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Lawrence YR, Miszczyk M, Dawson LA, Diaz Pardo DA, Aguiar A, Limon D, Pfeffer RM, Buckstein M, Barry AS, Meron T, Dicker AP, Wydmański J, Zimmermann C, Margalit O, Hausner D, Morag O, Golan T, Jacobson G, Dubinski S, Stanescu T, Fluss R, Freedman LS, Ben-Ayun M, Symon Z. Celiac plexus radiosurgery for pain management in advanced cancer: a multicentre, single-arm, phase 2 trial. Lancet Oncol 2024; 25:1070-1079. [PMID: 39029483 DOI: 10.1016/s1470-2045(24)00223-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 04/18/2024] [Accepted: 04/19/2024] [Indexed: 07/21/2024]
Abstract
BACKGROUND Refractory upper abdominal pain or lower back pain (retroperitoneal pain syndrome) related to celiac plexus involvement characterises pancreatic and other upper gastrointestinal malignancies and is an unmet need. We hypothesised that ablative radiation delivered to the celiac plexus would decrease pain. METHODS This multicentre, single-arm, phase 2 study was done at eight hospitals in five countries (Israel, Poland, Canada, the USA, and Portugal). Eligible patients aged 18 years or older with an average pain level of 5-10 on the Brief Pain Inventory short form (BPI-SF), an Eastern Cooperative Oncology Group performance status score of 0-2, and either pancreatic cancer or other tumours involving the celiac axis, received a single fraction of 25 Gy of external-beam photons to the celiac plexus. The primary endpoint was complete or partial pain response based on a reduction of the BPI-SF average pain score of 2 points or more from baseline to 3 weeks after treatment. All evaluable patients with stable pain scores were included in response assessment. The trial is registered with ClinicalTrials.gov, NCT03323489, and is complete. FINDINGS Between Jan 3, 2018, and Dec 28, 2021, 125 patients were treated, 90 of whom were evaluable. Patients were followed up until death. Median age was 65·5 years (IQR 58·3-71·8), 50 (56%) were female and 40 (44%) were male, 83 (92%) had pancreatic cancer, and 77 (86%) had metastatic disease. Median baseline BPI-SF average pain score was 6 (IQR 5-7). Of the 90 evaluable patients at 3 weeks, 48 (53%; 95% CI 42-64) had at least a partial pain response. The most common grade 3-4 adverse events, irrespective of attribution, were abdominal pain (35 [28%] of 125) and fatigue (23 [18%]). 11 serious adverse events of grade 3 or worse were recorded. Two grade 3 serious adverse events were probably attributed to treatment by the local investigators (abdominal pain [n=1] and nausea [n=1]), and nine were possibly attributed to treatment (seven were grade 3: blood bilirubin increased [n=1], duodenal haemorrhage [n=2], abdominal pain [n=2], and progressive disease [n=2]; and two were grade 5: gastrointestinal bleed from suspected varices 24 days after treatment [n=1] and progressive disease [advanced pancreatic cancer] 89 days after treatment [n=1]). INTERPRETATION Celiac plexus radiosurgery could potentially be a non-invasive palliative option for patients with retroperitoneal pain syndrome. Further investigation by means of a randomised comparison with conventional celiac block or neurolysis is warranted. FUNDING Gateway for Cancer Research and the Israel Cancer Association.
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Affiliation(s)
- Yaacov R Lawrence
- Department of Radiation Oncology, Sheba Medical Center, Ramat Gan, Israel; School of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Marcin Miszczyk
- III Department of Radiotherapy and Chemotherapy, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice, Poland; Collegium Medicum, Faculty of Medicine, WSB University, Dąbrowa Górnicza, Poland
| | - Laura A Dawson
- Department of Radiation Oncology, Princess Margaret Hospital Cancer Centre, University of Toronto, Toronto, ON, Canada
| | | | - Artur Aguiar
- Department of Radiation Oncology, Instituto Português de Oncologia, Porto, Portugal
| | - Dror Limon
- Department of Radiation Oncology, Rabin Medical Center, Petah Tikvah, Israel
| | - Raphael M Pfeffer
- Department of Radiation Oncology, Assuta Medical Center, Tel Aviv, Israel
| | - Michael Buckstein
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Aisling S Barry
- Cancer Research @UCC, University College Cork, Cork, Ireland; Department of Radiation Oncology, Cork University Hospital, Cork, Ireland
| | - Tikva Meron
- Department of Medical Oncology, Sheba Medical Center, Ramat Gan, Israel
| | - Adam P Dicker
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jerzy Wydmański
- Department of Radiation Oncology, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Hospital Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Ofer Margalit
- Department of Medical Oncology, Sheba Medical Center, Ramat Gan, Israel; School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Hausner
- Department of Palliative Care, Sheba Medical Center, Ramat Gan, Israel; School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ofir Morag
- Department of Medical Oncology, Sheba Medical Center, Ramat Gan, Israel; School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Talia Golan
- Department of Medical Oncology, Sheba Medical Center, Ramat Gan, Israel; School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Galia Jacobson
- Department of Radiation Oncology, Rabin Medical Center, Petah Tikvah, Israel
| | - Sergey Dubinski
- Department of Radiation Oncology, Sheba Medical Center, Ramat Gan, Israel
| | - Teo Stanescu
- Department of Radiation Oncology, Princess Margaret Hospital Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Ronen Fluss
- The Biostatistics and Biomathematics Unit, The Gertner Institute for Health Policy and Epidemiology, Sheba Medical Center, Ramat Gan, Israel
| | - Laurence S Freedman
- The Biostatistics and Biomathematics Unit, The Gertner Institute for Health Policy and Epidemiology, Sheba Medical Center, Ramat Gan, Israel
| | - Maoz Ben-Ayun
- Department of Radiation Oncology, Sheba Medical Center, Ramat Gan, Israel
| | - Zvi Symon
- Department of Radiation Oncology, Sheba Medical Center, Ramat Gan, Israel; School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Courtney PT, Valle LF, Raldow AC, Steinberg ML. MRI-Guided Radiation Therapy-An Emerging and Disruptive Process of Care: Healthcare Economic and Policy Considerations. Semin Radiat Oncol 2024; 34:4-13. [PMID: 38105092 DOI: 10.1016/j.semradonc.2023.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
MRI-guided radiation therapy (MRgRT) is an emerging, innovative technology that provides opportunities to transform and improve the current clinical care process in radiation oncology. As with many new technologies in radiation oncology, careful evaluation from a healthcare economic and policy perspective is required for its successful implementation. In this review article, we describe the current evidence surrounding MRgRT, framing it within the context of value within the healthcare system. Additionally, we highlight areas in which MRgRT may disrupt the current process of care, and discuss the evidence thresholds and timeline required for the widespread adoption of this promising technology.
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Affiliation(s)
- P Travis Courtney
- Department of Radiation Oncology, University of California, Los Angeles, CA
| | - Luca F Valle
- Department of Radiation Oncology, University of California, Los Angeles, CA
| | - Ann C Raldow
- Department of Radiation Oncology, University of California, Los Angeles, CA
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California, Los Angeles, CA.
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