on-board visualization of this important boundary between the radiation target and dose-limiting, radiosensitive duodenum, facilitating efforts to safely deliver dose-escalated radiation therapy. © 2018 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). This study presents the feasibility and safety of marking the pancreas and duodenum interface with a high-contrast hydrogel and demonstrates acceptable visibility of the marked location on cone beam computed tomography using a porcine model. Translation of this technique to the radiation therapy treatment of pancreatic cancer patients would enable on-board visualization of this important boundary between the radiation target and the dose- limiting duodenum, facilitating future efforts toward safe dose escalation.
Collapse
|
42
|
de Geus SWL, Eskander MF, Kasumova GG, Ng SC, Kent TS, Mancias JD, Callery MP, Mahadevan A, Tseng JF. Stereotactic body radiotherapy for unresected pancreatic cancer: A nationwide review. Cancer 2017; 123:4158-4167. [PMID: 28708929 DOI: 10.1002/cncr.30856] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 05/02/2017] [Accepted: 05/30/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND The role of conventional radiotherapy in the management of pancreatic cancer has yet to be elucidated. Over the past decade, stereotactic body radiotherapy (SBRT) has emerged as a novel therapeutic option in pancreatic cancer care. This study evaluated the survival impact of SBRT on patients with unresected pancreatic cancer. METHODS The National Cancer Data Base was queried for unresected patients who received chemotherapy for nonmetastatic pancreatic adenocarcinoma between 2004 and 2012. Four treatment groups were identified: chemotherapy alone, chemotherapy combined with external-beam radiotherapy (EBRT), chemotherapy combined with intensity-modulated radiotherapy (IMRT), and chemotherapy combined with SBRT. Propensity score models predicting the odds of receiving SBRT were created to control for potential selection bias, and patients were matched by propensity scores. The survival analysis was performed with the Kaplan-Meier method. RESULTS A total of 14,331 patients met the inclusion criteria. Chemotherapy alone was delivered to 5464 patients (38.1%); 6418 (44.8%), 322 (2.3%), and 2127 (14.8%) received chemotherapy along with EBRT, IMRT, and SBRT, respectively. The unadjusted median survival before matching was 9.9, 10.9, 12.0, and 13.9 months for patients treated with chemotherapy, EBRT, IMRT, and SBRT, respectively. In separate matched analyses, SBRT remained superior to chemotherapy alone (log-rank P < .0001) and EBRT (log-rank P = .0180). After matching, survival did not differ between patients receiving IMRT and patients receiving SBRT (log-rank P = .0492). CONCLUSIONS SBRT is associated with a significantly better outcome than chemotherapy alone or in conjunction with traditional EBRT. These results support the idea that SBRT is a promising treatment approach for patients with unresected pancreatic cancer. Cancer 2017;123:4158-4167. © 2017 American Cancer Society.
