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Guan M, Zhang D, Zhao Y, Mao M, Shen K, Wang X, Bi C. Nimotuzumab combined with radiotherapy+/- chemotherapy for definitive treatment of locally advanced squamous cell carcinoma of head and neck: a metanalysis of randomized controlled trials. Front Oncol 2024; 14:1380428. [PMID: 38939342 PMCID: PMC11208318 DOI: 10.3389/fonc.2024.1380428] [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: 02/01/2024] [Accepted: 04/12/2024] [Indexed: 06/29/2024] Open
Abstract
Objectives To assess the efficacy and safety of nimotuzumab in combination with radiotherapy or chemoradiotherapy for locally advanced head and neck squamous cell carcinoma. Methods Systematic searches were performed on PubMed, Web of Science, Embase, Cochrane Library, China National Knowledge Infrastructure, China Biomedical Medicine, Wanfang, VIP databases. Seven eligible randomized controlled trials (n = 1012) were selected through rigorous inclusion and exclusion criteria. Results A total of 1012 cases were included. including 508 (50.2%) in the nimotuzumab combination treatment group; There were 504 cases (49.8%) in the control group. The results of meta-analysis showed that the overall survival (Hazard Ratio [HR]=0.75, 95% Confidence Interval [CI]: 0.62-0.90, P<0.05), progression-free survival (HR=0.69, 95% CI: 0.54-0.87, P<0.05), complete response rate (Risk Ratio [RR]=1.52, 95% CI: 1.24-1.86, P<0.05), and objective response rate (RR=1.32, 95% CI: 1.17-1.48, P<0.05) were significantly improved in the nimotuzumab combination treatment group compared with the control group. In terms of the incidence of adverse effects, only the incidence of rash was the nimotuzumab combination group higher than in the treatment alone group, and there was no significant difference between the remaining adverse reactions (neutropenia, anemia, nausea/vomiting, mucositis, dermatitis, dysphagia). Conclusion Nimotuzumab combined with radiotherapy or chemoradiotherapy is more effective than radiotherapy alone or chemoradiotherapy in locally advanced squamous cell carcinoma of the head and neck, and the safety profile is controllable. Therefore, the addition of nimotuzumab to treatment is expected to be an effective treatment option for this disease. However, more prospective randomized controlled trials are needed to fully explore the effectiveness of this treatment in patients with locally advanced head and neck squamous cell carcinoma. Systematic Review Registration identifier PROSPERO (CRD: 42022383313).
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Affiliation(s)
- Meng Guan
- Department of Oncology, The First People's Hospital of Jiangxia District, Wuhan City and Union Jiangnan Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Dan Zhang
- The First Clinical College of Xuzhou Medical University, Xuzhou, China
| | - Yue Zhao
- The First Clinical College of Xuzhou Medical University, Xuzhou, China
| | - Mingdi Mao
- The First Clinical College of Xuzhou Medical University, Xuzhou, China
| | - Kang Shen
- Siyang Hospital Oncology Department, Suqian, China
| | - Xia Wang
- The First Clinical College of Xuzhou Medical University, Xuzhou, China
| | - Chun Bi
- Siyang Hospital Oncology Department, Suqian, China
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Calvert M, King M, Mercieca-Bebber R, Aiyegbusi O, Kyte D, Slade A, Chan AW, Basch E, Bell J, Bennett A, Bhatnagar V, Blazeby J, Bottomley A, Brown J, Brundage M, Campbell L, Cappelleri JC, Draper H, Dueck AC, Ells C, Frank L, Golub RM, Griebsch I, Haywood K, Hunn A, King-Kallimanis B, Martin L, Mitchell S, Morel T, Nelson L, Norquist J, O'Connor D, Palmer M, Patrick D, Price G, Regnault A, Retzer A, Revicki D, Scott J, Stephens R, Turner G, Valakas A, Velikova G, von Hildebrand M, Walker A, Wenzel L. SPIRIT-PRO Extension explanation and elaboration: guidelines for inclusion of patient-reported outcomes in protocols of clinical trials. BMJ Open 2021; 11:e045105. [PMID: 34193486 PMCID: PMC8246371 DOI: 10.1136/bmjopen-2020-045105] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 12/21/2020] [Accepted: 01/08/2021] [Indexed: 01/21/2023] Open
Abstract
Patient-reported outcomes (PROs) are used in clinical trials to provide valuable evidence on the impact of disease and treatment on patients' symptoms, function and quality of life. High-quality PRO data from trials can inform shared decision-making, regulatory and economic analyses and health policy. Recent evidence suggests the PRO content of past trial protocols was often incomplete or unclear, leading to research waste. To address this issue, international, consensus-based, PRO-specific guidelines were developed: the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT)-PRO Extension. The SPIRIT-PRO Extension is a 16-item checklist which aims to improve the content and quality of aspects of clinical trial protocols relating to PRO data collection to minimise research waste, and ultimately better inform patient-centred care. This SPIRIT-PRO explanation and elaboration (E&E) paper provides information to promote understanding and facilitate uptake of the recommended checklist items, including a comprehensive protocol template. For each SPIRIT-PRO item, we provide a detailed description, one or more examples from existing trial protocols and supporting empirical evidence of the item's importance. We recommend this paper and protocol template be used alongside the SPIRIT 2013 and SPIRIT-PRO Extension paper to optimise the transparent development and review of trial protocols with PROs.
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Affiliation(s)
- Melanie Calvert
- Centre for Patient Reported Outcome Research, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Birmingham Health Partners Centre for Regulatory Science and Innovation, University of Birmingham, Birmingham, UK
- NIHR Biomedical Research Centre, Institute of Translational Medicine, Birmingham, UK
- NIHR Surgical Reconstruction and Microbiology Research Centre, Birmingham, UK
- NIHR Applied Research Collaboration West Midlands, University of Birmingham, Birmingham, UK
| | - Madeleine King
- Faculty of Science, School of Psychology, University of Sydney, Sydney, New South Wales, Australia
| | - Rebecca Mercieca-Bebber
- Faculty of Medicine and Health, NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Olalekan Aiyegbusi
- Centre for Patient Reported Outcome Research, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- NIHR Biomedical Research Centre, Institute of Translational Medicine, Birmingham, UK
| | - Derek Kyte
- Centre for Patient Reported Outcome Research, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Anita Slade
- Centre for Patient Reported Outcome Research, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- NIHR Surgical Reconstruction and Microbiology Research Centre, Birmingham, UK
| | - An-Wen Chan
- Women's College Research Institute, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - E Basch
- University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jill Bell
- Oncology Digital Health, AstraZeneca, Gaithersburg, Maryland, USA
| | - Antonia Bennett
- Cancer Outcomes Research Program, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | - Jane Blazeby
- NIHR Bristol Biomedical Research Centre, University of Bristol, Bristol, UK
- Division of Surgery, Head and Neck, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Andrew Bottomley
- Department of Quality of Life, European Organisation for Research and Treatment of Cancer, Brussels, Belgium
| | - Julia Brown
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Michael Brundage
- Department of Oncology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada
| | - Lisa Campbell
- Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Joseph C Cappelleri
- Global Biometrics & Data Management-Statistics, Pfizer Inc, New York City, New York, USA
| | | | - Amylou C Dueck
- Department of Health Sciences Research, Mayo Clinic, Scottsdale, Arizona, USA
| | - Carolyn Ells
- School of Population and Global Health, McGill University, Montreal, Quebec, Canada
| | - Lori Frank
- Patient-Centered Outcomes Research Institute, Washington, DC, USA
| | | | | | - Kirstie Haywood
- Warwick Research in Nursing, University of Warwick, Warwick Medical School, Coventry, UK
| | | | | | | | | | - Thomas Morel
- Patient-Centered Outcomes Research, UCB Pharma, Brussels, Belgium
| | - Linda Nelson
- Value Evidence and Outcomes-Patient Centered Outcomes, GSK, Collegeville, Pennsylvania, USA
| | - Josephine Norquist
- Center for Observational Real-world Evidence (CORE), Patient-Centered Endpoints & Strategy, Merck & Co Inc, Kenilworth, New Jersey, USA
| | - Daniel O'Connor
- Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Michael Palmer
- Cancer Research Institute, Queen's University, Kingston, Ontario, Canada
| | - Donald Patrick
- Department of Health Services, University of Washington, Seattle, Washington, USA
| | - Gary Price
- Centre for Patient Reported Outcome Research, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Ameeta Retzer
- Centre for Patient Reported Outcome Research, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Jane Scott
- Johnson and Johnson, Janssen Global Services LLC, High Wycombe, UK
| | | | - Grace Turner
- Centre for Patient Reported Outcome Research, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- NIHR Surgical Reconstruction and Microbiology Research Centre, Birmingham, UK
| | - Antonia Valakas
- EMD Serono Inc, Healthcare Business of Merck KGaA, Darmstadt, Germany
| | - Galina Velikova
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - Maria von Hildebrand
- Centre for Patient Reported Outcome Research, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Anita Walker
- Centre for Patient Reported Outcome Research, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Lari Wenzel
- University of California, Irvine, California, USA
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Jones CM, Lyles A, Foley KG. A national cross-sectional survey investigating the use of endoscopic ultrasound in the diagnosis and treatment of oesophageal cancer in the UK. Clin Radiol 2021; 76:458-464. [PMID: 33752881 DOI: 10.1016/j.crad.2021.02.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/17/2021] [Indexed: 01/01/2023]
Abstract
AIM To evaluate variation in the pre-pandemic use of endoscopic ultrasound (EUS) for oesophageal cancer diagnosis and treatment planning up to 2019, and which factors contributed to this. MATERIALS AND METHODS A UK-wide online survey of oesophagogastric multidisciplinary team lead clinicians was undertaken to determine perceptions towards, and the use of, EUS to aid staging and treatment planning in oesophageal cancer. RESULTS Thirty-five responses were received, representing 97 UK National Health Service Trusts/Health Boards. A majority of centres (n=21, 60%) did not have formal written guidance for EUS use. Although all respondents had access to EUS, a perceived lack of utility (n=7) and concerns about delaying treatment start dates (n=8) each restricted EUS use for a fifth of respondents. For most centres (n=24, 68.6%), EUS use is case-specific, whereas for 10 (28.6%) EUS is used for all patients with potentially curable disease. A majority of centres use diagnostic positron-emission tomography for radiotherapy target volume delineation (TVD), whereas 22 (62.9%) use EUS. The factors contributing to decisions to use EUS for staging, TVD and surgical planning varied between centres. The proportion of centre respondents who would request EUS in each of six clinical scenarios varied considerably. CONCLUSION There were substantial differences in the patient and disease characteristics that are perceived to be indications for EUS use for both staging and treatment planning. Research to clarify in which patients with oesophageal cancer EUS affords benefit is required, as is urgent standardisation of its role in the diagnostic pathway.
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Affiliation(s)
- C M Jones
- Leeds Cancer Centre, The Leeds Teaching Hospitals NHS Trust, Leeds, UK; Radiotherapy Research Group, Faculty of Medicine & Health, University of Leeds, Leeds, UK.
| | - A Lyles
- Leeds Cancer Centre, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - K G Foley
- Department of Clinical Radiology, Velindre Cancer Centre, Cardiff, UK
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Derby S, Forshaw M, Lowrie C, Grose D, Marashi H, McLoone P, Wilson C, McIntosh D. Single modality radical radiotherapy is an acceptable alternative for the older patient with squamous cell carcinoma of the oesophagus. BMJ Open Gastroenterol 2021; 8:bmjgast-2020-000492. [PMID: 33504498 PMCID: PMC7843319 DOI: 10.1136/bmjgast-2020-000492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 12/01/2020] [Accepted: 12/20/2020] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Oesophageal cancer remains a common cause of cancer mortality worldwide. Increasingly, oncology centres are treating an older population and comorbidities may preclude multimodality treatment with chemoradiotherapy (CRT). We review outcomes of radical radiotherapy (RT) in an older population treating squamous cell carcinoma (SCC) oesophagus. METHODS Patients over 65 years receiving RT for SCC oesophagus between 2013 and 2016 in the West of Scotland were identified. Kaplan-Meier and Cox-regression analysis were used to compare overall survival (OS) between patients treated with radical RT and radical CRT. RESULTS There were 83 patients over 65 years treated with either RT (n=21) or CRT (n=62). There was no significant difference in median OS between CRT versus RT (26.8 months vs 28.5 months, p=0.92). All patients receiving RT completed their treatment whereas 11% of CRT patients did not complete treatment. CONCLUSION Survival in this non-trial older patient group managed with CRT is comparable to that reported in previous trials. RT shows better than expected outcomes which may reflect developments in RT technique. This review supports RT as an alternative in older patients, unfit for concurrent treatment.
