1
|
Siddiq S, Murray V, Tyagi N, Borman P, Gui C, Crane C, Wu C, Otazo R. MR signature matching (MRSIGMA) implementation for true real-time free-breathing volumetric imaging with sub-200 ms latency on an MR-Linac. Magn Reson Med 2024; 92:1162-1176. [PMID: 38576131 PMCID: PMC11209806 DOI: 10.1002/mrm.30097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 02/20/2024] [Accepted: 03/14/2024] [Indexed: 04/06/2024]
Abstract
PURPOSE Develop a true real-time implementation of MR signature matching (MRSIGMA) for free-breathing 3D MRI with sub-200 ms latency on the Elekta Unity 1.5T MR-Linac. METHODS MRSIGMA was implemented on an external computer with a network connection to the MR-Linac. Stack-of-stars with partial kz sampling was used to accelerate data acquisition and ReconSocket was employed for simultaneous data transmission. Movienet network computed the 4D MRI motion dictionary and correlation analysis was used for signature matching. A programmable 4D MRI phantom was utilized to evaluate MRSIGMA with respect to a ground-truth translational motion reference. In vivo validation was performed on patients with pancreatic cancer, where 15 patients were employed to train Movienet and 7 patients to test the real-time implementation of MRSIGMA. Dice coefficients between real-time MRSIGMA and a retrospectively computed 4D reference were used to evaluate motion tracking performance. RESULTS Motion dictionary was computed in under 5 s. Signature acquisition and matching presented 173 ms latency on the phantom and 193 ms on patients. MRSIGMA presented a mean error of 1.3-1.6 mm for all phantom experiments, which was below the 2 mm acquisition resolution along the motion direction. The Dice coefficient over time between MRSIGMA and reference contours was 0.88 ± 0.02 (GTV), 0.87 ± 0.02(duodenum-stomach), and 0.78 ± 0.02(small bowel), demonstrating high motion tracking performance for both tumor and organs at risk. CONCLUSION The real-time implementation of MRSIGMA enabled true real-time free-breathing 3D MRI with sub-200 ms imaging latency on a clinical MR-Linac system, which can be used for treatment monitoring, adaptive radiotherapy and dose accumulation mapping in tumors affected by respiratory motion.
Collapse
Affiliation(s)
- Saad Siddiq
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Victor Murray
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Neelam Tyagi
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Pim Borman
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Chengcheng Gui
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Christopher Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Can Wu
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ricardo Otazo
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| |
Collapse
|
2
|
Dee EC, Ng VC, O’Reilly EM, Wei AC, Lobaugh SM, Varghese AM, Zinovoy M, Romesser PB, Wu AJ, Hajj C, Cuaron JJ, Khalil DN, Park W, Yu KH, Zhang Z, Drebin JA, Jarnagin WR, Crane CH, Reyngold M. Salvage Ablative Radiotherapy for Isolated Local Recurrence of Pancreatic Adenocarcinoma following Definitive Surgery. J Clin Med 2024; 13:2631. [PMID: 38731159 PMCID: PMC11084663 DOI: 10.3390/jcm13092631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/22/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024] Open
Abstract
Introduction: The rate of isolated locoregional recurrence after surgery for pancreatic adenocarcinoma (PDAC) approaches 25%. Ablative radiation therapy (A-RT) has improved outcomes for locally advanced disease in the primary setting. We sought to evaluate the outcomes of salvage A-RT for isolated locoregional recurrence and examine the relationship between subsequent patterns of failure, radiation dose, and treatment volume. Methods: We conducted a retrospective analysis of all consecutive participants who underwent A-RT for an isolated locoregional recurrence of PDAC after prior surgery at our institution between 2016 and 2021. Treatment consisted of ablative dose (BED10 98-100 Gy) to the gross disease with an additional prophylactic low dose (BED10 < 50 Gy), with the elective volume covering a 1.5 cm isotropic expansion around the gross disease and the circumference of the involved vessels. Local and locoregional failure (LF and LRF, respectively) estimated by the cumulative incidence function with competing risks, distant metastasis-free and overall survival (DMFS and OS, respectively) estimated by the Kaplan-Meier method, and toxicities scored by CTCAE v5.0 are reported. Location of recurrence was mapped to the dose region on the initial radiation plan. Results: Among 65 participants (of whom two had two A-RT courses), the median age was 67 (range 37-87) years, 36 (55%) were male, and 53 (82%) had undergone pancreaticoduodenectomy with a median disease-free interval to locoregional recurrence of 16 (range, 6-71) months. Twenty-seven participants (42%) received chemotherapy prior to A-RT. With a median follow-up of 35 months (95%CI, 26-56 months) from diagnosis of recurrence, 24-month OS and DMFS were 57% (95%CI, 46-72%) and 22% (95%CI, 14-37%), respectively, while 24-month cumulative incidence of in-field LF and total LRF were 28% (95%CI, 17-40%) and 36% (95%CI 24-48%), respectively. First failure after A-RT was distant in 35 patients (53.8%), locoregional in 12 patients (18.5%), and synchronous distant and locoregional in 10 patients (15.4%). Most locoregional failures occurred in elective low-dose volumes. Acute and chronic grade 3-4 toxicities were noted in 1 (1.5%) and 5 patients (7.5%), respectively. Conclusions: Salvage A-RT achieves favorable OS and local control outcomes in participants with an isolated locoregional recurrence of PDAC after surgical resection. Consideration should be given to extending high-dose fields to include adjacent segments of at-risk vessels beyond direct contact with the gross disease.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Marsha Reyngold
- Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; (E.C.D.); (V.C.N.); (C.H.C.)