Collapse
Affiliation(s)
- Susanna W L de Geus
- Surgical Outcomes Analysis and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Mariam F Eskander
- Surgical Outcomes Analysis and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Gyulnara G Kasumova
- Surgical Outcomes Analysis and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Sing Chau Ng
- Surgical Outcomes Analysis and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Tara S Kent
- Surgical Outcomes Analysis and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Joseph D Mancias
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts
| | - Mark P Callery
- Surgical Outcomes Analysis and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Anand Mahadevan
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jennifer F Tseng
- Surgical Outcomes Analysis and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
43
|
Zhong J, Patel K, Switchenko J, Cassidy RJ, Hall WA, Gillespie T, Patel PR, Kooby D, Landry J. Outcomes for patients with locally advanced pancreatic adenocarcinoma treated with stereotactic body radiation therapy versus conventionally fractionated radiation. Cancer 2017; 123:3486-3493. [PMID: 28493288 DOI: 10.1002/cncr.30706] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 02/17/2017] [Accepted: 03/09/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND As systemic therapy has improved for locally advanced pancreatic cancer (LAPC), efforts to improve local control with optimal radiotherapy may be critical. Although conventionally fractionated radiation therapy (CFRT) has more recently shown a limited role in LAPC, stereotactic body radiation therapy (SBRT) is an emerging approach with promising results. With no studies to date comparing SBRT with CFRT for LAPC, this study used the National Cancer Data Base (NCDB) to evaluate these 2 modalities. METHODS With the NCDB, patients with American Joint Committee on Cancer cT2-4/N0-1/M0 adenocarcinoma of the pancreas diagnosed from 2004 to 2013 were analyzed. Radiation therapy delivered at ≤2 Gy was deemed CFRT, and radiation therapy delivered at ≥4 Gy per fraction was considered SBRT. Kaplan-Meier analysis, log-rank testing, and multivariate Cox proportional hazards regression were performed with overall survival (OS) as the primary outcome. Propensity score matching was used. RESULTS Among 8450 patients, 7819 (92.5%) were treated with CFRT, and 631 (7.5%) underwent SBRT. Receipt of SBRT was associated with superior OS in the multivariate analysis (hazard ratio, 0.84; 95% confidence interval, 0.75-0.93; P < .001). With propensity score matching, 988 patients in all were matched, with 494 patients in each cohort. Within the propensity-matched cohorts, the median OS (13.9 vs 11.6 months) and the 2-year OS rate (21.7% vs 16.5%) were significantly higher with SBRT versus CFRT (P = .0014). CONCLUSIONS In this retrospective review using a large national database, SBRT was associated with superior OS in comparison with CFRT for LAPC, and these findings remained significant in a propensity-matched analysis. Further prospective studies investigating these hypothesis-generating results are warranted. Cancer 2017;123:3486-93. © 2017 American Cancer Society.
Collapse
Affiliation(s)
- Jim Zhong
- Department of Radiation Oncology, Emory University, Atlanta, Georgia.,Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Kirtesh Patel
- Department of Radiation Oncology, Emory University, Atlanta, Georgia.,Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Jeffrey Switchenko
- Winship Cancer Institute, Emory University, Atlanta, Georgia.,Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia
| | - Richard J Cassidy
- Department of Radiation Oncology, Emory University, Atlanta, Georgia.,Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - William A Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Theresa Gillespie
- Winship Cancer Institute, Emory University, Atlanta, Georgia.,Department of Surgery, Emory University, Atlanta, Georgia
| | - Pretesh R Patel
- Department of Radiation Oncology, Emory University, Atlanta, Georgia.,Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - David Kooby
- Winship Cancer Institute, Emory University, Atlanta, Georgia.,Department of Surgery, Emory University, Atlanta, Georgia
| | - Jerome Landry
- Department of Radiation Oncology, Emory University, Atlanta, Georgia.,Winship Cancer Institute, Emory University, Atlanta, Georgia
| |
Collapse
|
44
|
Abstract
Hepatobiliary malignancies represent a heterogeneous group of diseases, which often arise in a background of underlying hepatic dysfunction complicating their local management. Surgical resection continues to be the standard of care for hepatocellular carcinoma (HCC) and cholangiocarcinoma (CC); unfortunately the majority of patients are inoperable at presentation. The aggressiveness of these lesions makes locoregional control of particular importance. Historical experience with less sophisticated radiotherapy resulted in underwhelming efficacy and oftentimes prohibitive liver toxicity. However, with the advent of extremely conformal and precise radiotherapy delivery, dose escalation to the tumor with sparing of surrounding normal tissue has yielded notable improvements in efficacy for this modality of treatment. Dose escalation has come in a variety of forms most notably as stereotactic body radiation therapy (SBRT) and hypofractionated proton therapy. As radiation techniques continue to improve, their proper incorporation into the local management of hepatobiliary malignancies will be paramount in improving the prognosis of what is a grave diagnosis.