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Affiliation(s)
- Sarah Derby
- Clinical Oncology, Beatson West of Scotland Cancer Centre, Glasgow, UK .,Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Matthew Forshaw
- Upper Gastrointestinal Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | - Caroline Lowrie
- Clinical Oncology, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Derek Grose
- Clinical Oncology, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Husam Marashi
- Clinical Oncology, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Philip McLoone
- Biostatistics, University of Glasgow Institute of Health and Wellbeing, Glasgow, UK
| | - Christina Wilson
- Clinical Oncology, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - David McIntosh
- Clinical Oncology, Beatson West of Scotland Cancer Centre, Glasgow, UK
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Chargari C, Levy A, Paoletti X, Soria JC, Massard C, Weichselbaum RR, Deutsch E. Methodological Development of Combination Drug and Radiotherapy in Basic and Clinical Research. Clin Cancer Res 2020; 26:4723-4736. [PMID: 32409306 DOI: 10.1158/1078-0432.ccr-19-4155] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 02/14/2020] [Accepted: 05/12/2020] [Indexed: 01/03/2023]
Abstract
Newer technical improvements in radiation oncology have been rapidly implemented in recent decades, allowing an improved therapeutic ratio. The development of strategies using local and systemic treatments concurrently, mainly targeted therapies, has however plateaued. Targeted molecular compounds and immunotherapy are increasingly being incorporated as the new standard of care for a wide array of cancers. A better understanding of possible prior methodology issues is therefore required and should be integrated into upcoming early clinical trials including individualized radiotherapy-drug combinations. The outcome of clinical trials is influenced by the validity of the preclinical proofs of concept, the impact on normal tissue, the robustness of biomarkers and the quality of the delivery of radiation. Herein, key methodological aspects are discussed with the aim of optimizing the design and implementation of future precision drug-radiotherapy trials.
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Affiliation(s)
- Cyrus Chargari
- Department of Radiation Oncology, Gustave Roussy, Université Paris-Saclay, Villejuif, France
- Université Paris-Sud, Orsay, France
- INSERM U1030, Molecular Radiotherapy, Gustave Roussy, Université Paris-Saclay, Villejuif, France
- Institut de Recherche Biomédicale des Armées, Brétigny sur Orge, France
| | - Antonin Levy
- Department of Radiation Oncology, Gustave Roussy, Université Paris-Saclay, Villejuif, France.
- Université Paris-Sud, Orsay, France
- INSERM U1030, Molecular Radiotherapy, Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - Xavier Paoletti
- University of Versailles St. Quentin, France
- Institut Curie INSERM U900, Biostatistics for Personalized Medicine Team, St. Cloud, France
| | | | - Christophe Massard
- Université Paris-Sud, Orsay, France
- Drug Development Department (DITEP), Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - Ralph R Weichselbaum
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, Illinois
| | - Eric Deutsch
- Department of Radiation Oncology, Gustave Roussy, Université Paris-Saclay, Villejuif, France.
- Université Paris-Sud, Orsay, France
- INSERM U1030, Molecular Radiotherapy, Gustave Roussy, Université Paris-Saclay, Villejuif, France
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Shi Z, Foley KG, Pablo de Mey J, Spezi E, Whybra P, Crosby T, van Soest J, Dekker A, Wee L. External Validation of Radiation-Induced Dyspnea Models on Esophageal Cancer Radiotherapy Patients. Front Oncol 2019; 9:1411. [PMID: 31921668 PMCID: PMC6927468 DOI: 10.3389/fonc.2019.01411] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 11/28/2019] [Indexed: 12/18/2022] Open
Abstract
Purpose: Radiation-induced lung disease (RILD), defined as dyspnea in this study, is a risk for patients receiving high-dose thoracic irradiation. This study is a TRIPOD (Transparent Reporting of A Multivariable Prediction Model for Individual Prognosis or Diagnosis) Type 4 validation of previously-published dyspnea models via secondary analysis of esophageal cancer SCOPE1 trial data. We quantify the predictive performance of these two models for predicting the maximal dyspnea grade ≥ 2 within 6 months after the end of high-dose chemo-radiotherapy for primary esophageal cancer. Materials and methods: We tested the performance of two previously published dyspnea risk models using baseline, treatment and follow-up data on 258 esophageal cancer patients in the UK enrolled into the SCOPE1 multi-center trial. The tested models were developed from lung cancer patients treated at MAASTRO Clinic (The Netherlands) from the period 2002 to 2011. The adverse event of interest was dyspnea ≥ Grade 2 (CTCAE v3) within 6 months after the end of radiotherapy. As some variables were missing randomly and cannot be imputed, 212 patients in the SCOPE1 were used for validation of model 1 and 255 patients were used for validation of model 2. The model parameter Forced Expiratory Volume in 1 s (FEV1), as a predictor to both validated models, was imputed using the WHO performance status. External validation was performed using an automated, decentralized approach, without exchange of individual patient data. Results: Out of 258 patients with esophageal cancer in SCOPE1 trial data, 38 patients (14.7%) developed radiation-induced dyspnea (≥ Grade 2) within 6 months after chemo-radiotherapy. The discrimination performance of the models in esophageal cancer patients treated with high-dose external beam radiotherapy was moderate, area under curve (AUC) of 0.68 (95% CI 0.55–0.76) and 0.70 (95% CI 0.58–0.77), respectively. The curves and AUCs derived by distributed learning were identical to the results from validation on a local host. Conclusion: We have externally validated previously published dyspnea models using an esophageal cancer dataset. FEV1 that is not routinely measured for esophageal cancer was imputed using WHO performance status. Prediction performance was not statistically different from previous training and validation sets. Risk estimates were dominated by WHO score in Model 1 and baseline dyspnea in Model 2. The distributed learning approach gave the same answer as local processing, and could be performed without accessing a validation site's individual patients-level data.
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Affiliation(s)
- Zhenwei Shi
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, Netherlands
| | | | - Juan Pablo de Mey
- Faculty of Health Medicine and Life Sciences (FHML), Maastricht University, Maastricht, Netherlands
| | - Emiliano Spezi
- School of Engineering, Cardiff University, Cardiff, United Kingdom
| | - Philip Whybra
- School of Engineering, Cardiff University, Cardiff, United Kingdom
| | - Tom Crosby
- Velindre Cancer Centre, Cardiff, United Kingdom
| | - Johan van Soest
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Andre Dekker
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Leonard Wee
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, Netherlands
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Piazzese C, Foley K, Whybra P, Hurt C, Crosby T, Spezi E. Discovery of stable and prognostic CT-based radiomic features independent of contrast administration and dimensionality in oesophageal cancer. PLoS One 2019; 14:e0225550. [PMID: 31756181 PMCID: PMC6874382 DOI: 10.1371/journal.pone.0225550] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 11/06/2019] [Indexed: 02/07/2023] Open
Abstract
The aim of this work was to investigate radiomic analysis of contrast and non-contrast enhanced planning CT images of oesophageal cancer (OC) patients in terms of stability, dimensionality and contrast agent dependency. The prognostic significance of CT-based radiomic features was also evaluated. Different 2D and 3D radiomic features were extracted from contrast and non-contrast enhanced CT images of 213 patients from the multi-centre SCOPE1 randomised controlled trial (RCT) in OC. Feature stability was evaluated by randomly dividing patients into three groups and identifying textures with similar distributions among groups with a Kruskal-Wallis analysis. A paired two-sided Wilcoxon signed rank test was used to assess for significant differences in the remaining corresponding 2D and 3D stable features. A prognostic model was constructed using clinical characteristics and remaining filtered features. The discriminative ability of significant variables was tested using Kaplan-Meier analysis. A total of 238 2D and 3D radiomic features were computed from oesophageal CT images. More than 75 features were stable if extracted from homogeneous cohort (contrast or non-contrast enhanced CT images) and inhomogeneous cohort (contrast and non-contrast enhanced CT images). Among the remaining corresponding stable features computed from both cohorts, only 4 features did not show a statistically significant difference if obtained in 2D or in 3D (p-value < 0.05). A Cox regression model constructed using 5 clinical variables (age, sex, tumour, node and metastasis (TNM) stage, WHO performance status and contrast administration) and 4 radiomic variables (inverse varianceGLCM, large distance emphasisGLDZM, zone distance non uniformity normGLDZM, zone distance varianceGLDZM), identified one radiomic feature (zone distance varianceGLDZM) that was significantly associated with overall survival (p-value = 0.032, HR = 1.25, 95% CI = 1.02-1.52). A significant difference in overall survival between groups was found when considering a threshold of zone distance varianceGLDZM equals to 1.70 (X2 = 7.692, df = 1, p-value = 0.006). Zone distance varianceGLDZM was identified as the only stable CT radiomic feature statistically correlated with overall survival, independent of dimensionality and contrast administration. This feature was able to identify high-risk patients and if validated, could be the subject of a future clinical trial aiming to improve clinical decision making and personalise OC treatment.
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Affiliation(s)
- Concetta Piazzese
- School of Engineering, Cardiff University, Cardiff, United Kingdom
- Velindre Cancer Centre, Cardiff, United Kingdom
| | | | - Philip Whybra
- School of Engineering, Cardiff University, Cardiff, United Kingdom
| | - Chris Hurt
- Centre for Trials Research, Cardiff, United Kingdom
| | - Tom Crosby
- Velindre Cancer Centre, Cardiff, United Kingdom
| | - Emiliano Spezi
- School of Engineering, Cardiff University, Cardiff, United Kingdom
- Velindre Cancer Centre, Cardiff, United Kingdom
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Jones CM, Spencer K, Hitchen C, Pelly T, Wood B, Hatfield P, Crellin A, Sebag-Montefiore D, Goody R, Crosby T, Radhakrishna G. Hypofractionated Radiotherapy in Oesophageal Cancer for Patients Unfit for Systemic Therapy: A Retrospective Single-Centre Analysis. Clin Oncol (R Coll Radiol) 2019; 31:356-364. [PMID: 30737068 DOI: 10.1016/j.clon.2019.01.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 11/24/2018] [Accepted: 12/06/2018] [Indexed: 02/06/2023]
Abstract
AIMS Chemoradiotherapy (CRT) is established as a superior treatment option to definitive radiotherapy in the non-surgical management of oesophageal cancer. For patients precluded from CRT through choice or comorbidity there is little evidence to guide delivery of single-modality radiotherapy. In this study we outline outcomes for patients unfit for CRT who received a hypofractionated radiotherapy (HRT) regimen. MATERIALS AND METHODS A retrospective UK single-centre analysis of 61 consecutive patients with lower- or middle-third adenocarcinoma (OAC; 61%) or squamous cell carcinoma of the oesophagus managed using HRT with radical intent between April 2009 and 2014. Treatment consisted of 50 Gy in 16 fractions (n = 49, 80.3%) or 50-52.5 Gy in 20 fractions (n = 12, 19.7%). Outcomes were referenced against a contemporaneous comparator cohort of 80 (54% OAC) consecutive patients managed with conventionally fractionated CRT within the same centre. RESULTS Three-year and median overall survival were, respectively, 56.9% and 29 months with HRT compared with 55.5% and 26 months for CRT; adjusted hazard ratio 0.79 (95% confidence interval 0.48-1.28). Grade 3 and 4 toxicity rates were low at 16.4% (n = 10) for those receiving HRT and 40.2% (n = 32) for the CRT group. In patients with OAC, CRT delivered superior overall survival (hazard ratio 0.46; 95% confidence interval 0.25-0.85) and progression-free survival (hazard ratio 0.45; 95% confidence interval 0.23-0.88) when compared with HRT. CONCLUSIONS The HRT regimen described here was safe and tolerable in patients unable to receive CRT, and delivered promising survival outcomes. The use of HRT for the treatment of oesophageal cancer, both alone and as a sequential or concurrent treatment with chemotherapy, requires further study. New precision radiotherapy technologies may provide additional scope for improving outcomes in oesophageal cancer using HRT-based approaches and should be evaluated.