| |
Collapse
|
3
|
Ejlsmark MW, Schytte T, Bernchou U, Bahij R, Weber B, Mortensen MB, Pfeiffer P. Radiotherapy for Locally Advanced Pancreatic Adenocarcinoma-A Critical Review of Randomised Trials. Curr Oncol 2023; 30:6820-6837. [PMID: 37504359 PMCID: PMC10378124 DOI: 10.3390/curroncol30070499] [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: 06/16/2023] [Revised: 07/08/2023] [Accepted: 07/14/2023] [Indexed: 07/29/2023] Open
Abstract
Pancreatic cancer is rising as one of the leading causes of cancer-related death worldwide. Patients often present with advanced disease, limiting curative treatment options and therefore making management of the disease difficult. Systemic chemotherapy has been an established part of the standard treatment in patients with both locally advanced and metastatic pancreatic cancer. In contrast, the use of radiotherapy has no clear defined role in the treatment of these patients. With the evolving imaging and radiation techniques, radiation could become a plausible intervention. In this review, we give an overview over the available data regarding radiotherapy, chemoradiation, and stereotactic body radiation therapy. We performed a systematic search of Embase and the PubMed database, focusing on studies involving locally advanced pancreatic cancer (or non-resectable pancreatic cancer) and radiotherapy without any limitation for the time of publication. We included randomised controlled trials involving patients with locally advanced pancreatic cancer, including radiotherapy, chemoradiation, or stereotactic body radiation therapy. The included articles represented mainly small patient groups and had a high heterogeneity regarding radiation delivery and modality. This review presents conflicting results concerning the addition of radiation and modality in the treatment regimen. Further research is needed to improve outcomes and define the role of radiation therapy in pancreatic cancer.
Collapse
Affiliation(s)
- Mathilde Weisz Ejlsmark
- Department of Oncology, Odense University Hospital, 5000 Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark
| | - Tine Schytte
- Department of Oncology, Odense University Hospital, 5000 Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark
| | - Uffe Bernchou
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark
- Laboratory of Radiation Physics, Odense University Hospital, 5000 Odense, Denmark
| | - Rana Bahij
- Department of Oncology, Odense University Hospital, 5000 Odense, Denmark
| | - Britta Weber
- Department of Oncology, Aarhus University Hospital, 8200 Aarhus, Denmark
- Danish Centre of Particle Therapy, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Michael Bau Mortensen
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark
- Department of Surgery, Odense University Hospital, 5000 Odense, Denmark
| | - Per Pfeiffer
- Department of Oncology, Odense University Hospital, 5000 Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark
| |
Collapse
|
4
|
Sim AJ, Hoffe SE, Latifi K, Palm RF, Feygelman V, Leuthold S, Dookhoo M, Dennett M, Rosenberg SA, Frakes JM. A Practical Workflow for Magnetic Resonance-Guided Stereotactic Body Radiation Therapy to the Pancreas. Pract Radiat Oncol 2023; 13:e45-e53. [PMID: 35901947 DOI: 10.1016/j.prro.2022.07.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/11/2022] [Accepted: 07/13/2022] [Indexed: 01/10/2023]
Abstract
The increased adoption of stereotactic body radiation therapy has allowed for delivery of higher doses, potentially associated with better outcomes but at the risk of higher toxicity. The intimate association of radiosensitive organs at risk (eg, stomach, duodenum, bowel) has historically limited the delivery of ablative doses to the pancreas. The advent of magnetic resonance-guided radiation therapy with improved soft-tissue contrast allows for gated delivery without an internal target volume and online adaptive replanning to maximize the therapeutic ratio. Patient selection requires additional resources, including increased patient on-table time, physician time, and physics support. Within our center's workflow, integrating an educational video at consultation as well as optimizing biofeedback mechanisms have significantly improved the experience for our patients.
Collapse
Affiliation(s)
- Austin J Sim
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida; Department of Radiation Oncology, James Cancer Hospital and Solove Research Institute, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Sarah E Hoffe
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Kujtim Latifi
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Russell F Palm
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Vladimir Feygelman
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Susan Leuthold
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Marsha Dookhoo
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Maria Dennett
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Stephen A Rosenberg
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Jessica M Frakes
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida.