Collapse
Affiliation(s)
- Jonathan W Lischalk
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, USA
| | - Michael C Repka
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, USA
| | - Keith Unger
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, USA
| |
Collapse
|
45
|
Petrelli F, Comito T, Ghidini A, Torri V, Scorsetti M, Barni S. Stereotactic Body Radiation Therapy for Locally Advanced Pancreatic Cancer: A Systematic Review and Pooled Analysis of 19 Trials. Int J Radiat Oncol Biol Phys 2017; 97:313-322. [PMID: 28068239 DOI: 10.1016/j.ijrobp.2016.10.030] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Revised: 10/08/2016] [Accepted: 10/17/2016] [Indexed: 02/07/2023]
Abstract
PURPOSE Although surgery is the standard of care for resectable pancreatic cancer (PC), standard-dose chemoradiation therapy and chemotherapy alone are suitable for patients with unresectable disease. Stereotactic body radiation therapy (SBRT) is an alternative, focused local therapy that delivers high radiation doses within a few fractions to the cancer, sparing the surrounding critical tissue. We performed a systematic review and pooled analysis of published trials to evaluate the efficacy and safety of this emerging treatment modality. METHODS AND MATERIALS We searched the Cochrane Central Register of Controlled Trials, PubMed, EMBASE, SCOPUS, the Web of Science, and CINAHL for publications regarding SBRT for locally advanced PC. The 1-year overall survival (OS) rate was the primary endpoint, and the median OS, 2-year OS rate, 1-year locoregional control (LRC) rate, and grade 3 to 4 toxicities were the secondary endpoints. A multivariate random-effects meta-analysis was performed to calculate the aggregated OS rates at 1 and 2 years and the 1-year LRC rate. RESULTS A total of 19 studies, encompassing 1009 patients, were included in the present analysis. The pooled 1-year OS was 51.6% in 13 trials with data available. The median OS ranged from 5.7 to 47 months (median 17). The LRC rate at 1 year was 72.3%. Overall, the occurrence of severe adverse events did not exceed 10%. LRC appeared to correlate with the total SBRT dose and the number of fractions. CONCLUSIONS The advantages of SBRT in terms of treatment time, satisfactory OS, and LRC indicate that it is an effective option for inoperable PC. However, a definitive validation of this treatment modality in large randomized studies is required, owing to the nonrandomized nature of the included studies and the limitations of small single-center series that include mixed populations.
Collapse
Affiliation(s)
- Fausto Petrelli
- Oncology Unit, Department of Oncology, ASST Bergamo Ovest, Treviglio, Italy.
| | - Tiziana Comito
- Department of Radiosurgery and Radiotherapy, Istituto Clinico Humanitas Cancer Center and Research Hospital, Milan, Italy
| | | | - Valter Torri
- Department of Biomedical Sciences, Humanitas University and Radiotherapy and Radiosurgery Department-Humanitas Research Hospital, Milan, Italy
| | - Marta Scorsetti
- Department of Radiosurgery and Radiotherapy, Istituto Clinico Humanitas Cancer Center and Research Hospital, Milan, Italy
| | - Sandro Barni
- Oncology Unit, Department of Oncology, ASST Bergamo Ovest, Treviglio, Italy
| |
Collapse
|
46
|
Stereotactic body radiotherapy (SBRT) in recurrent or oligometastatic pancreatic cancer : A toxicity review of simultaneous integrated protection (SIP) versus conventional SBRT. Strahlenther Onkol 2017; 193:433-443. [PMID: 28138949 DOI: 10.1007/s00066-017-1099-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 01/06/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Stereotactic body radiotherapy (SBRT) in pancreatic cancer can be limited by its proximity to organs at risk (OAR). In this analysis, we evaluated the toxicity and efficacy of two different treatment approaches in patients with locally recurrent or oligometastatic pancreatic cancer. MATERIALS AND METHODS According to the prescription method, patients were divided in two cohorts (C1 and C2). The planning target volume (PTV) was created through a 4 mm expansion of the internal target volume. In C2, a subvolume was additionally created, a simultaneous integrated protection (SIP), which is the overlap of the PTV with the planning risk volume of an OAR to which we prescribed a reduced dose. RESULTS In all, 18 patients were treated (7 with local recurrences, 9 for oligometastases, 2 for both). Twelve of 23 lesions were treated without SIP (C1) and 11 with SIP (C2). The median follow-up was 12.8 months. Median overall survival (OS) was 13.2 (95% confidence interval [CI] 9.8-14.6) months. The OS rates at 6 and 12 months were 87 and 58%, respectively. Freedom from local progression for combined cohorts at 6 and 12 months was 93 and 67% (95% CI 15-36), respectively. Local control was not statistically different between the two groups. One patient in C2 experienced grade ≥3 acute toxicities and 1 patient in C1 experienced a grade ≥3 late toxicity. CONCLUSION The SIP approach is a useful prescription method for abdominal SBRT with a favorable toxicity profile which does not compromise local control and overall survival despite dose sacrifices in small subvolumes.
