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Mukherjee S, Qi C, Shaw R, Jones CM, Bridgewater JA, Radhakrishna G, Patel N, Holmes J, Virdee PS, Tranter B, Parsons P, Falk S, Wasan HS, Ajithkumar TV, Holyoake D, Roy R, Scott-Brown M, Hurt CN, O'Neill E, Sebag-Montefiore D, Maughan TS, Hawkins MA, Corrie P. Standard or high dose chemoradiotherapy, with or without the protease inhibitor nelfinavir, in patients with locally advanced pancreatic cancer: The phase 1/randomised phase 2 SCALOP-2 trial. Eur J Cancer 2024; 209:114236. [PMID: 39059185 DOI: 10.1016/j.ejca.2024.114236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 07/08/2024] [Accepted: 07/16/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND The multi-centre two-stage SCALOP-2 trial (ISRCTN50083238) assessed whether dose escalation of consolidative chemoradiotherapy (CRT) or concurrent sensitization using the protease inhibitor nelfinavir improve outcomes in locally advanced pancreatic cancer (LAPC) following four cycles of gemcitabine/nab-paclitaxel. METHODS In stage 1, the maximum tolerated dose (MTD) of nelfinavir concurrent with standard-dose CRT (50.4 Gy in 28 fractions) was identified from a cohort of 27 patients. In stage 2, 159 patients were enrolled in an open-label randomized controlled comparison of standard versus high dose (60 Gy in 30 fractions) CRT, with or without nelfinavir at MTD. Primary outcomes following dose escalation and nelfinavir use were respectively overall survival (OS) and progression free survival (PFS). Secondary endpoints included health-related quality of life (HRQoL). RESULTS High dose CRT did not improve OS (16.9 (60 % confidence interval, CI 16.2-17.7) vs. 15.6 (60 %CI 14.3-18.2) months; adjusted hazard ratio, HR 1.13 (60 %CI 0.91-1.40; p = 0.68)). Similarly, median PFS was not improved by nelfinavir (10.0 (60 %CI 9.9-10.2) vs. 11.1 (60 %CI 10.3-12.8) months; adjusted HR 1.71 (60 %CI 1.38-2.12; p = 0.98)). Local progression at 12 months was numerically lower with high-dose CRT than with standard dose CRT (n = 11/46 (23.9 %) vs. n = 15/45 (33.3 %)). Neither nelfinavir nor radiotherapy dose escalation impacted on treatment compliance or grade 3/4 adverse event rate. There were no sustained differences in HRQoL scores between treatment groups over 28 weeks post-treatment. CONCLUSIONS Dose-escalated CRT may improve local tumour control and is well tolerated when used as consolidative treatment in LAPC but does not impact OS. Nelfinavir use does not improve PFS.
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Affiliation(s)
- Somnath Mukherjee
- Oxford Cancer Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Cathy Qi
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Rachel Shaw
- Oncology Clinical Trials Office (OCTO), Department of Oncology, University of Oxford, Oxford, UK
| | - Christopher M Jones
- Department of Oncology, University of Cambridge, Cambridge, UK; Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - John A Bridgewater
- UCL Cancer Institute, University College London Hospitals NHS Foundation Trust, London, UK
| | - Ganesh Radhakrishna
- The Christie Hospital, The Christie Hospitals NHS Foundation Trust, Manchester, UK
| | - Neel Patel
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jane Holmes
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Pradeep S Virdee
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Bethan Tranter
- Velindre Cancer Centre, Velindre University NHS Trust, Cardiff, UK
| | - Philip Parsons
- Velindre Cancer Centre, Velindre University NHS Trust, Cardiff, UK
| | - Stephen Falk
- Bristol Cancer Centre, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Harpreet S Wasan
- Department of Surgery & Cancer, Imperial College London, London, UK
| | - Thankamma V Ajithkumar
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Daniel Holyoake
- Norfolk & Norwich University Hospital, Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Rajarshi Roy
- Queen's Centre for Oncology, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Martin Scott-Brown