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Affiliation(s)
- C M Jones
- Radiotherapy Research Group, Leeds Cancer Centre, The Leeds Teaching Hospitals NHS Trust, Leeds, UK; School of Molecular & Cellular Biology, Faculty of Biological Sciences, University of Leeds, Leeds, UK; Leeds Institute of Medical Research at St James's, Faculty of Medicine & Health, University of Leeds, Leeds, UK
| | - K Spencer
- Radiotherapy Research Group, Leeds Cancer Centre, The Leeds Teaching Hospitals NHS Trust, Leeds, UK; Leeds Institute of Medical Research at St James's, Faculty of Medicine & Health, University of Leeds, Leeds, UK; Leeds Institute of Health Sciences, Faculty of Medicine & Health, University of Leeds, Leeds, UK
| | - C Hitchen
- School of Medicine, Faculty of Medicine & Health, University of Leeds, Leeds, UK
| | - T Pelly
- School of Medicine, Faculty of Medicine & Health, University of Leeds, Leeds, UK
| | - B Wood
- School of Medicine, Faculty of Medicine & Health, University of Leeds, Leeds, UK
| | - P Hatfield
- Radiotherapy Research Group, Leeds Cancer Centre, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - A Crellin
- Radiotherapy Research Group, Leeds Cancer Centre, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - D Sebag-Montefiore
- Radiotherapy Research Group, Leeds Cancer Centre, The Leeds Teaching Hospitals NHS Trust, Leeds, UK; Leeds Institute of Medical Research at St James's, Faculty of Medicine & Health, University of Leeds, Leeds, UK
| | - R Goody
- Radiotherapy Research Group, Leeds Cancer Centre, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - T Crosby
- Velindre Cancer Centre, Velindre Hospital, Cardiff, UK
| | - G Radhakrishna
- Radiotherapy Research Group, Leeds Cancer Centre, The Leeds Teaching Hospitals NHS Trust, Leeds, UK.
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Mazorra Z, Chao L, Lavastida A, Sanchez B, Ramos M, Iznaga N, Crombet T. Nimotuzumab: beyond the EGFR signaling cascade inhibition. Semin Oncol 2018; 45:18-26. [DOI: 10.1053/j.seminoncol.2018.04.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 04/20/2018] [Indexed: 12/11/2022]
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10
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Wills L, Maggs R, Lewis G, Jones G, Nixon L, Staffurth J, Crosby T. Quality assurance of the SCOPE 1 trial in oesophageal radiotherapy. Radiat Oncol 2017; 12:179. [PMID: 29141663 PMCID: PMC5688711 DOI: 10.1186/s13014-017-0916-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 11/02/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND SCOPE 1 was the first UK based multi-centre trial involving radiotherapy of the oesophagus. A comprehensive radiotherapy trials quality assurance programme was launched with two main aims: 1. To assist centres, where needed, to adapt their radiotherapy techniques in order to achieve protocol compliance and thereby enable their participation in the trial. 2. To support the trial's clinical outcomes by ensuring the consistent planning and delivery of radiotherapy across all participating centres. METHODS A detailed information package was provided and centres were required to complete a benchmark case in which the delineated target volumes and organs at risk, dose distribution and completion of a plan assessment form were assessed prior to recruiting patients into the trial. Upon recruiting, the quality assurance (QA) programme continued to monitor the outlining and planning of radiotherapy treatments. Completion of a questionnaire was requested in order to gather information about each centre's equipment and techniques relating to their trial participation and to assess the impact of the trial nationally on standard practice for radiotherapy of the oesophagus. During the trial, advice was available for individual planning issues, and was circulated amongst the SCOPE 1 community in response to common areas of concern using bulletins. RESULTS 36 centres were supported through QA processes to enable their participation in SCOPE1. We discuss the issues which have arisen throughout this process and present details of the benchmark case solutions, centre questionnaires and on-trial protocol compliance. The range of submitted benchmark case GTV volumes was 29.8-67.8cm3; and PTV volumes 221.9-513.3 cm3. For the dose distributions associated with these volumes, the percentage volume of the lungs receiving 20Gy (V20Gy) ranged from 20.4 to 33.5%. Similarly, heart V40Gy ranged from 16.1 to 33.0%. Incidence of incorrect outlining of OAR volumes increased from 50% of centres at benchmark case, to 64% on trial. Sixty-five percent of centres, who returned the trial questionnaire, stated that their standard practice had changed as a result of their participation in the SCOPE1 trial. CONCLUSIONS The SCOPE 1 QA programme outcomes lend support to the trial's clinical conclusions. The range of patient planning outcomes for the benchmark case indicated, at the outset of the trial, the significant degree of variation present in UK oesophageal radiotherapy planning outcomes, despite the presence of a protocol. This supports the case for increasingly detailed definition of practice by means of consensus protocols, training and peer review. The incidence of minor inconsistencies of technique highlights the potential for improved QA systems and the need for sufficient resource for this to be addressed within future trials. As indicated in questionnaire responses, the QA exercise as a whole has contributed to greater consistency of oesophageal radiotherapy in the UK via the adoption into standard practice of elements of the protocol. TRIAL REGISTRATION The SCOPE1 trial is an International Standard Randomized Controlled Trial, ISRCTN47718479 .
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Affiliation(s)
- Lucy Wills
- Department of Medical Physics, Velindre Cancer Centre, Cardiff, CF14 2TL UK
- National Radiotherapy Trials QA (RTTQA) Group, Velindre Cancer Centre, Cardiff, CF14 2TL UK
| | - Rhydian Maggs
- Department of Medical Physics, Velindre Cancer Centre, Cardiff, CF14 2TL UK
- National Radiotherapy Trials QA (RTTQA) Group, Velindre Cancer Centre, Cardiff, CF14 2TL UK
| | - Geraint Lewis
- Department of Medical Physics, Velindre Cancer Centre, Cardiff, CF14 2TL UK
- National Radiotherapy Trials QA (RTTQA) Group, Velindre Cancer Centre, Cardiff, CF14 2TL UK
| | - Gareth Jones
- Department of Medical Physics, Velindre Cancer Centre, Cardiff, CF14 2TL UK
- National Radiotherapy Trials QA (RTTQA) Group, Velindre Cancer Centre, Cardiff, CF14 2TL UK
| | - Lisette Nixon
- Wales Cancer Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, CF14 1YS UK
| | - John Staffurth
- School of Medicine, Cardiff University, University Hospital Wales, Cardiff, CF14 4XN UK
- National Radiotherapy Trials QA (RTTQA) Group, Velindre Cancer Centre, Cardiff, CF14 2TL UK
| | - Tom Crosby
- Department of Clinical Oncology, Velindre Cancer Centre, Cardiff, CF14 2TL UK
| | - on behalf of the SCOPE 1 trial management group and collaborators
- Department of Medical Physics, Velindre Cancer Centre, Cardiff, CF14 2TL UK
- Department of Clinical Oncology, Velindre Cancer Centre, Cardiff, CF14 2TL UK
- Wales Cancer Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, CF14 1YS UK
- School of Medicine, Cardiff University, University Hospital Wales, Cardiff, CF14 4XN UK
- National Radiotherapy Trials QA (RTTQA) Group, Velindre Cancer Centre, Cardiff, CF14 2TL UK
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Impact of Positron Emission Tomography and Endoscopic Ultrasound Length of Disease Difference on Treatment Planning in Patients with Oesophageal Cancer. Clin Oncol (R Coll Radiol) 2017; 29:760-766. [DOI: 10.1016/j.clon.2017.07.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 07/13/2017] [Accepted: 07/19/2017] [Indexed: 11/21/2022]
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Modi RM, Mikhail S, Ciombor K, Perry KA, Hinton A, Stanich PP, Zhang C, Conwell DL, Krishna SG. Outcomes of nutritional interventions to treat dysphagia in esophageal cancer: a population-based study. Dis Esophagus 2017; 30:1-8. [PMID: 28881909 DOI: 10.1093/dote/dox101] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Indexed: 12/11/2022]
Abstract
Esophageal cancer (EC) is increasing in prevalence due to rising incidence and improved treatment strategies. Dysphagia is a significant morbidity in patients with EC requiring nutritional intervention. We sought to evaluate outcomes of nutritional interventions for EC patients hospitalized with dysphagia at a population level. The National Inpatient Sample (2002-2012) was utilized to include all adult inpatients (≥18 years of age) with EC and presence of dysphagia and stricture that underwent nutritional interventions including feeding tube (FT) placement, esophageal stenting, or parenteral nutrition (PN). Temporal trends were examined with multivariate analysis performed for mortality, length of stay (LOS), and cost of hospitalization. A total of 509,593 EC patients had 12,205 hospitalizations related to dysphagia. The hospitalization rates doubled over the study period (1.52% vs. 3.28%, p < 0.001). The most common nutritional intervention was FT (27%), followed by esophageal stenting (13%), and PN (11%). PN was more frequently associated with a diagnosis of sepsis (6.1%, p = 0.023) compared to FT (2.5%) or esophageal stenting (1.8%). Multivariate analysis demonstrated FT and esophageal stenting had comparable mortality (OR 1.06, 95% CI: 0.49, 2.32); however, PN was associated with higher mortality (OR 2.37, 95% CI: 1.22, 4.63), cost of hospitalization ($5,510, 95% CI: 2,262, 8,759), and LOS (2.13 days, 95% CI: 0.72, 3.54). This study shows that hospitalizations for EC with dysphagia and related nutritional interventions are increasing. As a single modality, parenteral nutrition should be avoided. Among our esophageal stent and FT population, further studies are necessary to determine adequate interventions based on disease stage.
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Affiliation(s)
| | | | | | - K A Perry
- Division of General and Gastrointestinal Surgery
| | - A Hinton
- Division of Gastroenterology, Hepatology and Nutrition, Wexner Medical Center
| | - P P Stanich
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, Ohio, USA
| | - C Zhang
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, Ohio, USA
| | - D L Conwell
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, Ohio, USA
| | - S G Krishna
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, Ohio, USA
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Cox S, Hurt C, Grenader T, Mukherjee S, Bridgewater J, Crosby T. The prognostic value of derived neutrophil to lymphocyte ratio in oesophageal cancer treated with definitive chemoradiotherapy. Radiother Oncol 2017; 125:154-159. [PMID: 28893415 PMCID: PMC5648078 DOI: 10.1016/j.radonc.2017.08.023] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 08/29/2017] [Accepted: 08/29/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE The derived neutrophil-lymphocyte ratio (dNLR) is a validated prognostic biomarker for cancer survival but has not been extensively studied in locally-advanced oesophageal cancer treated with definitive chemoradiotherapy (dCRT). We aimed to identify the prognostic value of dNLR in patients recruited to the SCOPE1 trial. MATERIALS AND METHODS 258 patients were randomised to receive dCRT±cetuximab. Kaplan-Meier's curves and both univariable and multivariable Cox regression models were calculated for overall survival (OS), progression free survival (PFS), local PFS inside the radiation volume (LPFSi), local PFS outside the radiation volume (LPFSo), and distant PFS (DPFS). RESULTS An elevated pre-treatment dNLR≥2 was significantly associated with decreased OS in univariable (HR 1.74 [95% CI 1.29-2.35], p<0.001) and multivariable analyses (HR 1.64 [1.17-2.29], p=0.004). Median OS was 36months (95% CI 27.8-42.4) if dNLR<2 and 18.4months (95% CI 14.1-24.9) if dNLR≥2. All measures of PFS were also significantly reduced with an elevated dNLR. dNLR was prognostic for OS in cases of squamous cell carcinoma with a non-significant trend for adenocarcinoma/undifferentiated tumours. CONCLUSIONS An elevated pre-treatment dNLR may be an independent prognostic biomarker for OS and PFS in oesophageal cancer patients treated with definitive CRT. dNLR is a simple, inexpensive and readily available tool for risk-stratification and should be considered for use in future oesophageal cancer clinical trials. The SCOPE1 trial was an International Standard Randomised Controlled Trial [number 47718479].