| |
Collapse
|
5
|
Doppenberg D, Besselink MG, van Eijck CHJ, Intven MPW, Koerkamp BG, Kazemier G, van Laarhoven HWM, Meijerink M, Molenaar IQ, Nuyttens JJME, van Os R, van Santvoort HC, van Tienhoven G, Verkooijen HM, Versteijne E, Wilmink JW, Lagerwaard FJ, Bruynzeel AME. Stereotactic ablative radiotherapy or best supportive care in patients with localized pancreatic cancer not receiving chemotherapy and surgery (PANCOSAR): a nationwide multicenter randomized controlled trial according to a TwiCs design. BMC Cancer 2022; 22:1363. [PMID: 36581914 PMCID: PMC9801528 DOI: 10.1186/s12885-022-10419-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/06/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Significant comorbidities, advanced age, and a poor performance status prevent surgery and systemic treatment for many patients with localized (non-metastatic) pancreatic ductal adenocarcinoma (PDAC). These patients are currently treated with 'best supportive care'. Therefore, it is desirable to find a treatment option which could improve both disease control and quality of life in these patients. A brief course of high-dose high-precision radiotherapy i.e. stereotactic ablative body radiotherapy (SABR) may be feasible. METHODS A nationwide multicenter trial performed within a previously established large prospective cohort (the Dutch Pancreatic cancer project; PACAP) according to the 'Trial within cohorts' (TwiCs) design. Patients enrolled in the PACAP cohort routinely provide informed consent to answer quality of life questionnaires and to be randomized according to the TwiCs design when eligible for a study. Patients with localized PDAC who are unfit for chemotherapy and surgery or those who refrain from these treatments are eligible. Patients will be randomized between SABR (5 fractions of 8 Gy) with 'best supportive care' and 'best supportive care' only. The primary endpoint is overall survival from randomization. Secondary endpoints include preservation of quality of life (EORTC-QLQ-C30 and -PAN26), NRS pain score response and WHO performance scores at baseline, and, 3, 6 and 12 months. Acute and late toxicity will be scored using CTCAE criteria version 5.0: assessed at baseline, day of last fraction, at 3 and 6 weeks, and 3, 6 and 12 months following SABR. DISCUSSION The PANCOSAR trial studies the added value of SBRT as compared to 'best supportive care' in patients with localized PDAC who are medically unfit to receive chemotherapy and surgery, or refrain from these treatments. This study will assess whether SABR, in comparison to best supportive care, can relieve or delay tumor-related symptoms, enhance quality of life, and extend survival in these patients. TRIAL REGISTRATION Clinical trials, NCT05265663 , Registered March 3 2022, Retrospectively registered.
Collapse
Affiliation(s)
- D. Doppenberg
- grid.509540.d0000 0004 6880 3010Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Radiation Oncology, Amsterdam, The Netherlands ,grid.7177.60000000084992262Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands ,grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, The Netherlands
| | - M. G. Besselink
- grid.7177.60000000084992262Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands ,grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, The Netherlands
| | - C. H. J. van Eijck
- grid.508717.c0000 0004 0637 3764Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - M. P. W. Intven
- grid.5477.10000000120346234Department of Radiation Oncology, Regional Academic Cancer Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - B. Groot Koerkamp
- grid.508717.c0000 0004 0637 3764Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - G. Kazemier
- grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, The Netherlands ,grid.509540.d0000 0004 6880 3010Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam, The Netherlands
| | - H. W. M. van Laarhoven
- grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, The Netherlands ,grid.7177.60000000084992262Amsterdam UMC, Location University of Amsterdam, Department of Medical Oncology, Amsterdam, The Netherlands
| | - M. Meijerink
- grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, The Netherlands ,grid.509540.d0000 0004 6880 3010Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Intervention Radiology, Amsterdam, The Netherlands
| | - I. Q. Molenaar
- grid.5477.10000000120346234Department of Surgery, Regional Academic Cancer Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - J. J. M. E. Nuyttens
- grid.508717.c0000 0004 0637 3764Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - R. van Os
- grid.509540.d0000 0004 6880 3010Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Radiation Oncology, Amsterdam, The Netherlands
| | - H. C. van Santvoort
- grid.5477.10000000120346234Department of Surgery, Regional Academic Cancer Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - G. van Tienhoven
- grid.509540.d0000 0004 6880 3010Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Radiation Oncology, Amsterdam, The Netherlands ,grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, The Netherlands
| | - H. M. Verkooijen
- grid.5477.10000000120346234Department of Surgery, Regional Academic Cancer Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - E. Versteijne
- grid.509540.d0000 0004 6880 3010Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Radiation Oncology, Amsterdam, The Netherlands ,grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, The Netherlands
| | - J. W. Wilmink
- grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, The Netherlands ,grid.7177.60000000084992262Amsterdam UMC, Location University of Amsterdam, Department of Medical Oncology, Amsterdam, The Netherlands
| | - F. J. Lagerwaard
- grid.509540.d0000 0004 6880 3010Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Radiation Oncology, Amsterdam, The Netherlands ,grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, The Netherlands
| | - A. M. E. Bruynzeel
- grid.509540.d0000 0004 6880 3010Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Radiation Oncology, Amsterdam, The Netherlands ,grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
6
|
Bulking agents in gastrointestinal endoscopy: present applications and future advances. Curr Opin Gastroenterol 2022; 38:472-480. [PMID: 35881970 DOI: 10.1097/mog.0000000000000858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW Bulking agents are inert materials injected into an organ to affect the physical properties of the organ for a therapeutic purpose. Various agents have been developed to aid in the treatment of diseases like gastroesophageal reflux disease (GERD), fecal incontinence, obesity, malignancy, hemostasis, and tissue dissection. Here, we review the state of the art in bulking agents in gastrointestinal endoscopy, past failures, current limitations, and where we see the field heading in the future. RECENT FINDINGS Though bulking agents have been trialed for various different gastrointestinal diseases, there are currently limited uses in gastrointestinal endoscopy. Though various agents have been trialed for GERD, numerous complications and adverse events have limited its current use. However, for the treatment of fecal incontinence endoscopic bulking agent therapy is a reasonable option. Though in early stages of exploration, bulking agent therapy for enteric protection from radiotherapy may be a promising tool to improve treatment of pancreatic cancer. Bulking agents for tissue dissection have substantially improved lifting agents and complex polyp removal. Bulking agent therapy has not really been explored for endoscopic bariatric therapy or hemostasis but may be a fruitful area for exploration in the future. SUMMARY Bulking agent therapy has been trialed for various gastrointestinal diseases with mixed success. There is currently a therapeutic roll in the endoscopic management of fecal incontinence and tissue dissection. A future role in the treatment of GERD, obesity, malignancy, and hemostasis seem feasible.