Collapse
|
47
|
Holyoake DLP, Ward E, Grose D, McIntosh D, Sebag-Montefiore D, Radhakrishna G, Patel N, Silva M, Mukherjee S, Strauss VY, Odondi L, Fokas E, Melcher A, Hawkins MA. A phase-I trial of pre-operative, margin intensive, stereotactic body radiation therapy for pancreatic cancer: the 'SPARC' trial protocol. BMC Cancer 2016; 16:728. [PMID: 27619800 PMCID: PMC5020462 DOI: 10.1186/s12885-016-2765-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 08/17/2016] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Standard therapy for borderline-resectable pancreatic cancer in the UK is surgery with adjuvant chemotherapy, but rates of resection with clear margins are unsatisfactory and overall survival remains poor. Meta-analysis of single-arm studies shows the potential of neo-adjuvant chemo-radiotherapy but the relative radio-resistance of pancreatic cancer means the efficacy of conventional dose schedules is limited. Stereotactic radiotherapy achieves sufficient accuracy and precision to enable pre-operative margin-intensive dose escalation with the goal of increasing rates of clear resection margins and local disease control. METHODS/DESIGN SPARC is a "rolling-six" design single-arm study to establish the maximum tolerated dose for margin-intensive stereotactic radiotherapy before resection of pancreatic cancer at high risk of positive resection margins. Eligible patients will have histologically or cytologically proven pancreatic cancer defined as borderline-resectable per National Comprehensive Cancer Network criteria or operable tumour in contact with vessels increasing the risk of positive margin. Up to 24 patients will be recruited from up to 5 treating centres and a 'rolling-six' design is utilised to minimise delays and facilitate ongoing recruitment during dose-escalation. Radiotherapy will be delivered in 5 daily fractions and surgery, if appropriate, will take place 5-6 weeks after radiotherapy. The margin-intense radiotherapy concept includes a systematic method to define the target volume for a simultaneous integrated boost in the region of tumour-vessel infiltration, and up to 4 radiotherapy dose levels will be investigated. Maximum tolerated dose is defined as the highest dose at which no more than 1 of 6 patients or 0 of 3 patients experience a dose limiting toxicity. Secondary endpoints include resection rate, resection margin status, response rate, overall survival and progression free survival at 12 and 24 months. Translational work will involve exploratory analyses of the cytological and humoral immunological responses to stereotactic radiotherapy in pancreatic cancer. Radiotherapy quality assurance of target definition and radiotherapy planning is enforced with pre-trial test cases and on-trial review. Recruitment began in April 2015. DISCUSSION This prospective multi-centre study aims to establish the maximum tolerated dose of pre-operative margin-intensified stereotactic radiotherapy in pancreatic cancer at high risk of positive resection margins with a view to subsequent definitive comparison with other neoadjuvant treatment options. TRIAL REGISTRATION ISRCTN14138956 . Funded by CRUK.