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Affiliation(s)
- Samantha Cox
- Department of Oncology, Velindre Cancer Centre, Cardiff, United Kingdom.
| | - Christopher Hurt
- Wales Cancer Trials Unit, Cardiff University, Cardiff, United Kingdom.
| | - Tal Grenader
- Oncology Institute, Shaare Zedek Medical Centre, Jerusalem, Israel.
| | - Somnath Mukherjee
- Department of Oncology, Oxford Cancer Centre, University of Oxford, Churchill Hospital, Oxford, United Kingdom.
| | - John Bridgewater
- University College Hospital Macmillan Cancer Centre, London, United Kingdom.
| | - Thomas Crosby
- Department of Oncology, Velindre Cancer Centre, Cardiff, United Kingdom.
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Rice L, Goldsmith C, Green MM, Cleator S, Price PM. An effective deep-inspiration breath-hold radiotherapy technique for left-breast cancer: impact of post-mastectomy treatment, nodal coverage, and dose schedule on organs at risk. BREAST CANCER-TARGETS AND THERAPY 2017; 9:437-446. [PMID: 28652810 PMCID: PMC5476442 DOI: 10.2147/bctt.s130090] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background We developed, applied, and prospectively evaluated a novel deep-inspiration breath-hold (DIBH) screening and delivery technique to optimize cardiac sparing in left-breast radiotherapy (RT) at our clinic. The impact of set-up and dose variables upon organs at risk (OAR) dose in DIBH RT was investigated. Methods and materials All patients with left-breast cancer referred between 2011 and 2014 – of all disease stages, set-up variations, and dose prescriptions – were included. Radiographers used simple screening criteria at CT simulation, to systematically assess patients for obvious DIBH benefit and capability. Selected patients received forward-planned intensity-modulated RT (IMRT) based on a DIBH CT scan. A 3D-surface monitoring system with visual feedback assured reproducible DIBH positioning during gated radiation delivery. Patient, target set-up, and OAR dose information were collected at treatment. Results Of 272 patients who were screened, 4 withdrew, 56 showed no obvious advantage, and 56 showed benefit but had suitability issues; 156 patients were selected and successfully completed DIBH treatment. The technique was compatible with complex set-up and optimal target coverage was maintained. Comparison of free-breathing (FB) and DIBH treatment plans in the first five patients enrolled confirmed DIBH reduced heart radiation by ~80% (p = 0.032). Low OAR doses were achieved overall: the mean (95% confidence interval [CI]) heart dose was 1.17 (1.12–1.22) Gy, and the mean ipsilateral lung dose was 5.26 (5.01–5.52) Gy. Patients who underwent a standard radiation schedule (40 Gy/15#) after breast-conserving surgery had the lowest OAR doses: post-mastectomy treatment, simultaneous supraclavicular (SCV) node coverage, and alternative dose schedule (50 Gy/25#) were interrelated variables associated with increased OAR risk and compromised ipsilateral lung dose constraints. Conclusion The DIBH technique was successfully implemented and resulted in optimally low heart radiation. All patients who demonstrate sufficient DIBH technique at planning CT are now offered DIBH RT at our clinic. Patients with more advanced disease, particularly those with additional pulmonary risk factors, warrant additional focus to improve lung sparing.
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Affiliation(s)
- Lynsey Rice
- Department of Radiation Oncology, The Harley Street Clinic.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - Christy Goldsmith
- Department of Radiation Oncology, The Harley Street Clinic.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - Melanie Ml Green
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Susan Cleator
- Department of Radiation Oncology, The Harley Street Clinic.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - Patricia M Price
- Department of Radiation Oncology, The Harley Street Clinic.,Department of Surgery and Cancer, Imperial College London, London, UK
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15
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Crosby T, Hurt CN, Falk S, Gollins S, Staffurth J, Ray R, Bridgewater JA, Geh JI, Cunningham D, Blazeby J, Roy R, Maughan T, Griffiths G, Mukherjee S. Long-term results and recurrence patterns from SCOPE-1: a phase II/III randomised trial of definitive chemoradiotherapy +/- cetuximab in oesophageal cancer. Br J Cancer 2017; 116:709-716. [PMID: 28196063 PMCID: PMC5355926 DOI: 10.1038/bjc.2017.21] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 01/03/2017] [Accepted: 01/16/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The SCOPE-1 study tested the role of adding cetuximab to conventional definitive chemoradiotherapy (dCRT), and demonstrated greater toxicity and worse survival outcomes. We present the long-term outcomes and patterns of recurrence. METHODS SCOPE-1 was a phase II/III trial in which patients were randomised to cisplatin 60 mg m-2 (day 1) and capecitabine 625 mg m-2 bd (days 1-21) for four cycles +/- cetuximab 400 mg m-2 day 1 then by 250 mg m-2 weekly. Radiotherapy consisted of 50 Gy/25# given concurrently with cycles 3 and 4. Recruitment was between February 2008 and February 2012, when the IDMC recommended closure on the basis of futility. RESULTS About 258 patients (dCRT=129; dCRT+cetuximab (dCRT+C)=129) were recruited from 36 centres. About 72.9% (n=188) had squamous cell histology. The median follow-up (IQR) was 46.2 (35.9-48.3) months for surviving patients. The median overall survival (OS; months; 95% CI) was 34.5 (24.7-42.3) in dCRT and 24.7 (18.6-31.3) in dCRT+C (hazard ratio (HR)=1.25, 95% CIs: 0.93-1.69, P=0.137). Median progression-free survival (PFS; months; 95% CI) was 24.1 (15.3-29.9) and 15.9 (10.7-20.8) months, respectively (HR=1.28, 95% CIs: 0.94-1.75; P=0.114). On multivariable analysis only earlier stage, full-dose RT, and higher cisplatin dose intensity were associated with improved OS. CONCLUSIONS The mature analysis demonstrates that the dCRT regimen used in the study provided useful survival outcomes despite its use in patients who were largely unfit for surgery or who had inoperable disease. Given the competing risk of systemic and local failure, future studies should continue to focus on enhancing local control as well as optimising systemic therapy.
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Affiliation(s)
- T Crosby
- Velindre Cancer Centre, Velindre Hospital, Cardiff CF14 2TL, UK
| | - C N Hurt
- Wales Cancer Trials Unit, Cardiff University, Cardiff CF14 4YS, UK
| | - S Falk
- Bristol Haematology and Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Bristol BS2 8ED, UK
| | - S Gollins
- North Wales Cancer Treatment Centre, Conwy and Denbighshire NHS Trust, Rhyl LL18 5UJ, UK
| | - J Staffurth
- Velindre Cancer Centre, Velindre Hospital, Cardiff CF14 2TL, UK
| | - R Ray
- Wales Cancer Trials Unit, Cardiff University, Cardiff CF14 4YS, UK
| | - J A Bridgewater
- UCL Cancer Institute, University College London, London WC1E 6BT, UK
| | - J I Geh
- Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust Birmingham B15 2GW, UK
| | - D Cunningham
- The Royal Marsden Hospital NHS Foundation Trust, London SM2 5PT, UK
| | - J Blazeby
- Centre for Surgical Research, University of Bristol, Bristol BS8 2PS, UK
| | - R Roy
- Diana Princess of Wales Hospital, Northern Lincolnshire and Goole NHS Foundation Trust, Grimsby DN33 2BA, UK
| | - T Maughan
- CRUK/MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford OX3 7DQ, UK
| | - G Griffiths
- Southampton Clinical Trials Unit, University of Southampton, Southampton SO16 6YD, UK
| | - S Mukherjee
- CRUK/MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford OX3 7DQ, UK
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16
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Cox S, Powell C, Carter B, Hurt C, Mukherjee S, Crosby TDL. Role of nutritional status and intervention in oesophageal cancer treated with definitive chemoradiotherapy: outcomes from SCOPE1. Br J Cancer 2016; 115:172-7. [PMID: 27328311 PMCID: PMC4947693 DOI: 10.1038/bjc.2016.129] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 04/18/2016] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Malnutrition is common in oesophageal cancer. We aimed to identify nutritional prognostic factors and survival outcomes associated with nutritional intervention in the SCOPE1 (Study of Chemoradiotherapy in OesoPhageal Cancer with or without Erbitux) trial. METHODS Two hundred and fifty eight patients were randomly allocated to definitive chemoradiotherapy (dCRT) +/- cetuximab. Nutritional Risk Index (NRI) scores were calculated; NRI<100 identified patients at risk of malnutrition. Nutritional intervention included dietary advice, oral supplementation or major intervention (enteral feeding/tube placement). Univariable and multivariable analyses using Cox proportional hazard modelling were conducted. RESULTS At baseline NRI<100 strongly predicted for reduced overall survival (hazard ratio (HR) 12.45, 95% CI 5.24-29.57; P<0.001). Nutritional intervention improved survival if provided at baseline (dietary advice (HR 0.12, P=0.004), oral supplementation (HR 0.13, P<0.001) or major intervention (HR 0.13, P=0.003)), but not if provided later in the treatment course. Cetuximab patients receiving major nutritional intervention had worse outcomes compared with controls (13 vs 28 months, P=0.003). CONCLUSIONS Pre-treatment assessment and correction of malnutrition may improve survival outcomes in oesophageal cancer patients treated with dCRT. Nutritional Risk Index is a simple and objective screening tool to identify patients at risk of malnutrition.
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Affiliation(s)
- S Cox
- Department of Oncology, Velindre Cancer Centre, Cardiff CF14 2TL, UK
| | - C Powell
- Department of Oncology, Velindre Cancer Centre, Cardiff CF14 2TL, UK
| | - B Carter
- Institute of Primary Care and Public Health, Cardiff University School of Medicine, Neuadd Meirionnydd, Heath Park, Cardiff CF14 4YS, UK
| | - C Hurt
- Wales Cancer Trials Unit, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff CF14 4YS, UK
| | - Somnath Mukherjee
- Department of Oncology, Oxford Cancer Centre, University of Oxford, Level 2 Admin, Churchill Hospital, Oxford OX3 7LE, UK
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Kjær I, Lindsted T, Fröhlich C, Olsen JV, Horak ID, Kragh M, Pedersen MW. Cetuximab Resistance in Squamous Carcinomas of the Upper Aerodigestive Tract Is Driven by Receptor Tyrosine Kinase Plasticity: Potential for mAb Mixtures. Mol Cancer Ther 2016; 15:1614-26. [PMID: 27196767 DOI: 10.1158/1535-7163.mct-15-0565] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 04/28/2016] [Indexed: 11/16/2022]
Abstract
Squamous cell carcinomas (SCC) arising in upper parts of the aerodigestive tract are among the leading causes of death worldwide. EGFR has been found to play an essential role in driving the malignancy of SCC of the upper aerodigestive tract (SCCUAT), but, despite this, clinical results using a range of different EGFR-targeted agents have been disappointing. Cetuximab is currently the only EGFR-targeted agent approved by the FDA for treatment of SCCUAT. However, intrinsic and acquired cetuximab resistance is a major problem for effective therapy. Thus, a better understanding of the mechanisms responsible for cetuximab resistance is valuable for development of the next generation of antibody therapeutics. In order to better understand the underlying mechanisms of cetuximab resistance in SCCUAT, we established from cetuximab-sensitive models cell lines with acquired resistance to cetuximab by continuous selective pressure in vitro and in vivo Our results show that resistant clones maintain partial dependency on EGFR and that receptor tyrosine kinase plasticity mediated by HER3 and IGF1R plays an essential role. A multitarget mAb mixture against EGFR, HER3, and IGF1R was able to overcome cetuximab resistance in vitro To our surprise, these findings could be extended to include SCCUAT cell lines with intrinsic resistance to cetuximab, suggesting that the triad consisting of EGFR, HER3, and IGF1R plays a key role in SCCUAT. Our results thus provide a rationale for simultaneous targeting of EGFR, HER3, and IGF1R in SCCUAT. Mol Cancer Ther; 15(7); 1614-26. ©2016 AACR.