Collapse
|
7
|
Zhou Q, An Y, Liu T, Liu Z, Li R, Wang C, Zhou F, Liu C, Zhu K. Prognosis of patients with hepatocellular carcinoma and portal vein tumor thrombus treated with combination of transarterial chemoembolization and palliative thermal ablation. Int J Hyperthermia 2022; 39:97-107. [PMID: 34979845 DOI: 10.1080/02656736.2021.2021303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
PURPOSE Transarterial chemoembolization (TACE) was obtained acceptable benefit for advanced hepatocellular carcinoma (HCC). Here in this study, we compared the benefit of TACE combined palliative thermal ablation with TACE alone for HCC with portal vein tumor thrombus (PVTT). METHODS Patients with HCC and PVTT were retrospectively analyzed from January 2012 to December 2017, who accepted treatment of TACE alone (TACE group) or TACE plus palliative thermal ablation (TACE + P-ablation group). Propensity score matching (PSM) was applied to balance differences between the two groups. Overall survival (OS) and progression-free survival (PFS) rates were compared between groups. RESULTS Median follow-up time was 7.4 (3.0-60.0) months. In the cohort, 142 patients were enrolled in TACE group and 86 patients were enrolled in TACE + P-ablation group. The pre-PSM estimated 6-, 12-, and 18-month OS rates for the TACE + P-ablation group were 70.9, 46.5, and 31%, respectively, whereas rates for the TACE group were 57, 23.1, and 10%, respectively. After PSM, OS and PFS rates remained coincident with the pre-PSM. Risk factors for poor OS included PVTT type III and type II relative to type I (HR = 1.76; 95% CI, 1.13-2.74; p = .01) and (HR = 1.86; 95% CI, 1.2-2.88; p = .006), TACE alone (HR = 1.40; 95% CI, 1.01-1.96; p = .04), a single TACE treatment (HR = 2.69; 95% CI, 1.79-4.03; p < .001), 2 or 3 TACE treatments (HR = 2.02; 95% CI, 1.32-3.09; p = .001). CONCLUSIONS The combination of TACE and palliative thermal ablation for HCC with PVTT could obtain delayed progression and longer survival.
Collapse
Affiliation(s)
- Qunfang Zhou
- Department of Minimally Invasive Interventional Radiology, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, PR China.,Department of Radiology, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, PR China.,Department of Minimally Invasive Interventional Radiology, Sun Yat-sen University Cancer Center, Sun Yat-sen University, Guangzhou, PR China
| | - Yongcheng An
- Department of Minimally Invasive Interventional Radiology, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, PR China.,Department of Radiology, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, PR China
| | - Ting Liu
- Department of Minimally Invasive Interventional Radiology, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, PR China.,Department of Radiology, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, PR China
| | - Zishan Liu
- Department of Minimally Invasive Interventional Radiology, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, PR China.,Department of Radiology, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, PR China
| | - Ruixia Li
- Department of Minimally Invasive Interventional Radiology, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, PR China.,Department of Radiology, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, PR China
| | - Chenmeng Wang
- Department of Minimally Invasive Interventional Radiology, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, PR China.,Department of Radiology, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, PR China
| | - Feng Zhou
- Department of Minimally Invasive Interventional Radiology, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, PR China.,Department of Radiology, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, PR China
| | - Congjuan Liu
- Department of Ultrasound, NingXiang People's Hospital, Changsha, PR China
| | - Kangshun Zhu
- Department of Minimally Invasive Interventional Radiology, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, PR China.,Department of Radiology, the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, PR China
| |
Collapse
|
8
|
Jolissaint JS, Reyngold M, Bassmann J, Seier KP, Gönen M, Varghese AM, Yu KH, Park W, O’Reilly EM, Balachandran VP, D’Angelica MI, Drebin JA, Kingham TP, Soares KC, Jarnagin WR, Crane CH, Wei AC. Local Control and Survival After Induction Chemotherapy and Ablative Radiation Versus Resection for Pancreatic Ductal Adenocarcinoma With Vascular Involvement. Ann Surg 2021; 274:894-901. [PMID: 34269717 PMCID: PMC8599622 DOI: 10.1097/sla.0000000000005080] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We sought to compare overall survival (OS) and disease control for patients with localized pancreatic ductal adenocarcinoma (PDAC) treated with ablative dose radiotherapy (A-RT) versus resection. SUMMARY BACKGROUND DATA Locoregional treatment for PDAC includes resection when possible or palliative RT. A-RT may offer durable tumor control and encouraging survival. METHODS This was a single-institution retrospective analysis of patients with PDAC treated with induction chemotherapy followed by A-RT [≥98 Gy biologically effective dose (BED) using 15-25 fractions in 3-4.5 Gy/fraction] or