- Coventry Cancer Centre, University Hospital Coventry & Warwickshire, Coventry, UK
| | | | - Eric O'Neill
- Department of Oncology, University of Oxford, Oxford, UK
| | | | - Tim S Maughan
- Oxford Institute for Radiation Oncology, University of Oxford, Oxford, UK
| | - Maria A Hawkins
- Department of Medical Physics & Biomedical Engineering, University College London, London, UK
| | - Pippa Corrie
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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2
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Reddy AV, Sehgal S, Hill CS, Zheng L, He J, Herman JM, Meyer J, Narang AK. Upfront Chemotherapy Followed by Stereotactic Body Radiation Therapy with or without Surgery in Older Patients with Localized Pancreatic Cancer: A Single Institution Experience and Review of the Literature. Curr Oncol 2022; 29:308-320. [PMID: 35049702 PMCID: PMC8774377 DOI: 10.3390/curroncol29010028] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 12/30/2021] [Accepted: 01/10/2022] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To report on clinical outcomes and toxicity in older (age ≥ 70 years) patients with localized pancreatic cancer treated with upfront chemotherapy followed by stereotactic body radiation therapy (SBRT) with or without surgery. METHODS Endpoints included overall survival (OS), local progression-free survival (LPFS), distant metastasis-free survival (DMFS), progression-free survival (PFS), and toxicity. RESULTS A total of 57 older patients were included in the study. Median OS was 19.6 months, with six-month, one-year, and two-year OS rates of 83.4, 66.5, and 42.4%. On MVA, resection status (HR: 0.30, 95% CI 0.12-0.91, p = 0.031) was associated with OS. Patients with surgically resected tumors had improved median OS (29.1 vs. 7.0 months, p < 0.001). On MVA, resection status (HR: 0.40, 95% CI 0.17-0.93, p = 0.034) was also associated with PFS. Patients with surgically resected tumors had improved median PFS (12.9 vs. 1.6 months, p < 0.001). There were 3/57 cases (5.3%) of late grade 3 radiation toxicity and 2/38 cases (5.3%) of Clavien-Dindo grade 3b toxicity in those who underwent resection. CONCLUSION Multimodality therapy involving SBRT is safe and feasible in older patients with localized pancreatic cancer. Surgical resection was associated with improved clinical outcomes. As such, older patients who complete chemotherapy should not be excluded from aggressive local therapy when possible.
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Affiliation(s)
- Abhinav V. Reddy
- Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Cancer Center, Johns Hopkins University School of Medicine, 401 N Broadway, Baltimore, MD 21231, USA; (S.S.); (C.S.H.); (J.M.); (A.K.N.)
| | - Shuchi Sehgal
- Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Cancer Center, Johns Hopkins University School of Medicine, 401 N Broadway, Baltimore, MD 21231, USA; (S.S.); (C.S.H.); (J.M.); (A.K.N.)
| | - Colin S. Hill
- Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Cancer Center, Johns Hopkins University School of Medicine, 401 N Broadway, Baltimore, MD 21231, USA; (S.S.); (C.S.H.); (J.M.); (A.K.N.)
| | - Lei Zheng
- Department of Oncology, Sidney Kimmel Cancer Center, Johns Hopkins University School of Medicine, 401 N Broadway, Baltimore, MD 21231, USA;
| | - Jin He
- Department of Surgery, Sidney Kimmel Cancer Center, Johns Hopkins University School of Medicine, 401 N Broadway, Baltimore, MD 21231, USA;
| | - Joseph M. Herman
- Department of Radiation Oncology, Northwell Health, 450 Lakeville Road, New Hyde Park, NY 11042, USA;
| | - Jeffrey Meyer
- Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Cancer Center, Johns Hopkins University School of Medicine, 401 N Broadway, Baltimore, MD 21231, USA; (S.S.); (C.S.H.); (J.M.); (A.K.N.)
| | - Amol K. Narang
- Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Cancer Center, Johns Hopkins University School of Medicine, 401 N Broadway, Baltimore, MD 21231, USA; (S.S.); (C.S.H.); (J.M.); (A.K.N.)