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Affiliation(s)
- Ida Kjær
- Symphogen A/S, Ballerup, Denmark. The Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Jesper Velgaard Olsen
- The Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Warren S, Partridge M, Bolsi A, Lomax AJ, Hurt C, Crosby T, Hawkins MA. An Analysis of Plan Robustness for Esophageal Tumors: Comparing Volumetric Modulated Arc Therapy Plans and Spot Scanning Proton Planning. Int J Radiat Oncol Biol Phys 2016; 95:199-207. [PMID: 27084641 PMCID: PMC4838670 DOI: 10.1016/j.ijrobp.2016.01.044] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 01/18/2016] [Accepted: 01/22/2016] [Indexed: 12/25/2022]
Abstract
PURPOSE Planning studies to compare x-ray and proton techniques and to select the most suitable technique for each patient have been hampered by the nonequivalence of several aspects of treatment planning and delivery. A fair comparison should compare similarly advanced delivery techniques from current clinical practice and also assess the robustness of each technique. The present study therefore compared volumetric modulated arc therapy (VMAT) and single-field optimization (SFO) spot scanning proton therapy plans created using a simultaneous integrated boost (SIB) for dose escalation in midesophageal cancer and analyzed the effect of setup and range uncertainties on these plans. METHODS AND MATERIALS For 21 patients, SIB plans with a physical dose prescription of 2 Gy or 2.5 Gy/fraction in 25 fractions to planning target volume (PTV)50Gy or PTV62.5Gy (primary tumor with 0.5 cm margins) were created and evaluated for robustness to random setup errors and proton range errors. Dose-volume metrics were compared for the optimal and uncertainty plans, with P<.05 (Wilcoxon) considered significant. RESULTS SFO reduced the mean lung dose by 51.4% (range 35.1%-76.1%) and the mean heart dose by 40.9% (range 15.0%-57.4%) compared with VMAT. Proton plan robustness to a 3.5% range error was acceptable. For all patients, the clinical target volume D98 was 95.0% to 100.4% of the prescribed dose and gross tumor volume (GTV) D98 was 98.8% to 101%. Setup error robustness was patient anatomy dependent, and the potential minimum dose per fraction was always lower with SFO than with VMAT. The clinical target volume D98 was lower by 0.6% to 7.8% of the prescribed dose, and the GTV D98 was lower by 0.3% to 2.2% of the prescribed GTV dose. CONCLUSIONS The SFO plans achieved significant sparing of normal tissue compared with the VMAT plans for midesophageal cancer. The target dose coverage in the SIB proton plans was less robust to random setup errors and might be unacceptable for certain patients. Robust optimization to ensure adequate target coverage of SIB proton plans might be beneficial.
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Affiliation(s)
- Samantha Warren
- Cancer Research UK/Medical Research Council Oxford Institute for Radiation Oncology, Gray Laboratories, University of Oxford, Oxford, United Kingdom.
| | - Mike Partridge
- Cancer Research UK/Medical Research Council Oxford Institute for Radiation Oncology, Gray Laboratories, University of Oxford, Oxford, United Kingdom
| | - Alessandra Bolsi
- Centre for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
| | - Anthony J Lomax
- Centre for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
| | - Chris Hurt
- Wales Cancer Trials Unit, School of Medicine, Heath Park, Cardiff, United Kingdom
| | - Thomas Crosby
- Velindre Cancer Centre, Velindre Hospital, Cardiff, United Kingdom
| | - Maria A Hawkins
- Cancer Research UK/Medical Research Council Oxford Institute for Radiation Oncology, Gray Laboratories, University of Oxford, Oxford, United Kingdom
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Cost-Effectiveness of Cetuximab for Advanced Esophageal Squamous Cell Carcinoma. PLoS One 2016; 11:e0153943. [PMID: 27100871 PMCID: PMC4839693 DOI: 10.1371/journal.pone.0153943] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 04/06/2016] [Indexed: 01/09/2023] Open
Abstract
Background Costly biologicals in palliative oncology are emerging at a rapid pace. For example, in patients with advanced esophageal squamous cell carcinoma addition of cetuximab to a palliative chemotherapy regimen appears to improve survival. However, it simultaneously results in higher costs. We aimed to determine the incremental cost-effectiveness ratio of adding cetuximab to first-line chemotherapeutic treatment of patients with advanced esophageal squamous cell carcinoma, based on data from a randomized controlled phase II trial. Methods A cost effectiveness analysis model was applied based on individual patient data. It included only direct medical costs from the health-care perspective. Quality-adjusted life-years and incremental cost-effectiveness ratios were calculated. Sensitivity analysis was performed by a Monte Carlo analysis. Results Adding cetuximab to a cisplatin-5-fluorouracil first-line regimen for advanced esophageal squamous cell carcinoma resulted in an the incremental cost-effectiveness ratio of €252,203 per quality-adjusted life-year. Sensitivity analysis shows that there is a chance of less than 0.001 that the incremental cost-effectiveness ratio will be less than a maximum willingness to pay threshold of €40,000 per quality-adjusted life-year, which is representative for the threshold used in The Netherlands and other developed countries. Conclusions Addition of cetuximab to a cisplatin-5-fluorouracil first-line regimen for advanced esophageal squamous cell carcinoma is not cost-effective when appraised according to currently accepted criteria. Cost-effectiveness analyses using outcome data from early clinical trials (i.c. a phase II trial) enable pharmaceutical companies and policy makers to gain early insight into whether a new drug meets the current eligibility standards for reimbursement and thereby potential admittance for use in regular clinical practice.
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Carrington R, Spezi E, Gwynne S, Dutton P, Hurt C, Staffurth J, Crosby T. The influence of dose distribution on treatment outcome in the SCOPE 1 oesophageal cancer trial. Radiat Oncol 2016; 11:19. [PMID: 26852238 PMCID: PMC4744439 DOI: 10.1186/s13014-016-0594-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 01/27/2016] [Indexed: 01/06/2023] Open
Abstract
PURPOSE The first aim of this study was to assess plan quality using a conformity index (CI) and analyse its influence on patient outcome. The second aim was to identify whether clinical and technological factors including planning treatment volume (PTV) volume and treatment delivery method could be related to the CI value. METHODS AND MATERIALS By extending the original concept of the mean distance to conformity (MDC) index, the OverMDC and UnderMDC of the 95 % isodose line (50Gy prescribed dose) to the PTV was calculated for 97 patients from the UK SCOPE 1 trial (ISCRT47718479). Data preparation was carried out in CERR, with Kaplan-Meier and multivariate analysis undertaken in EUCLID and further tests in Microsoft Excel and IBM's SPSS. RESULTS A statistically significant breakpoint in the overall survival data, independent of cetuximab, was found with OverMDC (4.4 mm, p < 0.05). This was not the case with UnderMDC. There was a statistically significant difference in PTV volume either side of the OverMDC breakpoint (Mann Whitney p < 0.001) and in OverMDC value dependent on the treatment delivery method (mean IMRT = 2.1 mm, mean 3D-CRT = 4.1 mm Mann Whitney p < 0.001). Re-planning the worst performing patients according to OverMDC from 3D-CRT to VMAT resulted in a mean reduction in OverMDC of 2.8 mm (1.6-4.0 mm). OverMDC was not significant in multivariate analysis that included age, sex, staging, tumour type, and position. CONCLUSION Although not significant when included in multivariate analysis, we have shown in univariate analysis that a patient's OverMDC is correlated with overall survival. OverMDC is strongly related to IMRT and to a lesser extent with PTV volume. We recommend that VMAT planning should be used for oesophageal planning when available and that attention should be paid to the conformity of the 95 % to the PTV.
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Affiliation(s)
| | | | | | - Peter Dutton
- Wales Cancer Trials Unit, Cardiff University, Cardiff, UK.
| | - Chris Hurt
- Wales Cancer Trials Unit, Cardiff University, Cardiff, UK.
| | - John Staffurth
- Department of Clinical Oncology, Velindre Cancer Centre, Cardiff, UK.
| | - Thomas Crosby
- Department of Clinical Oncology, Velindre Cancer Centre, Cardiff, UK.
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Carrington R, Staffurth J, Warren S, Partridge M, Hurt C, Spezi E, Gwynne S, Hawkins MA, Crosby T. The effect of dose escalation on gastric toxicity when treating lower oesophageal tumours: a radiobiological investigation. Radiat Oncol 2015; 10:236. [PMID: 26586375 PMCID: PMC4653919 DOI: 10.1186/s13014-015-0537-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 11/04/2015] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Using radiobiological modelling to estimate normal tissue toxicity, this study investigates the effects of dose escalation for concurrent chemoradiation therapy (CRT) in lower third oesophageal tumours on the stomach. METHODS AND MATERIALS 10 patients with lower third oesophageal cancer were selected from the SCOPE 1 database (ISCRT47718479) with a mean planning target volume (PTV) of 348 cm(3). The original 3D conformal plans (50 Gy3D) were compared to newly created RapidArc plans of 50 GyRA and 60 GyRA, the latter using a simultaneous integrated boost (SIB) technique using a boost volume, PTV2. Dose-volume metrics and estimates of normal tissue complication probability (NTCP) were compared. RESULTS There was a significant increase in NTCP of the stomach wall when moving from the 50 GyRA to the 60 GyRA plans (11-17 %, Wilcoxon signed rank test, p = 0.01). There was a strong correlation between the NTCP values of the stomach wall and the volume of the stomach wall/PTV 1 and stomach wall/PTV2 overlap structures (R = 0.80 and R = 0.82 respectively) for the 60 GyRA plans. CONCLUSION Radiobiological modelling suggests that increasing the prescribed dose to 60 Gy may be associated with a significantly increased risk of toxicity to the stomach. It is recommended that stomach toxicity be closely monitored when treating patients with lower third oesophageal tumours with 60 Gy.
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Affiliation(s)
| | - John Staffurth
- Department of Clinical Oncology, Velindre Cancer Centre, Cardiff, UK.
| | - Samantha Warren
- CRUK MRC Oxford Institute for Radiation Oncology Gray Laboratories, University of Oxford, Old Road Campus Research Building, Oxford, UK.
| | - Mike Partridge
- CRUK MRC Oxford Institute for Radiation Oncology Gray Laboratories, University of Oxford, Old Road Campus Research Building, Oxford, UK.
| | - Chris Hurt
- Wales Cancer Trials Unit, Cardiff University, Cardiff, UK.
| | | | | | - Maria A Hawkins
- CRUK MRC Oxford Institute for Radiation Oncology Gray Laboratories, University of Oxford, Old Road Campus Research Building, Oxford, UK.
| | - Thomas Crosby
- School of Medicine, Cardiff University, Cardiff, UK.
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Derer A, Deloch L, Rubner Y, Fietkau R, Frey B, Gaipl US. Radio-Immunotherapy-Induced Immunogenic Cancer Cells as Basis for Induction of Systemic Anti-Tumor Immune Responses - Pre-Clinical Evidence and Ongoing Clinical Applications. Front Immunol 2015; 6:505. [PMID: 26500646 PMCID: PMC4597129 DOI: 10.3389/fimmu.2015.00505] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 09/16/2015] [Indexed: 01/18/2023] Open
Abstract
Radiotherapy (RT) primarily aims to locally destroy the tumor via the induction of DNA damage in the tumor cells. However, the so-called abscopal, namely systemic and immune–mediated, effects of RT move over more and more in the focus of scientists and clinicians since combinations of local irradiation with immune therapy have been demonstrated to induce anti-tumor immunity. We here summarize changes of the phenotype and microenvironment of tumor cells after exposure to irradiation, chemotherapeutic agents, and immune modulating agents rendering the tumor more immunogenic. The impact of therapy-modified tumor cells and damage-associated molecular patterns on local and systemic control of the primary tumor, recurrent tumors, and metastases will be outlined. Finally, clinical studies affirming the bench-side findings of interactions and synergies of radiation therapy and immunotherapy will be discussed. Focus is set on combination of radio(chemo)therapy (RCT) with immune checkpoint inhibitors, growth factor inhibitors, and chimeric antigen receptor T-cell therapy. Well-deliberated combination of RCT with selected immune therapies and growth factor inhibitors bear the great potential to further improve anti-cancer therapies.