pancreatectomy. RESULTS One hundred and four patients received A-RT (49.8%) and 105 (50.2%) underwent resection. Patients receiving A-RT had larger median tumor size after induction chemotherapy [3.2 cm (undetectable-10.9) vs 2.6 cm (undetectable-10.7), P < 0.001], and were more likely to have celiac or hepatic artery encasement (48.1% vs 11.4%, P <0.001), or superior mesenteric artery encasement (43.3% vs 9.5%, P < 0.001); however, there was no difference in the degree of SMV/PV involvement (P = 0.123). There was no difference in locoregional recurrence/progression at 18-months between A-RT and resection; cumulative incidence was 16% [(95% confidence interval (CI) 10%-24%] versus 21% (95% CI 14%-30%), respectively (P= 0.252). However, patients receiving A-RT had a 19% higher 18-month cumulative incidence of distant recurrence/progression [58% (95% CI 48%-67%) vs 30% (95% CI 30%-49%), P= 0.004]. Median OS from completion of chemotherapy was 20.1 months for A-RT patients (95% CI 16.4-23.1 months) versus 32.9 months (95% CI 29.7-42.3 months) for resected patients (P < 0.001). CONCLUSION Ablative radiation is a promising new treatment option for PDAC, offering locoregional disease control similar to that associated with resection and encouraging survival.
Collapse
Affiliation(s)
- Joshua S. Jolissaint
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Surgery, Brigham and Women’s Hospital, Boston, MA
| | - Marsha Reyngold
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jared Bassmann
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kenneth P. Seier
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Mithat Gönen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Anna M. Varghese
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kenneth H. Yu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Wungki Park
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Eileen M. O’Reilly
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Jeffrey A. Drebin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - T. Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kevin C. Soares
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Christopher H. Crane
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alice C. Wei
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| |
Collapse
|
9
|
Kim N, Tringale KR, Crane C, Tyagi N, Otazo R. MR SIGnature MAtching (MRSIGMA) with retrospective self-evaluation for real-time volumetric motion imaging. Phys Med Biol 2021; 66. [PMID: 34619666 DOI: 10.1088/1361-6560/ac2dd2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 10/07/2021] [Indexed: 11/11/2022]
Abstract
Objective. MR SIGnature MAtching (MRSIGMA) is a real-time volumetric MRI technique to image tumor and organs at risk motion in real-time for radiotherapy applications, where a dictionary of high-resolution 3D motion states and associated motion signatures are computed first during offline training and real-time 3D imaging is performed afterwards using fast signature-only acquisition and signature matching. However, the lack of a reference image with similar spatial resolution and temporal resolution introduces significant challenges forin vivovalidation.Approach. This work proposes a retrospective self-validation for MRSIGMA, where the same data used for real-time imaging are used to create a non-real-time reference for comparison. MRSIGMA with self-validation is tested in patients with liver tumors using quantitative metrics defined on the tumor and nearby organs-at-risk structures. The dice coefficient between contours defined on the real-time MRSIGMA and non-real-time reference was used to assess motion imaging performance.Main Results. Total latency (including signature acquisition and signature matching) was between 250 and 314 ms, which is sufficient for organs affected by respiratory motion. Mean ± standard deviation dice coefficient over time was 0.74 ± 0.03 for patients imaged without contrast agent and 0.87 ± 0.03 for patients imaged with contrast agent, which demonstrated high-performance real-time motion imaging.Signficance. MRSIGMA with self-evaluation provides a means to perform real-time volumetric MRI for organ motion tracking with quantitative performance measures.
Collapse
Affiliation(s)
- Nathanael Kim
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Kathryn R Tringale
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Christopher Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Neelam Tyagi
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Ricardo Otazo
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America.,Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| |
Collapse
|
10
|
Hall WA, Erickson B, Crane CH. Evolving Concepts Regarding Radiation Therapy for Pancreatic Cancer. Surg Oncol Clin N Am 2021; 30:719-730. [PMID: 34511192 PMCID: PMC8462521 DOI: 10.1016/j.soc.2021.06.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
In todays practice most institutions individualize the use of adjuvant, neoadjuvant, and definitive RT based on their interpretation of the available data. This review highlights novel concepts and approaches to the use of RT that should be considered by the surgical oncologist.