Collapse
Affiliation(s)
- Daniel L. P. Holyoake
- CRUK/MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Old Road Campus Research Building, Roosevelt Drive, Oxford, OX3 7DQ UK
| | - Elizabeth Ward
- Oncology Clinical Trials Office, Department of Oncology, University of Oxford, Old Road Campus Research Building, Roosevelt Drive, Oxford, OX3 7DQ UK
| | - Derek Grose
- The Beatson West of Scotland Cancer Centre, 1053 Great Western Rd, Glasgow, G12 0YN UK
| | - David McIntosh
- The Beatson West of Scotland Cancer Centre, 1053 Great Western Rd, Glasgow, G12 0YN UK
| | - David Sebag-Montefiore
- The University of Leeds, Cancer Research UK Leeds Centre,14 Leeds Institute of Cancer and Pathology, Cancer Genetics Building, St James’s University Hospital, 15 Beckett Street, Leeds, West Yorkshire LS9 7TF UK
- Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Bexley Wing, Beckett Street, Leeds, LS9 7TF UK
| | - Ganesh Radhakrishna
- Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Bexley Wing, Beckett Street, Leeds, LS9 7TF UK
| | - Neel Patel
- Oxford University Hospitals NHS Foundation Trust, Old Road, Headington, Oxford, OX3 7LE UK
| | - Michael Silva
- Oxford University Hospitals NHS Foundation Trust, Old Road, Headington, Oxford, OX3 7LE UK
| | - Somnath Mukherjee
- CRUK/MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Old Road Campus Research Building, Roosevelt Drive, Oxford, OX3 7DQ UK
- Oxford University Hospitals NHS Foundation Trust, Old Road, Headington, Oxford, OX3 7LE UK
| | - Victoria Y. Strauss
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD UK
| | - Lang’o Odondi
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD UK
| | - Emmanouil Fokas
- CRUK/MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Old Road Campus Research Building, Roosevelt Drive, Oxford, OX3 7DQ UK
| | - Alan Melcher
- The Institute of Cancer Research, Chester Beatty Laboratories, 237, Fulham Rd, London, SW3 6JB UK
| | - Maria A. Hawkins
- CRUK/MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Old Road Campus Research Building, Roosevelt Drive, Oxford, OX3 7DQ UK
| |
Collapse
|
48
|
Stereotactic body radiation for pancreatic cancer: results of an international survey of practice patterns. ACTA ACUST UNITED AC 2016. [DOI: 10.1007/s13566-016-0267-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
|
49
|
Eskander MF, Bliss LA, Tseng JF. Pancreatic adenocarcinoma. Curr Probl Surg 2016; 53:107-54. [DOI: 10.1067/j.cpsurg.2016.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 01/04/2016] [Indexed: 12/17/2022]
|
50
|
Zaheer A, Wadhwa V, Oh J, Fishman EK. Pearls and pitfalls of imaging metastatic disease from pancreatic adenocarcinoma: a systematic review. Clin Imaging 2015; 39:750-8. [PMID: 25981735 DOI: 10.1016/j.clinimag.2015.04.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 04/21/2015] [Accepted: 04/29/2015] [Indexed: 12/12/2022]
Abstract
Pancreatic adenocarcinoma is a systemic disease due to the presence of metastatic disease at the time of diagnosis and local recurrence as well as distant metastatic disease after treatment in a majority of patients. Recognition of these metastatic sites may help in accurate staging and assessment of therapeutic response. The authors discuss and illustrate imaging findings of metastatic disease from pancreatic adenocarcinoma in different organ systems with emphasis on entities that can mimic metastatic pancreatic cancer.
Collapse
Affiliation(s)
- Atif Zaheer
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, Baltimore, MD 21231; Pancreatitis Center, Johns Hopkins Medical Institutions, Baltimore, MD 21231.
| | - Vibhor Wadhwa
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, Baltimore, MD 21231
| | - Joseph Oh
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, Baltimore, MD 21231
| | - Elliot K Fishman
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, Baltimore, MD 21231
| |
Collapse
|