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Affiliation(s)
- Anja Derer
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg , Erlangen , Germany
| | - Lisa Deloch
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg , Erlangen , Germany
| | - Yvonne Rubner
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg , Erlangen , Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg , Erlangen , Germany
| | - Benjamin Frey
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg , Erlangen , Germany
| | - Udo S Gaipl
- Department of Radiation Oncology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg , Erlangen , Germany
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Rees J, Hurt CN, Gollins S, Mukherjee S, Maughan T, Falk SJ, Staffurth J, Ray R, Bashir N, Geh JI, Cunningham D, Roy R, Bridgewater J, Griffiths G, Nixon LS, Blazeby JM, Crosby T. Patient-reported outcomes during and after definitive chemoradiotherapy for oesophageal cancer. Br J Cancer 2015; 113:603-10. [PMID: 26203761 PMCID: PMC4647690 DOI: 10.1038/bjc.2015.258] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 05/07/2015] [Accepted: 06/15/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Limited data describe patient-reported outcomes (PROs) of localised oesophageal cancer treated with definitive chemoradiotherapy(CRT). The phase 2/3 SCOPE-1 trial assessed the effectiveness of CRT±cetuximab. The trial for the first time provided an opportunity to describe PROs from a multi-centre group of patients treated with CRT that are presented here. METHODS Patients undergoing CRT±cetuximab within the SCOPE-1 trial (258 patients from 36 UK centres) completed generic-, disease- and treatment-specific health-related quality of life (HRQL) questionnaires (EORTC QLQ-C30, QLQ-OES18, Dermatology Life-Quality Index (DLQI)) at baseline and at 7, 13, 24, 52 and 104 weeks. Mean EORTC functional scale scores (>15 point change significant), DLQI scores (>4 point change significant) and proportions of patients (>15% significant) with 'minimal' or 'severe' symptoms are presented. RESULTS Questionnaire response rates were good. At baseline, EORTC functional scores were high (>75%) and few symptoms were reported except for severe problems with fatigue, insomnia and eating-related symptoms (e.g., appetite loss, dysphagia, dry mouth) in both groups(>15%). Functional aspects of health deteriorated and symptoms increased with treatment and by week 13 global quality of life, physical, role and social function significantly deteriorated and more problems with fatigue, dyspnoea, appetite loss and trouble with taste were reported. Recovery occurred by 6 months (except severe fatigue and insomnia in >15% of patients) and maintained at follow-up with no differences between groups. CONCLUSIONS CRT for localised oesophageal cancer has a significant detrimental impact on many aspects of HRQL; however, recovery is achieved by 6 months and maintained with the exception of persisting problems with severe fatigue and insomnia. The data suggest that the HRQL recovery after definitive CRT is quicker, and there is little lasting deficit compared with treatment including surgery. These data need to be compared with HRQL data from studies evaluating treatments including surgery for oesophageal cancer.
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Affiliation(s)
- J Rees
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
- Division of Surgery, Head and Neck, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - C N Hurt
- Wales Cancer Trials Unit, School of Medicine, Cardiff University, Cardiff, UK
| | - S Gollins
- North Wales Cancer Treatment Centre, Glan Clwyd Hospital, Rhyl, North Wales, UK
| | - S Mukherjee
- CRUK/MRC Oxford Institute for Radiation Oncology, Oxford University, Oxford, UK
| | - T Maughan
- CRUK/MRC Oxford Institute for Radiation Oncology, Oxford University, Oxford, UK
| | - S J Falk
- Bristol Haematology and Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - J Staffurth
- Institute of Cancer and Genetics, School of Medicine, Cardiff University, Cardiff, UK
| | - R Ray
- Wales Cancer Trials Unit, School of Medicine, Cardiff University, Cardiff, UK
| | - N Bashir
- Wales Cancer Trials Unit, School of Medicine, Cardiff University, Cardiff, UK
| | - J I Geh
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Queen Elizabeth Medical Centre, Birmingham, UK
| | - D Cunningham
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - R Roy
- Queen's Centre for Oncology and Haematology, Hull and East Yorkshire NHS Trust, Hull, UK
| | | | - G Griffiths
- Wales Cancer Trials Unit, School of Medicine, Cardiff University, Cardiff, UK
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - L S Nixon
- Wales Cancer Trials Unit, School of Medicine, Cardiff University, Cardiff, UK
| | - J M Blazeby
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
- Division of Surgery, Head and Neck, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - T Crosby
- Velindre Cancer Centre, Velindre Hospital, Cardiff, UK
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Niccolai E, Taddei A, Prisco D, Amedei A. Gastric cancer and the epoch of immunotherapy approaches. World J Gastroenterol 2015; 21:5778-5793. [PMID: 26019442 PMCID: PMC4438012 DOI: 10.3748/wjg.v21.i19.5778] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 12/05/2014] [Accepted: 04/17/2015] [Indexed: 02/06/2023] Open
Abstract
The incidence of gastric cancer (GC) fell dramatically over the last 50 years, but according to IARC-Globocan 2008, it is the third most frequent cause of cancer-related deaths with a case fatality GC ratio higher than other common malignancies. Surgical resection is the primary curative treatment for GC though the overall 5-year survival rate remains poor (approximately 20%-25%). To improve the outcome of resectable gastric cancer, different treatment strategies have been evaluated such as adjuvant or perioperative chemotherapy. In resected gastric cancer, the addition of radiotherapy to chemotherapy does not appear to provide any additional benefit. Moreover, in metastatic patients, chemotherapy is the mainstay of palliative therapy with a median overall survival of 8-10 mo and objective response rates of merely 20%-40%. Therefore, the potential for making key beneficial progress is to investigate the GC molecular biology to realize innovative therapeutic strategies, such as specific immunotherapy. In this review, we provide a panoramic view of the different immune-based strategies used for gastric cancer treatment and the results obtained in the most significant clinical trials. In detail, firstly we describe the therapeutic approaches that utilize the monoclonal antibodies while in the second part we analyze the cell-based immunotherapies.
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Mukherjee S, Hurt CN, Gwynne S, Bateman A, Gollins S, Radhakrishna G, Hawkins M, Canham J, Lewis W, Grabsch HI, Sharma RA, Wade W, Maggs R, Tranter B, Roberts A, Sebag-Montefiore D, Maughan T, Griffiths G, Crosby T. NEOSCOPE: a randomised Phase II study of induction chemotherapy followed by either oxaliplatin/capecitabine or paclitaxel/carboplatin based chemoradiation as pre-operative regimen for resectable oesophageal adenocarcinoma. BMC Cancer 2015; 15:48. [PMID: 25880814 PMCID: PMC4329217 DOI: 10.1186/s12885-015-1062-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 01/30/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Both oxaliplatin/capecitabine-based chemoradiation (OXCAP-RT) and carboplatin-paclitaxel based radiation (CarPac-RT) are active regimens in oesophageal adenocarcinoma, but no randomised study has compared their efficacy and toxicity. This randomised phase II "pick a winner" trial will identify the optimum regimen to take forward to a future phase III trial against neo-adjuvant chemotherapy, the current standard in the UK. METHODS/DESIGN Patients with resectable adenocarcinoma of the oesophagus or Siewert Type 1-2 gastro-oesophageal junction (GOJ), ≥T3 and/or ≥ N1 are eligible for the study. Following two cycles of induction OXCAP chemotherapy (oxaliplatin 130 mg/m2 D1, Cape 625 mg/m(2) D1-21, q 3 wk), patients are randomised 1:1 to OXCAP-RT (oxaliplatin 85 mg/m(2) Day 1,15,29; capecitabine 625 mg/m(2) twice daily on days of RT; RT-45 Gy/25 fractions/5 weeks) or CarPac-RT (Carboplatin AUC2 and paclitaxel 50 mg/m2 Day 1,8,15,22,29; RT-45 Gy/25 fractions/5 weeks). Restaging CT/PET-CT is performed 4-6 weeks after CRT, and a two-phase oesophagectomy with two-field lymphadenectomy is performed six to eight weeks after CRT. The primary end-point is pathological complete response rate (pCR) at resection and will include central review. Secondary endpoints include: recruitment rate, toxicity, 30-day surgical morbidity/mortality, resection margin positivity rate and overall survival (median, 3- and 5-yr OS. 76 patients (38/arm) gives 90% power and one-sided type 1 error of 10% if patients on one novel treatment have a response rate of 35% while the second treatment has a response rate of 15%. A detailed RT Quality Assurance (RTQA) programme includes a detailed RT protocol and guidance document, pre-accrual RT workshop, outlining exercise, and central evaluation of contouring and planning. This trial has been funded by Cancer Research UK (C44694/A14614), sponsored by Velindre NHS Trust and conducted through the Wales Cancer Trials Unit at Cardiff University on behalf of the NCRI Upper GI CSG. DISCUSSION Following encouraging results from previous trials, there is an interest in neo-adjuvant chemotherapy and CRT containing regimens for treatment of oesophageal adenocarcinoma. NEOSCOPE will first establish the efficacy, safety and feasibility of two different neo-adjuvant CRT regimens prior to a potential phase III trial. TRIAL REGISTRATION Eudract No: 2012-000640-10. ClinicalTrials.gov: NCT01843829 .
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Affiliation(s)
- Somnath Mukherjee
- CRUK MRC Oxford Institute for Radiation Oncology Gray Laboratories, University of Oxford, Old Road Campus Research Building, Oxford, UK.
| | - Christopher N Hurt
- Wales Cancer Trials Unit, School of Medicine, Cardiff University, Cardiff, UK.
| | | | - Andrew Bateman
- Cancer Care, University Hospital Southampton, Southampton, UK.
| | - Simon Gollins
- Department of Clinical Oncology, North Wales Cancer Treatment Centre, Rhyl, UK.
| | | | - Maria Hawkins
- CRUK MRC Oxford Institute for Radiation Oncology Gray Laboratories, University of Oxford, Old Road Campus Research Building, Oxford, UK.
| | - Jo Canham
- Wales Cancer Trials Unit, School of Medicine, Cardiff University, Cardiff, UK.
| | - Wyn Lewis
- University Hospital of Wales, Cardiff and Vale NHS Trust, Cardiff, UK.
| | - Heike I Grabsch
- Department of Pathology, Maastricht University Medical Centre, Maastricht, The Netherlands.
| | - Ricky A Sharma
- CRUK MRC Oxford Institute for Radiation Oncology Gray Laboratories, University of Oxford, Old Road Campus Research Building, Oxford, UK.
| | - Wendy Wade
- NISCHR CRC South East Wales Research Network, Cardiff, UK.
| | - Rhydian Maggs
- Cardiff NCRI RTTQA group, Department of Medical Physics, Velindre Cancer Centre, Cardiff, UK.
| | - Bethan Tranter
- Velindre Cancer Centre, Velindre NHS Trust, Cardiff, UK.
| | - Ashley Roberts
- Velindre Cancer Centre, Velindre NHS Trust, Cardiff, UK.
| | - David Sebag-Montefiore
- University of Leeds, Cancer Research UK Leeds Centre, St James's University Hospital, Leeds, UK.
| | - Timothy Maughan
- CRUK MRC Oxford Institute for Radiation Oncology Gray Laboratories, University of Oxford, Old Road Campus Research Building, Oxford, UK.
| | - Gareth Griffiths
- Southampton Clinical Trials Unit, Faculty of Medicine, Southampton University, Southampton General Hospital, Southampton, UK.
| | - Tom Crosby
- Velindre Cancer Centre, Velindre NHS Trust, Cardiff, UK.
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Warren S, Partridge M, Carrington R, Hurt C, Crosby T, Hawkins MA. Radiobiological determination of dose escalation and normal tissue toxicity in definitive chemoradiation therapy for esophageal cancer. Int J Radiat Oncol Biol Phys 2014; 90:423-9. [PMID: 25304796 PMCID: PMC4165721 DOI: 10.1016/j.ijrobp.2014.06.028] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 06/04/2014] [Accepted: 06/06/2014] [Indexed: 12/25/2022]
Abstract
PURPOSE This study investigated the trade-off in tumor coverage and organ-at-risk sparing when applying dose escalation for concurrent chemoradiation therapy (CRT) of mid-esophageal cancer, using radiobiological modeling to estimate local control and normal tissue toxicity. METHODS AND MATERIALS Twenty-one patients with mid-esophageal cancer were selected from the SCOPE1 database (International Standard Randomised Controlled Trials number 47718479), with a mean planning target volume (PTV) of 327 cm(3). A boost volume, PTV2 (GTV + 0.5 cm margin), was created. Radiobiological modeling of tumor control probability (TCP) estimated the dose required for a clinically significant (+20%) increase in local control as 62.5 Gy/25 fractions. A RapidArc (RA) plan with a simultaneously integrated boost (SIB) to PTV2 (RA62.5) was compared to a standard dose plan of 50 Gy/25 fractions (RA50). Dose-volume metrics and estimates of normal tissue complication probability (NTCP) for heart and lungs were compared. RESULTS Clinically acceptable dose escalation was feasible for 16 of 21 patients, with significant gains (>18%) in tumor control from 38.2% (RA50) to 56.3% (RA62.5), and only a small increase in predicted toxicity: median heart NTCP 4.4% (RA50) versus 5.6% (RA62.5) P<.001 and median lung NTCP 6.5% (RA50) versus 7.5% (RA62.5) P<.001. CONCLUSIONS Dose escalation to the GTV to improve local control is possible when overlap between PTV and organ-at-risk (<8% heart volume and <2.5% lung volume overlap for this study) generates only negligible increase in lung or heart toxicity. These predictions from radiobiological modeling should be tested in future clinical trials.