Collapse
Affiliation(s)
- William A Hall
- Department of Radiation Oncology, Froedtert and the Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI 53226, USA; Graduate School of Biomedical Sciences, Medical College of Wisconsin; Department of Surgery, Froedtert and the Medical College of Wisconsin.
| | - Beth Erickson
- Department of Radiation Oncology, Froedtert and the Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI 53226, USA; Department of Surgery, Froedtert and the Medical College of Wisconsin
| | | |
Collapse
|
11
|
Hall WA, Small C, Paulson E, Koay EJ, Crane C, Intven M, Daamen LA, Meijer GJ, Heerkens HD, Bassetti M, Rosenberg SA, Aitken K, Myrehaug S, Dawson LA, Lee P, Gani C, Chuong MD, Parikh PJ, Erickson BA. Magnetic Resonance Guided Radiation Therapy for Pancreatic Adenocarcinoma, Advantages, Challenges, Current Approaches, and Future Directions. Front Oncol 2021; 11:628155. [PMID: 34046339 PMCID: PMC8144850 DOI: 10.3389/fonc.2021.628155] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 03/03/2021] [Indexed: 12/15/2022] Open
Abstract
Introduction Pancreatic adenocarcinoma (PAC) has some of the worst treatment outcomes for any solid tumor. PAC creates substantial difficulty for effective treatment with traditional RT delivery strategies primarily secondary to its location and limited visualization using CT. Several of these challenges are uniquely addressed with MR-guided RT. We sought to summarize and place into context the currently available literature on MR-guided RT specifically for PAC. Methods A literature search was conducted to identify manuscript publications since September 2014 that specifically used MR-guided RT for the treatment of PAC. Clinical outcomes of these series are summarized, discussed, and placed into the context of the existing pancreatic literature. Multiple international experts were involved to optimally contextualize these publications. Results Over 300 manuscripts were reviewed. A total of 6 clinical outcomes publications were identified that have treated patients with PAC using MR guidance. Successes, challenges, and future directions for this technology are evident in these publications. MR-guided RT holds theoretical promise for the treatment of patients with PAC. As with any new technology, immediate or dramatic clinical improvements associated with its use will take time and experience. There remain no prospective trials, currently publications are limited to small retrospective experiences. The current level of evidence for MR guidance in PAC is low and requires significant expansion. Future directions and ongoing studies that are currently open and accruing are identified and reviewed. Conclusions The potential promise of MR-guided RT for PAC is highlighted, the challenges associated with this novel therapeutic intervention are also reviewed. Outcomes are very early, and will require continued and long term follow up. MR-guided RT should not be viewed in the same fashion as a novel chemotherapeutic agent for which dosing, administration, and toxicity has been established in earlier phase studies. Instead, it should be viewed as a novel procedural intervention which must be robustly tested, refined and practiced before definitive conclusions on the potential benefits or detriments can be determined. The future of MR-guided RT for PAC is highly promising and the potential implications on PAC are substantial.
Collapse
Affiliation(s)
- William A Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Christina Small
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Eric Paulson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Eugene J Koay
- Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Christopher Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Martijn Intven
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Lois A Daamen
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Gert J Meijer
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Hanne D Heerkens
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Michael Bassetti
- Department of Radiation Oncology, University of Wisconsin-Madison, Madison, WI, United States
| | - Stephen A Rosenberg
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, United States
| | - Katharine Aitken
- Department of Radiation Oncology, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Sten Myrehaug
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Laura A Dawson
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Percy Lee
- Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Cihan Gani
- Department of Radiation Oncology, Faculty of Medicine, University of Tübingen, Tübingen, Germany
| | | | - Parag J Parikh
- Henry Ford Medical Center, Henry Ford Health System, Detroit, MI, United States
| | - Beth A Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| |
Collapse
|
12
|
Demaria S, Guha C, Schoenfeld J, Morris Z, Monjazeb A, Sikora A, Crittenden M, Shiao S, Khleif S, Gupta S, Formenti SC, Vikram B, Coleman CN, Ahmed MM. Radiation dose and fraction in immunotherapy: one-size regimen does not fit all settings, so how does one choose? J Immunother Cancer 2021; 9:jitc-2020-002038. [PMID: 33827904 PMCID: PMC8031689 DOI: 10.1136/jitc-2020-002038] [Citation(s) in RCA: 135] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2021] [Indexed: 12/12/2022] Open
Abstract
Recent evidence indicates that ionizing radiation can enhance immune responses to tumors. Advances in radiation delivery techniques allow hypofractionated delivery of conformal radiotherapy. Hypofractionation or other modifications of standard fractionation may improve radiation’s ability to promote immune responses to tumors. Other novel delivery options may also affect immune responses, including T-cell activation and tumor-antigen presentation changes. However, there is limited understanding of the immunological impact of hypofractionated and unique multifractionated radiotherapy regimens, as these observations are relatively recent. Hence, these differences in radiotherapy fractionation result in distinct immune-modulatory effects. Radiation oncologists and immunologists convened a virtual consensus discussion to identify current deficiencies, challenges, pitfalls and critical gaps when combining radiotherapy with immunotherapy and making recommendations to the field and advise National Cancer Institute on new directions and initiatives that will help further development of these two fields. This commentary aims to raise the awareness of this complexity so that the need to study radiation dose, fractionation, type and volume is understood and valued by the immuno-oncology research community. Divergence of approaches and findings between preclinical studies and clinical trials highlights the need for evaluating the design of future clinical studies with particular emphasis on radiation dose and fractionation, immune biomarkers and selecting appropriate end points for combination radiation/immune modulator trials, recognizing that direct effect on the tumor and potential abscopal effect may well be different. Similarly, preclinical studies should be designed as much as possible to model the intended clinical setting. This article describes a conceptual framework for testing different radiation therapy regimens as separate models of how radiation itself functions as an immunomodulatory ‘drug’ to provide alternatives to the widely adopted ‘one-size-fits-all’ strategy of frequently used 8 Gy×3 regimens immunomodulation.