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Chen YL, Tsai CL, Cheng JCH, Wang CW, Yang SH, Tien YW, Kuo SH. Competing Risk Analysis of Outcomes of Unresectable Pancreatic Cancer Patients Undergoing Definitive Radiotherapy. Front Oncol 2022; 11:730646. [PMID: 35070957 PMCID: PMC8773247 DOI: 10.3389/fonc.2021.730646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 12/08/2021] [Indexed: 11/13/2022] Open
Abstract
PURPOSE We investigated potential factors, including clinicopathological features, treatment modalities, neutrophil-to-lymphocyte ratio (NLR), carbohydrate antigen (CA) 19-9 level, tumor responses correlating with overall survival (OS), local progression (LP), and distant metastases (DMs), in patients with locally advanced pancreatic cancer (LAPC) who received definitive radiotherapy (RT). METHODS We retrospectively analyzed demographic characteristics; biologically effective doses (BED10, calculated with an α/β of 10) of RT; and clinical outcomes of 57 unresectable LAPC (all pancreatic adenocarcinoma) patients receiving definitive RT using modern techniques with and without systemic therapy between January 2009 and March 2019 at our institution. We used Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1 to evaluate the radiographic tumor response after RT. The association between prognostic factors and OS was assessed using the Kaplan-Meier analysis and a Cox regression model, whereas baseline characteristics and treatment details were collected for competing-risk regression of the association with LP and DM using the Fine-Gray model. RESULTS A median BED10 of 67.1 Gy resulted in a disease control rate of 87.7%, and the median OS was 11.8 months after a median follow-up of 32.1 months. The 1-year OS rate, cumulative incidences of LP, and DM were 49.2%, 38.5%, and 62.9%, respectively. Multivariate analyses showed that pre-RT NLR ≥3.5 (adjusted hazard ratio [HR] = 8.245, p < 0.001), CA19-9 reduction rate ≥50% (adjusted HR = 0.261, p = 0.005), RT without concurrent chemoradiotherapy (adjusted HR = 5.903, p = 0.004), and administration of chemotherapy after RT (adjusted HR = 0.207, p = 0.03) were independent prognostic factors for OS. Positive lymph nodal metastases (adjusted subdistribution HR [sHR] = 3.712, p = 0.003) and higher tumor reduction after RT (adjusted sHR = 0.922, p < 0.001) were significant prognostic factors for LP, whereas BED10 ≥ 67.1 Gy (adjusted sHR = 0.297, p = 0.002), CA19-9 reduction rate ≥50% (adjusted sHR = 0.334, p = 0.023), and RT alone (adjusted sHR = 2.633, p = 0.047) were significant prognostic factors for DM. CONCLUSION Our results indicate that pre-RT NLR and post-RT monitoring of CA19-9 and tumor size reduction can help identify whether patients belong to the good or poor prognostic group of LAPC. The incorporation of new systemic treatments during and after a higher BED10 RT dose for LAPC patients is warranted.
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Affiliation(s)
- Yi-Lun Chen
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chiao-Ling Tsai
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
- Cancer Research Center, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Jason Chia-Hsien Cheng
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Oncology, College of Medicine, National Taiwan University, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chun-Wei Wang
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
- Cancer Research Center, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Radiology, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Radiation Oncology, National Taiwan University Cancer Center, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shih-Hung Yang
- Cancer Research Center, College of Medicine, National Taiwan University, Taipei, Taiwan
- Division of Medical Oncology, Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Wen Tien
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Sung-Hsin Kuo
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
- Cancer Research Center, College of Medicine, National Taiwan University, Taipei, Taiwan
- Graduate Institute of Oncology, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Radiation Oncology, National Taiwan University Cancer Center, College of Medicine, National Taiwan University, Taipei, Taiwan
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Liauw SL, Ni L, Wu T, Arif F, Cloutier D, Posner MC, Kozloff M, Kindler HL. A prospective trial of stereotactic body radiation therapy for unresectable pancreatic cancer testing ablative doses. J Gastrointest Oncol 2020; 11:1399-1407. [PMID: 33457009 DOI: 10.21037/jgo-20-187] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background We explored the safety and efficacy of ablative doses of stereotactic body radiation therapy (SBRT) for unresectable pancreatic cancer. Methods This phase I/II trial included patients with unresectable pancreatic cancer previously treated with any number of cycles of induction chemotherapy. Patients were enrolled according to a 3+3 dose escalation design at 10, 12.5, and 15 Gy ×3, with subsequent patients at the maximally tolerated dose (MTD). Treatment was delivered to gross tumor delineated with MRI fusion using image-guidance to fiducial markers. Dose-limiting toxicity (DLT) was defined as grade 3+ toxicity within 30 days. Secondary endpoints included late gastrointestinal (GI) toxicity, freedom from local failure (FFLF), and survival. Results Fifteen patients received a median 10 cycles of chemotherapy. There were no DLTs, and the MTD was 15 Gy ×3. Thirty-day toxicity included grade 2 nausea (46%) and grade 2 diarrhea (7%). Median survival after SBRT was 12.8 months (23 months after diagnosis) and median relapse-free survival was 7 months. At 1-year, FFLF was 80%. Four patients had grade 3+ GI bleeding after 30 days (median 6 months). Grade 3+ GI bleeding was associated with tumor volume (P=0.01), heterogeneity of dose within the planning target volume (PTV) (V120, P=0.03), and duodenal dose (V26-30 Gy, P<0.2). Conclusions This aggressive SBRT regimen demonstrated limited 30-day morbidity, a moderate degree of local control, and a moderate risk for late GI bleeding. Further work is necessary to define the most appropriate hypofractionated radiation therapy (RT) regimen in the ablative dose range.