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Affiliation(s)
- Samantha Warren
- Department of Oncology, Gray Institute of Radiation Oncology and Biology, University of Oxford, Oxford, United Kingdom.
| | - Mike Partridge
- Department of Oncology, Gray Institute of Radiation Oncology and Biology, University of Oxford, Oxford, United Kingdom
| | - Rhys Carrington
- Velindre Cancer Centre, Velindre Hospital, Cardiff, United Kingdom
| | - Chris Hurt
- Wales Cancer Trials Unit, School of Medicine, Heath Park, Cardiff, United Kingdom
| | - Thomas Crosby
- Velindre Cancer Centre, Velindre Hospital, Cardiff, United Kingdom
| | - Maria A Hawkins
- Department of Oncology, Gray Institute of Radiation Oncology and Biology, University of Oxford, Oxford, United Kingdom
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Nicolay NH, Herfarth K. [Use of cetuximab with definitive chemoradiotherapy for esophageal cancer results in decreased overall survival]. Strahlenther Onkol 2013; 190:233-4. [PMID: 24362504 DOI: 10.1007/s00066-013-0523-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- N H Nicolay
- Klinik für Radioonkologie und Strahlentherapie, Universitätsklinikum Heidelberg, Neuenheimer Feld 400, 69120, Heidelberg, Deutschland,
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Orditura M, Galizia G, Fabozzi A, Lieto E, Gambardella V, Morgillo F, Del Genio GM, Fei L, Di Martino N, Renda A, Ciardiello F, De Vita F. Preoperative treatment of locally advanced esophageal carcinoma (Review). Int J Oncol 2013; 43:1745-53. [PMID: 24100679 DOI: 10.3892/ijo.2013.2118] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Accepted: 07/30/2013] [Indexed: 11/06/2022] Open
Abstract
Esophageal cancer (EC) is an aggressive malignancy with increasing incidence worldwide. Surgery is still the most effective treatment, however, both the high rate of local and distant recurrences and surgery-related complications led us to investigate new preoperative strategies. In this review, we discuss the role of neoadjuvant therapy for locally advanced EC with a focus on preoperative chemoradiation (trimodality treatment). Furthermore, the last fifteen years of published literature and our experience have been also reviewed. In the preoperative setting, few trials have reported a significant benefit with fluoropyrimidine and platinum compound-based neoadjuvant chemotherapy, compared to surgery alone. A large number of phase III trials and meta-analyses have demonstrated improved outcomes with preoperative chemoradiation vs. neoadjuvant chemotherapy or surgery alone. Therefore, trimodality therapy can be considered the most effective option in the management of locally advanced EC. Addition of drugs targeting VEGF or HER2 to standard chemotherapy appears to be feasible but needs to be explored more accurately. FDG-PET may predict both response to neoadjuvant treatments and prognosis.
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Affiliation(s)
- Michele Orditura
- Division of Medical Oncology, 'F. Magrassi - A. Lanzara' Department of Clinical and Experimental Medicine and Surgery, Second University of Naples, School of Medicine, Naples, Italy
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Zhang J, Hochwald SN. Targeting Receptor Tyrosine Kinases in Solid Tumors. Surg Oncol Clin N Am 2013; 22:685-703. [DOI: 10.1016/j.soc.2013.06.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Sehdev A, Catenacci DVT. Perioperative therapy for locally advanced gastroesophageal cancer: current controversies and consensus of care. J Hematol Oncol 2013; 6:66. [PMID: 24010946 PMCID: PMC3844370 DOI: 10.1186/1756-8722-6-66] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 08/29/2013] [Indexed: 02/07/2023] Open
Abstract
Gastroesophageal cancer (GEC) remains a challenging problem in oncology. Anatomically, GEC is comprised of distal gastric adenocarcinoma (GC), classically associated with Helicobacter Pylori, while proximal esophagogastric adenocarcinoma (EGJ AC) has increased significantly in incidence over the past years. Despite contrasting etiologies, histologies, and molecular phenotypes of distal and proximal GEC, in many cases perioperative (and metastatic) treatment strategies converge to similar approaches. For patients undergoing curative intent surgery, advances in perioperative chemotherapy and/or chemoradiotherapy, either before and/or after surgery, have demonstrated improved survivals compared to surgery alone. This review focuses on how the 'boundary' of the Z-line and/or the anatomical distinction of 'proximal' (EGJ) vs. 'distal' (GC) cancer has led to diverse inclusion/exclusion criteria for clinical trial enrollment, embodying various combinations of chemotherapy and radiation before and/or after surgery. Supporting evidence of each of these approaches consequently has led to a number of varying practices by geographical region and Institution/Physician, based on differing experience, preference, and clinical circumstance. Adequate direct comparison of these approaches is lacking currently, but data from a number of concerted efforts should be available in the next years to further direct best standards of care. Introduction of biologically targeted agents, namely anti-angiogenics and anti-HER family therapeutics are being evaluated to determine whether further therapeutic gains can be realized over classic cytotoxic chemotherapy alone (with/without radiotherapy). To date, novel molecularly targeted agents have yet to demonstrate benefit in this setting. In the following comprehensive review we will address the intricacies of perioperative treatment of locally advanced GEC, with focus on clinical trials supporting the diverse set of perioperative multidisciplinary approaches.
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Affiliation(s)
- Amikar Sehdev
- Department of Medicine, Section of Hematology Oncology, University of Chicago, 5841 S. Maryland Avenue, MC 2115, Chicago, IL 60637, USA
| | - Daniel VT Catenacci
- Department of Medicine, Section of Hematology Oncology, University of Chicago, 5841 S. Maryland Avenue, MC 2115, Chicago, IL 60637, USA
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Powathil GG, Adamson DJA, Chaplain MAJ. Towards predicting the response of a solid tumour to chemotherapy and radiotherapy treatments: clinical insights from a computational model. PLoS Comput Biol 2013; 9:e1003120. [PMID: 23874170 PMCID: PMC3708873 DOI: 10.1371/journal.pcbi.1003120] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Accepted: 05/13/2013] [Indexed: 11/24/2022] Open
Abstract
In this paper we use a hybrid multiscale mathematical model that incorporates both individual cell behaviour through the cell-cycle and the effects of the changing microenvironment through oxygen dynamics to study the multiple effects of radiation therapy. The oxygenation status of the cells is considered as one of the important prognostic markers for determining radiation therapy, as hypoxic cells are less radiosensitive. Another factor that critically affects radiation sensitivity is cell-cycle regulation. The effects of radiation therapy are included in the model using a modified linear quadratic model for the radiation damage, incorporating the effects of hypoxia and cell-cycle in determining the cell-cycle phase-specific radiosensitivity. Furthermore, after irradiation, an individual cell's cell-cycle dynamics are intrinsically modified through the activation of pathways responsible for repair mechanisms, often resulting in a delay/arrest in the cell-cycle. The model is then used to study various combinations of multiple doses of cell-cycle dependent chemotherapies and radiation therapy, as radiation may work better by the partial synchronisation of cells in the most radiosensitive phase of the cell-cycle. Moreover, using this multi-scale model, we investigate the optimum sequencing and scheduling of these multi-modality treatments, and the impact of internal and external heterogeneity on the spatio-temporal patterning of the distribution of tumour cells and their response to different treatment schedules. Anti-cancer treatments such as radiotherapy and chemotherapy have evolved through clinical trial-and-error over decades, and although they cure some cases and are partially effective in many, the majority of such cancers ultimately recur. Doctors turn to new, expensive drugs as they emerge, but perhaps fail to study and learn how to use the therapies they already have most effectively. This is partly because clinical trials are expensive to conduct, both in terms of time and money. The cancer cell is complicated, but many mechanisms that control its response to treatment are now understood. We show here how a mathematical model accurately reproduces the results of previous biological experiments of cancer treatment, opening up the possibility of using it to predict which combinations of drugs and radiotherapy would be best for patients.
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Affiliation(s)
- Gibin G Powathil
- Division of Mathematics, University of Dundee, Dundee, United Kingdom.
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Abstract
Despite recent improvements in surgery and radiotherapy, and refinements of systemic treatment options, including incorporation of targeted agents, long-term survival remains poor for patients with esophageal cancer. While surgical resection alone constitutes the standard approach for early-stage disease (stage I), multimodality therapy, including perioperative chemotherapy and neoadjuvant or definitive chemoradiotherapy (CRT), are internationally accepted treatment options for patients with locally advanced disease. In lower esophageal and esophagogastric junction adenocarcinomas, data from large, randomized phase III trials and meta-analyses support the use of both perioperative chemotherapy alone or neoadjuvant concurrent CRT. In patients with locally advanced squamous cell carcinoma (SCC) of the esophagus, neoadjuvant CRT but not neoadjuvant chemotherapy alone is the preferred treatment approach. Definitive CRT without surgery has also emerged as a useful option for the treatment of resectable SCC of the esophagus, avoiding potential surgical morbidity and mortality, with salvage surgery reserved for those with persistent disease. Functional imaging modalities, such as PET-CT, may create new opportunities for a more adequate therapy response assessment and patient selection. Patients with SCC that show clinical response by PET-CT are considered to have a more favorable outcome, regardless of whether surgery will be performed or not. In nonresponding patients, salvage surgery improves survival, especially if complete resection is achieved. Recent technological advances in radiotherapy, such as intensity-modulated radiotherapy, image guided-radiotherapy and PET-CT-based radiotherapy planning, may further improve the therapeutic ratio of CRT. Moreover, the traditional backbone of CRT, platinum plus fluorouracil, may be supplanted by more modern and easier-to-administer regimens incorporating taxanes, irinotecan and targeted agents.
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Affiliation(s)
- Emmanouil Fokas
- Department of Radiation Therapy and Oncology, Johann Wolfgang Goethe University, Frankfurt, Germany.
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Crosby T, Hurt CN, Falk S, Gollins S, Mukherjee S, Staffurth J, Ray R, Bashir N, Bridgewater JA, Geh JI, Cunningham D, Blazeby J, Roy R, Maughan T, Griffiths G. Chemoradiotherapy with or without cetuximab in patients with oesophageal cancer (SCOPE1): a multicentre, phase 2/3 randomised trial. Lancet Oncol 2013; 14:627-37. [PMID: 23623280 DOI: 10.1016/s1470-2045(13)70136-0] [Citation(s) in RCA: 274] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Definitive chemoradiotherapy (CRT) is an alternative to surgery for the curative treatment of oesophageal carcinoma. The SCOPE1 trial aimed to investigate the addition of cetuximab to cisplatin and fluoropyrimidine-based definitive CRT in patients with localised oesophageal squamous-cell cancer and adenocarcinomas to assess activity, safety, and feasibility of use. METHODS In this multicentre, randomised, open-label, phase 2/3 trial, we recruited patients aged 18 years and older from UK radiotherapy centres who had non-metastatic, histologically confirmed carcinoma of the oesophagus (adenocarcinoma, squamous-cell, or undifferentiated; WHO status 0-1; stage I-III disease) and been selected to receive definitive CRT. Patients were randomly assigned (1:1) via a central computerised system using stratified minimisation (with an 80:20 random element) to receive CRT alone or CRT with cetuximab (400 mg/m(2) on day 1 followed by 250 mg/m(2) weekly), stratified by recruiting hospital, primary reason for not having surgery, tumour histology, and tumour stage. CRT consisted of cisplatin 60 mg/m(2) (day 1) and capecitabine 625 mg/m(2) twice daily (days 1-21) for four cycles; cycles three and four were given concurrently with 50 Gy in 25 fractions of radiotherapy. The primary endpoint was the proportion of patients who were treatment failure free at week 24 for the phase 2 trial and overall survival for the phase 3 trial, both measured from randomisation. We analysed data by intention to treat. This trial is an International Standard Randomised Controlled Trial, number 47718479. FINDINGS 258 patients (129 assigned to each treatment group) from 36 UK centres were recruited between Feb 7, 2008, and Feb 22, 2012. Recruitment was stopped without continuation to phase 3 because the trial met criteria for futility, but we continued to follow-up recruited patients until all had reached at least 24-week follow-up (median follow-up of patients who survived was 16.8 months [IQR 11.2-24.5]). Fewer patients were treatment failure free at 24 weeks in the CRT plus cetuximab group (79 of 119 patients [66·4%, 90% CI 58·6-73·6]) than in the CRT only group (93 of 121 patients [76.9%, 69.7-83.0]). The CRT plus cetuximab group also had shorter median overall survival (22.1 months [95% CI 15.1-24.5] vs 25.4 months [20.5-37.9]; adjusted HR 1.53 [95% CI 1.03-2.27]; p=0.035). Patients who received CRT plus cetuximab had more non-haematological grade 3 or 4 toxicities (102 [79%] of 129 patients vs 81 [63%] of 129 patients; p=0.004). The most common grade 3 or 4 toxicities were low white blood cell count (14 [11%] in the CRT plus cetuximab group vs 21 [16%] in the CRT only group), low absolute neutrophil count (15 [12%] vs 24 [19%]), fatigue (26 [20%] vs 25 [19%]), and dysphagia (35 [27%] vs 37 [29%]). INTERPRETATION The addition of cetuximab to standard chemotherapy and radiotherapy cannot be recommended for patients with oesophageal cancer suitable for definitive CRT. FUNDING Cancer Research UK.