Collapse
Affiliation(s)
- Sandra Demaria
- Department of Radiation Oncology, Weill Cornell Medical College, New York, New York, USA
| | - Chandan Guha
- Radiation Oncology, Pathology and Urology, and Institute of Onco-Physics, Montefiore Hospital and Medical Center, Bronx, New York, USA
| | - Jonathan Schoenfeld
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Zachary Morris
- Human Oncology, University of Wisconsin Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Arta Monjazeb
- Radiation Oncology, UC Davis, Davis, California, USA
| | - Andrew Sikora
- Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Marka Crittenden
- Department of Radiation Oncology, Providence Portland Medical Center, Portland, Oregon, USA
| | - Stephen Shiao
- Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Samir Khleif
- The Loop Immuno-Oncology Laboratory, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Seema Gupta
- The Loop Immuno-Oncology Laboratory, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Silvia Chiara Formenti
- Department of Radiation Oncology, Weill Cornell Medical College, New York, New York, USA
| | - Bhadrasain Vikram
- Radiation Research Program, National Cancer Institute Division of Cancer Treatment and Diagnosis, Bethesda, Maryland, USA
| | - C Norman Coleman
- Radiation Research Program, National Cancer Institute Division of Cancer Treatment and Diagnosis, Bethesda, Maryland, USA
| | - Mansoor M Ahmed
- Radiation Research Program, National Cancer Institute Division of Cancer Treatment and Diagnosis, Bethesda, Maryland, USA
| |
Collapse
|
13
|
Otazo R, Lambin P, Pignol JP, Ladd ME, Schlemmer HP, Baumann M, Hricak H. MRI-guided Radiation Therapy: An Emerging Paradigm in Adaptive Radiation Oncology. Radiology 2020; 298:248-260. [PMID: 33350894 DOI: 10.1148/radiol.2020202747] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Radiation therapy (RT) continues to be one of the mainstays of cancer treatment. Considerable efforts have been recently devoted to integrating MRI into clinical RT planning and monitoring. This integration, known as MRI-guided RT, has been motivated by the superior soft-tissue contrast, organ motion visualization, and ability to monitor tumor and tissue physiologic changes provided by MRI compared with CT. Offline MRI is already used for treatment planning at many institutions. Furthermore, MRI-guided linear accelerator systems, allowing use of MRI during treatment, enable improved adaptation to anatomic changes between RT fractions compared with CT guidance. Efforts are underway to develop real-time MRI-guided intrafraction adaptive RT of tumors affected by motion and MRI-derived biomarkers to monitor treatment response and potentially adapt treatment to physiologic changes. These developments in MRI guidance provide the basis for a paradigm change in treatment planning, monitoring, and adaptation. Key challenges to advancing MRI-guided RT include real-time volumetric anatomic imaging, addressing image distortion because of magnetic field inhomogeneities, reproducible quantitative imaging across different MRI systems, and biologic validation of quantitative imaging. This review describes emerging innovations in offline and online MRI-guided RT, exciting opportunities they offer for advancing research and clinical care, hurdles to be overcome, and the need for multidisciplinary collaboration.
Collapse
Affiliation(s)
- Ricardo Otazo
- From the Departments of Medical Physics (R.O.) and Radiology (R.O., H.H.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10065; The D-Lab, Department of Precision Medicine, Department of Radiology & Nuclear Medicine, GROW-School for Oncology, Maastricht University Medical Centre, Maastricht, the Netherlands (P.L.); Department of Radiation Oncology, Dalhousie University, Halifax, Canada (J.P.P.); Divisions of Medical Physics in Radiology (M.E.L.), Radiology (H.P.S.), and Radiation Oncology/Radiobiology (M.B.), German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Physics and Astronomy (M.E.L.) and Faculty of Medicine (M.E.L., M.B.), Heidelberg University, Heidelberg, Germany; and OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany (M.B.)
| | - Philippe Lambin
- From the Departments of Medical Physics (R.O.) and Radiology (R.O., H.H.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10065; The D-Lab, Department of Precision Medicine, Department of Radiology & Nuclear Medicine, GROW-School for Oncology, Maastricht University Medical Centre, Maastricht, the Netherlands (P.L.); Department of Radiation Oncology, Dalhousie University, Halifax, Canada (J.P.P.); Divisions of Medical Physics in Radiology (M.E.L.), Radiology (H.P.S.), and Radiation Oncology/Radiobiology (M.B.), German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Physics and Astronomy (M.E.L.) and Faculty of Medicine (M.E.L., M.B.), Heidelberg University, Heidelberg, Germany; and OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany (M.B.)