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Affiliation(s)
- Stanley L Liauw
- Department of Radiation Oncology, University of Chicago Medical Center, Chicago, IL, USA
| | - Lisa Ni
- Department of Radiation Oncology, University of Chicago Medical Center, Chicago, IL, USA
| | - Tianming Wu
- Department of Radiation Oncology, University of Chicago Medical Center, Chicago, IL, USA
| | - Fauzia Arif
- Department of Radiation Oncology, University of Chicago Medical Center, Chicago, IL, USA
| | - Denise Cloutier
- Department of Radiation Oncology, University of Chicago Medical Center, Chicago, IL, USA
| | - Mitchell C Posner
- Department of Surgical Oncology, University of Chicago Medical Center, Chicago, IL, USA
| | - Mark Kozloff
- Department of Medical Oncology, University of Chicago Medical Center, Chicago, IL, USA
| | - Hedy L Kindler
- Department of Medical Oncology, University of Chicago Medical Center, Chicago, IL, USA
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5
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Ding Y, Campbell WG, Miften M, Vinogradskiy Y, Goodman KA, Schefter T, Jones BL. Quantifying Allowable Motion to Achieve Safe Dose Escalation in Pancreatic SBRT. Pract Radiat Oncol 2019; 9:e432-e442. [PMID: 30951868 PMCID: PMC6592725 DOI: 10.1016/j.prro.2019.03.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 03/04/2019] [Accepted: 03/23/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE Tumor motion plays a key role in the safe delivery of stereotactic body radiation therapy (SBRT) for pancreatic cancer. The purpose of this study was to use tumor motion measured in patients to establish limits on motion magnitude for safe delivery of pancreatic SBRT and to help guide motion-management decisions in potential dose-escalation scenarios. METHODS AND MATERIALS Using 91 sets of pancreatic tumor motion data, we calculated the motion-convolved dose of the gross tumor volume, duodenum, and stomach for 25 patients with pancreatic cancer. We derived simple linear or quadratic models relating motion to changes in dose and used these models to establish the maximum amount of motion allowable while satisfying error thresholds on key dose metrics. In the same way, we studied the effects of dose escalation and tumor volume on allowable motion. RESULTS In our patient cohort, the mean (range) allowable motion for 33, 40, and 50 Gy to the planning target volume was 11.9 (6.3-22.4), 10.4 (5.2-19.1), and 9.0 (4.2-16.0) mm, respectively. The maximum allowable motion decreased as the dose was escalated and was smaller in patients with larger tumors. We found significant differences in allowable motion between the different plans, suggesting a patient-specific approach to motion management is possible. CONCLUSIONS The effects of motion on pancreatic SBRT are highly variable among patients, and there is potential to allow more motion in certain patients, even in dose-escalated scenarios. In our dataset, a conservative limit of 6.3 mm would ensure safe treatment of all patients treated to 33 Gy in 5 fractions.
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Affiliation(s)
- Yijun Ding
- Department of Radiation Oncology, University of Colorado, Denver, Colorado
| | - Warren G Campbell
- Department of Radiation Oncology, University of Colorado, Denver, Colorado
| | - Moyed Miften
- Department of Radiation Oncology, University of Colorado, Denver, Colorado
| | | | - Karyn A Goodman
- Department of Radiation Oncology, University of Colorado, Denver, Colorado
| | - Tracey Schefter
- Department of Radiation Oncology, University of Colorado, Denver, Colorado
| | - Bernard L Jones
- Department of Radiation Oncology, University of Colorado, Denver, Colorado.