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Affiliation(s)
- Thomas Crosby
- Velindre Cancer Centre, Velindre Hospital, Cardiff, UK
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Hong TS, Wo JY, Kwak EL. Targeted therapies with chemoradiation in esophageal cancer: development and future directions. Semin Radiat Oncol 2013. [PMID: 23207045 DOI: 10.1016/j.semradonc.2012.09.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Targeted therapies have been studied in combination with chemoradiation therapy for esophageal and gastroesophageal junction cancers. To date, the Human Epidermal Growth Factor Receptor 2 (HER2) HER2, epidermal growth factor receptor, and vascular endothelial growth factor pathways have been most extensively studied in esophagogastric cancers. However, despite strong preclinical rationale and evidence of activity in other diseases, the efficacy of these agents has been mixed when studied in the metastatic setting or in combination with chemoradiation. In this review, the history of the development of targeted therapies in esophagogastric cancers is reviewed, with a specific focus on the incorporation of these agents with chemoradiation. Additionally, more recently identified targets of interest in esophagogastric cancers, including c-MET, heat shock protein 90, and Sonic hedgehog, are discussed in the context of chemoradiation.
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Affiliation(s)
- Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
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Gwynne S, Falk S, Gollins S, Wills L, Bateman A, Cummins S, Grabsch H, Hawkins MA, Maggs R, Mukherjee S, Radhakrishna G, Roy R, Sharma RA, Spezi E, Crosby T. Oesophageal Chemoradiotherapy in the UK--current practice and future directions. Clin Oncol (R Coll Radiol) 2013; 25:368-77. [PMID: 23489868 DOI: 10.1016/j.clon.2013.01.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Revised: 01/02/2013] [Accepted: 01/03/2013] [Indexed: 01/29/2023]
Abstract
The SCOPE 1 trial closed to recruitment in early 2012 and has demonstrably improved the quality of UK radiotherapy. It has also shown that there is an enthusiastic upper gastrointestinal clinical oncology community that can successfully complete trials and deliver high-quality radiotherapy. Following on from SCOPE 1, this paper, authored by a consensus of leading UK upper gastrointestinal radiotherapy specialists, attempts to define current best practice and the questions to be answered by future clinical studies. The two main roles for chemoradiotherapy (CRT) in the management of potentially curable oesophageal cancer are definitive (dCRT) and neoadjuvant (naCRT). The rates of local failure after dCRT are consistently high, showing the need to evaluate more effective treatments, both in terms of optimal local and systemic therapeutic components. This will be the primary objective of the next planned UK dCRT trial and here we discuss the role of dose escalation and systemic therapeutic options that will form the basis of that trial. The publication of the Dutch 'CROSS' trial of naCRT has shown that this pre-operative approach can both be given safely and offer a significant survival benefit over surgery alone. This has led to the development of the UK NeoSCOPE trial, due to open in 2013. There will be a translational substudy to this trial and currently available data on the role of biomarkers in predicting response to therapy are discussed. Postoperative reporting of the pathology specimen is discussed, with recommendations for the NeoSCOPE trial. Both of these CRT approaches may benefit from recent developments, such as positron emission tomography/computed tomography and four-dimensional computed tomography for target volume delineation, planning techniques such as intensity-modulated radiotherapy and 'type b' algorithms and new treatment verification methods, such as cone-beam computed tomography. These are discussed here and recommendations made for their use.
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Affiliation(s)
- S Gwynne
- Singleton Hospital, Swansea, UK; Velindre Cancer Centre, Cardiff, UK
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Yin YM, Zhou Y, Shao YF. Targeted therapies for esophageal cancer. Shijie Huaren Xiaohua Zazhi 2012; 20:3499-3504. [DOI: 10.11569/wcjd.v20.i35.3499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Esophageal cancer is a highly frequent malignancy, being the fourth leading cause of cancer-related deaths in China. Most patients are initially diagnosed with advanced disease. Despite recent advances in surgical techniques and adjuvant/neoadjuvant radiotherapy and chemotherapy, the prognosis of esophageal cancer is still poor. An emerging understanding of molecular pathways that characterizes cell growth, cell cycle, apoptosis, angiogenesis, and invasion has provided novel targets for cancer therapy. This review focuses on novel targeted treatments for esophageal cancer.
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Cetuximab plus cisplatin, irinotecan, and thoracic radiotherapy as definitive treatment for locally advanced, unresectable esophageal cancer: a phase-II study of the SWOG (S0414). J Thorac Oncol 2012; 7:906-12. [PMID: 22481235 DOI: 10.1097/jto.0b013e31824c7bed] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
INTRODUCTION The specific aims of the study were to evaluate the 2-year overall survival (OS) and progression-free survival (PFS), toxicity profile, and best objective response rate in patients with locally advanced, clinically unresectable esophageal cancer receiving cetuximab, cisplatin, irinotecan, and thoracic radiotherapy (TRT) within a multi-institutional cooperative-group setting. METHODS Eligible patients (cT4 M0 or medically unresectable, biopsy proven, and noncervical esophageal cancer) were to receive four 21-day cycles of cetuximab 400 mg/m (day 1, cycle 1), cetuximab 250 mg/m (day 8, 15, cycle 1; then days 1, 8, and 15 for subsequent cycles), cisplatin 30 mg/m (days 1 and 8, all cycles), and irinotecan 65 mg/m (days 1 and 8, all cycles). TRT was administered at 1.8 Gy in 28 daily fractions to a total dose of 50.4 Gy, to begin with on day 1 of cycle 3. The primary endpoint was 2-year OS, with an accrual goal of 75 patients with adenocarcinoma. RESULTS The study was closed because of slow accrual, with 21 eligible patients (11 squamous, 10 adenocarcinoma) enrolled from May 2005 to September 2007. Two-year OS and PFS (95% confidence interval [CI]) were 33.3% (14.6-57.0%) and 23.8% (8.2-47.2%), respectively. Kaplan-Meier estimates of median (95% CI) OS and PFS were 11.2 (6.4-43.6) and 6.4 (3.7-12.0) months, respectively. The overall response rate (95% CI) among 17 evaluable patients was 17.6% (3.8-43.4%), including 6% confirmed complete responders and 12% unconfirmed partial responders. Two deaths resulted from protocol treatment (sudden death and gastrointestinal necrosis). Ten (47.6%) and 6 (28.6%) patients had grade-3 or -4 toxicity, respectively: 52.4% were hematologic, 23.8% had fatigue, 19.0% had nausea, 19.0% had dehydration, and 19.0% had anorexia. CONCLUSIONS Concomitant cetuximab, cisplatin, irinotecan, and TRT were poorly tolerated in the first North American cooperative group trial testing this regimen for locally advanced esophageal cancer as treatment-related mortality approached 10%. Single-institution phase-II cetuximab-based combined modality trials have yielded encouraging results in preliminary analyses. The SWOG GI Committee endorses enrollment to open clinical trials to clarify the therapeutic ratio of cetuximab-based combined modality approaches for esophageal cancer.
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Runkle EA, Zhang H, Cai Z, Zhu Z, Karger BL, Wu SL, O'Rourke DM, Zhou Z, Wang Q, Greene MI. Reversion of the ErbB malignant phenotype and the DNA damage response. Exp Mol Pathol 2012; 93:324-33. [PMID: 23022358 DOI: 10.1016/j.yexmp.2012.09.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Accepted: 09/14/2012] [Indexed: 12/18/2022]
Abstract
The ErbB or HER family is a group of membrane bound tyrosine kinase receptors that initiate signal transduction cascades, which are critical to a wide range of biological processes. When over-expressed or mutated, members of this kinase family form homomeric or heteromeric kinase assemblies that are involved in certain human malignancies. Targeted therapy evolved from studies showing that monoclonal antibodies to the ectodomain of ErbB2/neu would reverse the malignant phenotype. Unfortunately, tumors develop resistance to targeted therapies even when coupled with genotoxic insults such as radiation. Radiation treatment predominantly induces double strand DNA breaks, which, if not repaired, are potentially lethal to the cell. Some tumors are resistant to radiation treatment because they effectively repair double strand breaks. We and others have shown that even in the presence of ionizing radiation, active ErbB kinase signaling apparently enhances the repair process, such that transformed cells resist genotoxic signal induced cell death. We review here the current understanding of ErbB signaling and DNA double strand break repair. Some studies have identified a mechanism by which DNA damage is coordinated to assemblies of proteins that associate with SUN domain containing proteins. These assemblies represent a new target for therapy of resistant tumor cells.
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Affiliation(s)
- E Aaron Runkle
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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Gwynne S, Spezi E, Wills L, Nixon L, Hurt C, Joseph G, Evans M, Griffiths G, Crosby T, Staffurth J. Toward semi-automated assessment of target volume delineation in radiotherapy trials: the SCOPE 1 pretrial test case. Int J Radiat Oncol Biol Phys 2012; 84:1037-42. [PMID: 22878126 DOI: 10.1016/j.ijrobp.2012.01.094] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Revised: 01/06/2012] [Accepted: 01/31/2012] [Indexed: 11/18/2022]
Abstract
PURPOSE To evaluate different conformity indices (CIs) for use in the analysis of outlining consistency within the pretrial quality assurance (Radiotherapy Trials Quality Assurance [RTTQA]) program of a multicenter chemoradiation trial of esophageal cancer and to make recommendations for their use in future trials. METHODS AND MATERIALS The National Cancer Research Institute SCOPE 1 trial is an ongoing Cancer Research UK-funded phase II/III randomized controlled trial of chemoradiation with capecitabine and cisplatin with or without cetuximab for esophageal cancer. The pretrial RTTQA program included a detailed radiotherapy protocol, an educational package, and a single mid-esophageal tumor test case that were sent to each investigator to outline. Investigator gross tumor volumes (GTVs) were received from 50 investigators in 34 UK centers, and CERR (Computational Environment for Radiotherapy Research) was used to perform an assessment of each investigator GTV against a predefined gold-standard GTV using different CIs. A new metric, the local conformity index (l-CI), that can localize areas of maximal discordance was developed. RESULTS The median Jaccard conformity index (JCI) was 0.69 (interquartile range, 0.62-0.70), with 14 of 50 investigators (28%) achieving a JCI of 0.7 or greater. The median geographical miss index was 0.09 (interquartile range, 0.06-0.16), and the mean discordance index was 0.27 (95% confidence interval, 0.25-0.30). The l-CI was highest in the middle section of the volume, where the tumor was bulky and more easily definable, and identified 4 slices where fewer than 20% of investigators achieved an l-CI of 0.7 or greater. CONCLUSIONS The available CIs analyze different aspects of a gold standard-observer variation, with JCI being the most useful as a single metric. Additional information is provided by the l-CI and can focus the efforts of the RTTQA team in these areas, possibly leading to semi-automated outlining assessment.
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Affiliation(s)
- Sarah Gwynne
- Department of Clinical Oncology, Velindre Cancer Centre, Cardiff, Wales.
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