| | - Jean-Philippe Pignol
- From the Departments of Medical Physics (R.O.) and Radiology (R.O., H.H.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10065; The D-Lab, Department of Precision Medicine, Department of Radiology & Nuclear Medicine, GROW-School for Oncology, Maastricht University Medical Centre, Maastricht, the Netherlands (P.L.); Department of Radiation Oncology, Dalhousie University, Halifax, Canada (J.P.P.); Divisions of Medical Physics in Radiology (M.E.L.), Radiology (H.P.S.), and Radiation Oncology/Radiobiology (M.B.), German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Physics and Astronomy (M.E.L.) and Faculty of Medicine (M.E.L., M.B.), Heidelberg University, Heidelberg, Germany; and OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany (M.B.)
| | - Mark E Ladd
- From the Departments of Medical Physics (R.O.) and Radiology (R.O., H.H.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10065; The D-Lab, Department of Precision Medicine, Department of Radiology & Nuclear Medicine, GROW-School for Oncology, Maastricht University Medical Centre, Maastricht, the Netherlands (P.L.); Department of Radiation Oncology, Dalhousie University, Halifax, Canada (J.P.P.); Divisions of Medical Physics in Radiology (M.E.L.), Radiology (H.P.S.), and Radiation Oncology/Radiobiology (M.B.), German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Physics and Astronomy (M.E.L.) and Faculty of Medicine (M.E.L., M.B.), Heidelberg University, Heidelberg, Germany; and OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany (M.B.)
| | - Heinz-Peter Schlemmer
- From the Departments of Medical Physics (R.O.) and Radiology (R.O., H.H.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10065; The D-Lab, Department of Precision Medicine, Department of Radiology & Nuclear Medicine, GROW-School for Oncology, Maastricht University Medical Centre, Maastricht, the Netherlands (P.L.); Department of Radiation Oncology, Dalhousie University, Halifax, Canada (J.P.P.); Divisions of Medical Physics in Radiology (M.E.L.), Radiology (H.P.S.), and Radiation Oncology/Radiobiology (M.B.), German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Physics and Astronomy (M.E.L.) and Faculty of Medicine (M.E.L., M.B.), Heidelberg University, Heidelberg, Germany; and OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany (M.B.)
| | - Michael Baumann
- From the Departments of Medical Physics (R.O.) and Radiology (R.O., H.H.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10065; The D-Lab, Department of Precision Medicine, Department of Radiology & Nuclear Medicine, GROW-School for Oncology, Maastricht University Medical Centre, Maastricht, the Netherlands (P.L.); Department of Radiation Oncology, Dalhousie University, Halifax, Canada (J.P.P.); Divisions of Medical Physics in Radiology (M.E.L.), Radiology (H.P.S.), and Radiation Oncology/Radiobiology (M.B.), German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Physics and Astronomy (M.E.L.) and Faculty of Medicine (M.E.L., M.B.), Heidelberg University, Heidelberg, Germany; and OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany (M.B.)
| | - Hedvig Hricak
- From the Departments of Medical Physics (R.O.) and Radiology (R.O., H.H.), Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10065; The D-Lab, Department of Precision Medicine, Department of Radiology & Nuclear Medicine, GROW-School for Oncology, Maastricht University Medical Centre, Maastricht, the Netherlands (P.L.); Department of Radiation Oncology, Dalhousie University, Halifax, Canada (J.P.P.); Divisions of Medical Physics in Radiology (M.E.L.), Radiology (H.P.S.), and Radiation Oncology/Radiobiology (M.B.), German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Physics and Astronomy (M.E.L.) and Faculty of Medicine (M.E.L., M.B.), Heidelberg University, Heidelberg, Germany; and OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany (M.B.)
| |
Collapse
|
14
|
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: 9] [Impact Index Per Article: 2.3] [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
|
15
|
Kerdsirichairat T, Narang AK, Thompson E, Kim SH, Rao A, Ding K, Shin EJ. Feasibility of Using Hydrogel Spacers for Borderline-Resectable and Locally Advanced Pancreatic Tumors. Gastroenterology 2019; 157:933-935. [PMID: 31306631 PMCID: PMC7263852 DOI: 10.1053/j.gastro.2019.07.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 06/24/2019] [Accepted: 07/01/2019] [Indexed: 01/11/2023]
Abstract
This article has an accompanying continuing medical education activity, also eligible for MOC credit, on page e14 (https://www.gastrojournal.org/cme/home). Learning Objective: Upon completion of this CME activity, successful learners will be able to describe the pharmacokinetics of hydrogel, identify appropriate candidates for hydrogel injection among patients with pancreatic cancer, and describe key techniques to successfully inject hydrogel as well as the histopathologic findings associated with hydrogel.
Collapse
Affiliation(s)
- Tossapol Kerdsirichairat
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Amol K. Narang
- Department of Radiation Oncology and Molecular Sciences, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Elizabeth Thompson
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Seong-Hun Kim
- Department of Internal Medicine, Chonbuk National University Medical School & Hospital, Jeonju, South Korea
| | - Avani Rao
- Department of Radiation Oncology and Molecular Sciences, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Kai Ding
- Department of Radiation Oncology and Molecular Sciences, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Eun Ji Shin
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland.
| |
Collapse
|