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Strauss VY, Shaw R, Virdee PS, Hurt CN, Ward E, Tranter B, Patel N, Bridgewater J, Parsons P, Radhakrishna G, O’Neill E, Sebag-Montefiore D, Hawkins M, Corrie PG, Maughan T, Mukherjee S. Study protocol: a multi-centre randomised study of induction chemotherapy followed by capecitabine ± nelfinavir with high- or standard-dose radiotherapy for locally advanced pancreatic cancer (SCALOP-2). BMC Cancer 2019; 19:121. [PMID: 30717707 PMCID: PMC6360784 DOI: 10.1186/s12885-019-5307-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 01/16/2019] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Induction chemotherapy followed by chemoradiation is a treatment option for patients with locally advanced pancreatic cancer (LAPC). However, overall survival is comparable to chemotherapy alone and local progression occurs in nearly half of all patients, suggesting chemoradiation strategies should be optimised. SCALOP-2 is a randomised phase II trial testing the role of radiotherapy dose escalation and/or the addition of the radiosensitiser nelfinavir, following induction chemotherapy of gemcitabine and nab-paclitaxel (GEMABX). A safety run-in phase (stage 1) established the nelfinavir dose to administer with chemoradiation in the randomised phase (stage 2). METHODS Patients with locally advanced, inoperable, non-metastatic pancreatic adenocarcinoma receive three cycles of induction GEMABX chemotherapy prior to radiological assessment. Those with stable/responding disease are eligible for further trial treatment. In Stage 1, participants received one further cycle of GEMABX followed by capecitabine-chemoradiation with escalating doses of nelfinavir in a rolling-six design. Stage 2 aims to register 262 and randomise 170 patients with responding/stable disease to one of five arms: capecitabine with high- (arms C + D) or standard-dose (arms A + B) radiotherapy with (arms A + C) or without (arms B + D) nelfinavir, or three more cycles of GEMABX (arm E). Participants allocated to the chemoradiation arms receive another cycle of GEMABX before chemoradiation begins. Co-primary outcomes are 12-month overall survival (radiotherapy dose-escalation question) and progression-free survival (nelfinavir question). Secondary outcomes include toxicity, quality of life, disease response rate, resection rate, treatment compliance, and CA19-9 response. SCALOP-2 incorporates a detailed radiotherapy quality assurance programme. DISCUSSION SCALOP-2 aims to optimise chemoradiation in LAPC and incorporates a modern induction regimen. TRIAL REGISTRATION Eudract No: 2013-004968-56; ClinicalTrials.gov : NCT02024009.
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Affiliation(s)
| | - Rachel Shaw
- Oncology Clinical Trials Office, University of Oxford, Oxford, UK
| | | | | | - Elizabeth Ward
- Clinical Trials and Evaluation Unit, Bristol Royal Infirmary, Bristol, UK
| | - Bethan Tranter
- Pharmacy Department, Velindre Cancer Centre, Velindre NHS University Trust, Cardiff, UK
| | - Neel Patel
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK
| | - John Bridgewater
- Department of Oncology, University College London Hospitals, London, UK
| | - Philip Parsons
- Cardiff NCRI RTTQA group, Department of Medical Physics, Velindre Cancer Centre, Cardiff, UK
| | - Ganesh Radhakrishna
- Oncology Department, The Christie NHS Foundation Trust, Wilmslow Road, Manchester, UK
| | - Eric O’Neill
- Department of Oncology, University of Oxford, CRUK MRC Oxford Institute for Radiation Oncology, Oxford, UK
| | | | - Maria Hawkins
- Department of Oncology, University of Oxford, CRUK MRC Oxford Institute for Radiation Oncology, Oxford, UK
| | - Pippa G. Corrie
- Cambridge Cancer Centre, Addenbrooke’s Hospital, Cambridge, UK
| | - Timothy Maughan
- Department of Oncology, University of Oxford, CRUK MRC Oxford Institute for Radiation Oncology, Oxford, UK
| | - Somnath Mukherjee
- Department of Oncology, University of Oxford, CRUK MRC Oxford Institute for Radiation Oncology, Oxford, UK
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Domínguez-Muñoz JE, Nieto-Garcia L, López-Díaz J, Lariño-Noia J, Abdulkader I, Iglesias-Garcia J. Impact of the treatment of pancreatic exocrine insufficiency on survival of patients with unresectable pancreatic cancer: a retrospective analysis. BMC Cancer 2018; 18:534. [PMID: 29728096 PMCID: PMC5935964 DOI: 10.1186/s12885-018-4439-x] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 04/26/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Malnutrition and weight loss are commonly observed in patients with pancreatic cancer and contribute to poor survival. Pancreatic exocrine insufficiency (PEI), which can be caused by ductal obstruction by a tumor, causes maldigestion and malabsorption of nutrients, thus contributing to malnutrition in these patients. In this study, we evaluated the effects of pancreatic enzyme replacement therapy (PERT) on survival in patients with unresectable pancreatic cancer. METHODS A retrospective analysis was conducted on a database of patients with unresectable, pathologically confirmed pancreatic cancer. All patients were evaluated for palliative chemotherapy and received the optimal palliative care. Patients were divided into two groups: Group 1 received standard therapy; Group 2 underwent additional evaluation of the pancreatic function and therapy with PERT, if needed. Survival (median and 95% confidence interval [CI]) was analyzed using Kaplan-Meier and Cox regression; groups were compared using the log-rank test. RESULTS Overall, 160 patients with unresectable pancreatic cancer were included in the analysis (mean age: 70.5 years [range 28-100]; gender: 57.5% male; tumor stage: 78.7% Stage IV). Eighty-six patients (53.75%) were in Group 1 and 74 (46.25%) were in Group 2. Age, gender, tumor size, location and stage, weight loss, and serum CA 19-9 were similar between groups. Ninety-three (58.1%) patients received palliative chemotherapy; 46.5% in Group 1 and 71.6% in Group 2 (P < 0.001). Forty-nine (66.2%) patients in Group 2 and none in Group 1 received PERT. Survival in Group 2 (189 days, 95% CI 167.0-211.0 days) was significantly longer than in Group 1 (95.0 days, 95% CI 75.4-114.6 days) (HR 2.117, 95% CI 1.493-3.002; P < 0.001). Chemotherapy and PERT were significantly and independently associated with longer survival in a model controlled by age and tumor stage. In patients with significant weight loss at diagnosis (> 10% bodyweight within 6 months), PERT was associated with longer survival (HR 2.52, 95% CI 1.55-4.11; P < 0.001). CONCLUSIONS In patients with unresectable pancreatic cancer, PERT in patients with PEI was associated with longer survival compared with those not receiving PERT, especially in those experiencing significant weight loss. This finding should guide future prospective clinical trials of similar interventions.
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Affiliation(s)
- Juan Enrique Domínguez-Muñoz
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, C/ Choupana s/n, 15706 Santiago de Compostela, Spain
- Health Research Institute (IDIS), University Hospital of Santiago de Compostela, C/ Choupana s/n, 15706 Santiago de Compostela, Spain
| | - Laura Nieto-Garcia
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, C/ Choupana s/n, 15706 Santiago de Compostela, Spain
- Health Research Institute (IDIS), University Hospital of Santiago de Compostela, C/ Choupana s/n, 15706 Santiago de Compostela, Spain
| | - Javier López-Díaz
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, C/ Choupana s/n, 15706 Santiago de Compostela, Spain
- Health Research Institute (IDIS), University Hospital of Santiago de Compostela, C/ Choupana s/n, 15706 Santiago de Compostela, Spain
| | - Jose Lariño-Noia
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, C/ Choupana s/n, 15706 Santiago de Compostela, Spain
- Health Research Institute (IDIS), University Hospital of Santiago de Compostela, C/ Choupana s/n, 15706 Santiago de Compostela, Spain
| | - Ihab Abdulkader
- Health Research Institute (IDIS), University Hospital of Santiago de Compostela, C/ Choupana s/n, 15706 Santiago de Compostela, Spain
- Department of Pathology, University Hospital of Santiago de Compostela, C/ Choupana s/n, 15706 Santiago de Compostela, Spain
| | - Julio Iglesias-Garcia
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, C/ Choupana s/n, 15706 Santiago de Compostela, Spain
- Health Research Institute (IDIS), University Hospital of Santiago de Compostela, C/ Choupana s/n, 15706 Santiago de Compostela, Spain
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Hypofractionated radiotherapy in pancreatic cancer: Lessons from the past in the era of stereotactic body radiation therapy. Crit Rev Oncol Hematol 2016; 103:49-61. [DOI: 10.1016/j.critrevonc.2016.05.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 03/05/2016] [Accepted: 05/10/2016] [Indexed: 12/31/2022] Open
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Hirata T, Teshima T, Nishiyama K, Ogawa K, Otani K, Kawaguchi Y, Konishi K, Tomita Y, Takahashi H, Ohigashi H, Ishikawa O. Histopathological effects of preoperative chemoradiotherapy for pancreatic cancer: an analysis for the impact of radiation and gemcitabine doses. Radiother Oncol 2015; 114:122-7. [PMID: 25614389 DOI: 10.1016/j.radonc.2015.01.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Revised: 01/03/2015] [Accepted: 01/04/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE Histopathological findings of patients who underwent resection for pancreatic adenocarcinoma (PC) after preoperative chemoradiotherapy (CRT) reportedly showed beneficial effects. The purpose of our study was to evaluate the correlation between histopathological effects (HE) of preoperative CRT and treatment parameters [radiation and gemcitabine (GEM) doses]. MATERIAL AND METHODS HE of CRT were assessed on 158 primary lesions of 157 patients with PC who underwent pancreatic resection after preoperative CRT with GEM between January 2006 and December 2011. The radiation dose delivered to the primary tumor site and surrounding regional nodal areas was 50 Gy until September 2009 followed by the dose escalation of a 10 Gy boost added for delivery with the field-in-field technique to the roots of the celiac and superior mesenteric arteries. Intravenous administration of GEM (1000 /m(2)) was initiated concurrently on days 1, 8, and 15, every 4 weeks and generally repeated for 3 cycles. HE of CRT on the primary tumor were categorized based on the number of tumor cells destroyed. RESULTS The median overall survival time was 74.5 months and 3-year and 5-year survival rates were 64.3% and 54.5%, respectively. Dose-volume parameters of radiation such as D33 with a cut-off value of 51.6 Gy were correlated significantly with HE (p=.0230). Lesions having received GEM>7625 mg/m(2) before surgical resection more frequently showed positive HE (p=.0002). Multivariate logistic regression analysis demonstrated that both D33 and cumulative GEM dose were significant predictors of definite HE (p=.0110 and <.0001, respectively). CONCLUSIONS Our retrospective analysis showed that dose intensity of radiation and GEM is significantly related to HE of preoperative CRT for PC.
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Affiliation(s)
- Takero Hirata
- Department of Radiation Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan; Department of Radiation Oncology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Teruki Teshima
- Department of Radiation Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan.
| | - Kinji Nishiyama
- Department of Radiation Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Kazuhiko Ogawa
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Keisuke Otani
- Department of Radiation Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan; Department of Radiation Oncology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshifumi Kawaguchi
- Department of Radiation Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Koji Konishi
- Department of Radiation Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Yasuhiko Tomita
- Department of Pathology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Hidenori Takahashi
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Hiroaki Ohigashi
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Osamu Ishikawa
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
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Chuong MD, Boggs DH, Patel KN, Regine WF. Adjuvant chemoradiation for pancreatic cancer: what does the evidence tell us? J Gastrointest Oncol 2014; 5:166-77. [PMID: 24982765 DOI: 10.3978/j.issn.2078-6891.2014.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 05/08/2014] [Indexed: 12/12/2022] Open
Abstract
The role of adjuvant chemoradiation (CRT) for pancreas cancer remains unclear. A handful of randomized trials conducted decades of ago ignited a debate that continues today about whether CRT improves survival after surgery. The many flaws in these trials are well described in the literature, which include the use of antiquated radiation delivery techniques and suboptimal doses. Recent prospective randomized data is lacking, and we eagerly await the results the ongoing Radiation Therapy Oncology Group (RTOG) 0848 trial that is evaluating the utility of high quality adjuvant CRT in resected pancreas cancer patients. Until the results of RTOG 0848 are available we should look to other studies from the modern era to guide adjuvant treatment recommendations. Here we review the current state of the art for adjuvant pancreas CRT with respect to patient selection, radiation techniques, radiation dose, and integration with novel systemic agents.
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Affiliation(s)
- Michael D Chuong
- Department of Radiation Oncology, University of Maryland Medical Systems, Baltimore, MD 21201, USA
| | - Drexell H Boggs
- Department of Radiation Oncology, University of Maryland Medical Systems, Baltimore, MD 21201, USA
| | - Kruti N Patel
- Department of Radiation Oncology, University of Maryland Medical Systems, Baltimore, MD 21201, USA
| | - William F Regine
- Department of Radiation Oncology, University of Maryland Medical Systems, Baltimore, MD 21201, USA
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11
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Kwak YK, Lee JH, Lee MA, Chun HG, Kim DG, You YK, Hong TH, Jang HS. Definitive concurrent chemoradiotherapy in locally advanced pancreatic cancer. Radiat Oncol J 2014; 32:49-56. [PMID: 25061572 PMCID: PMC4104219 DOI: 10.3857/roj.2014.32.2.49] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 05/07/2014] [Accepted: 05/21/2014] [Indexed: 01/29/2023] Open
Abstract
Purpose Survival outcome of locally advanced pancreatic cancer has been poor and little is known about prognostic factors of the disease, especially in locally advanced cases treated with concurrent chemoradiation. This study was to analyze overall survival and prognostic factors of patients treated with concurrent chemoradiotherapy (CCRT) in locally advanced pancreatic cancer. Materials and Methods Medical records of 34 patients diagnosed with unresectable pancreatic cancer and treated with definitive CCRT, from December 2003 to December 2012, were reviewed. Median prescribed radiation dose was 50.4 Gy (range, 41.4 to 55.8 Gy), once daily, five times per week, 1.8 to 3 Gy per fraction. Results With a mean follow-up of 10 months (range, 0 to 49 months), median overall survival was 9 months. The 1- and 2-year survival rates were 40% and 10%, respectively. Median and mean time to progression were 5 and 7 months, respectively. Prognostic parameters related to overall survival were post-CCRT CA19-9 (p = 0.02), the Eastern Cooperative Oncology Group (ECOG) status (p < 0.01), and radiation dose (p = 0.04) according to univariate analysis. In multivariate analysis, post-CCRT CA19-9 value below 180 U/mL and ECOG status 0 or 1 were statistically significant independent prognostic factors associated with improved overall survival (p < 0.01 and p = 0.02, respectively). Conclusion Overall treatment results in locally advanced pancreatic cancer are relatively poor and few improvements have been accomplished in the past decades. Post-treatment CA19-9 below 180 U/mL and ECOG performance status 0 and 1 were significantly associated with an improved overall survival.
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Affiliation(s)
- Yoo-Kang Kwak
- Department of Radiation Oncology, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Jong Hoon Lee
- Department of Radiation Oncology, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Myung-Ah Lee
- Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Hoo-Geun Chun
- Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Dong-Goo Kim
- Department of Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Young Kyoung You
- Department of Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Tae-Ho Hong
- Department of Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Hong Seok Jang
- Department of Radiation Oncology, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
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12
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Intensity modulated radiotherapy as neoadjuvant chemoradiation for the treatment of patients with locally advanced pancreatic cancer. Outcome analysis and comparison with a 3D-treated patient cohort. Strahlenther Onkol 2013; 189:738-44. [PMID: 23896630 DOI: 10.1007/s00066-013-0391-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2013] [Accepted: 05/20/2013] [Indexed: 01/14/2023]
Abstract
BACKGROUND To evaluate outcome after intensity modulated radiotherapy (IMRT) compared to 3D conformal radiotherapy (3D-RT) as neoadjuvant treatment in patients with locally advanced pancreatic cancer (LAPC). MATERIALS AND METHODS In total, 57 patients with LAPC were treated with IMRT and chemotherapy. A median total dose of 45 Gy to the PTV_baseplan and 54 Gy to the PTV_boost in single doses of 1.8 Gy for the PTV_baseplan and median single doses of 2.2 Gy in the PTV_boost were applied. Outcomes were evaluated and compared to a large cohort of patients treated with 3D-RT. RESULTS Overall treatment was well tolerated in all patients and IMRT could be completed without interruptions. Median overall survival was 11 months (range 5-37.5 months). Actuarial overall survival at 12 and 24 months was 36 % and 8 %, respectively. A significant impact on overall survival could only be observed for a decrease in CA 19-9 during treatment, patients with less pre-treatment CA 19-9 than the median, as well as weight loss during treatment. Local progression-free survival was 79 % after 6 months, 39 % after 12 months, and 13 % after 24 months. No factors significantly influencing local progression-free survival could be identified. There was no difference in overall and progression-free survival between 3D-RT and IMRT. Secondary resectability was similar in both groups (26 % vs. 28 %). Toxicity was comparable and consisted mainly of hematological toxicity due to chemotherapy. CONCLUSION IMRT leads to a comparable outcome compared to 3D-RT in patients with LAPC. In the future, the improved dose distribution, as well as advances in image-guided radiotherapy (IGRT) techniques, may improve the use of IMRT in local dose escalation strategies to potentially improve outcome.
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Kessel KA, Habermehl D, Jäger A, Floca RO, Zhang L, Bendl R, Debus J, Combs SE. Development and validation of automatic tools for interactive recurrence analysis in radiation therapy: optimization of treatment algorithms for locally advanced pancreatic cancer. Radiat Oncol 2013; 8:138. [PMID: 24499557 PMCID: PMC3682901 DOI: 10.1186/1748-717x-8-138] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 06/04/2013] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND In radiation oncology recurrence analysis is an important part in the evaluation process and clinical quality assurance of treatment concepts. With the example of 9 patients with locally advanced pancreatic cancer we developed and validated interactive analysis tools to support the evaluation workflow. METHODS After an automatic registration of the radiation planning CTs with the follow-up images, the recurrence volumes are segmented manually. Based on these volumes the DVH (dose volume histogram) statistic is calculated, followed by the determination of the dose applied to the region of recurrence and the distance between the boost and recurrence volume. We calculated the percentage of the recurrence volume within the 80%-isodose volume and compared it to the location of the recurrence within the boost volume, boost + 1 cm, boost + 1.5 cm and boost + 2 cm volumes. RESULTS Recurrence analysis of 9 patients demonstrated that all recurrences except one occurred within the defined GTV/boost volume; one recurrence developed beyond the field border/outfield. With the defined distance volumes in relation to the recurrences, we could show that 7 recurrent lesions were within the 2 cm radius of the primary tumor. Two large recurrences extended beyond the 2 cm, however, this might be due to very rapid growth and/or late detection of the tumor progression. CONCLUSION The main goal of using automatic analysis tools is to reduce time and effort conducting clinical analyses. We showed a first approach and use of a semi-automated workflow for recurrence analysis, which will be continuously optimized. In conclusion, despite the limitations of the automatic calculations we contributed to in-house optimization of subsequent study concepts based on an improved and validated target volume definition.
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Affiliation(s)
- Kerstin A Kessel
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, Heidelberg, 69120, Germany.
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