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Bhutani MS, Narang AK, Ding K, Casey B, Krishnan K, Koay EJ, Hong TS, Herman JM, Griffin KH, Shin EJ. EUS-guided hydrogel injection to separate pancreatic head carcinoma from duodenum for enhanced radiotherapy: Multi-site feasibility study. Endosc Int Open 2024; 12:E861-E867. [PMID: 38989255 PMCID: PMC11236477 DOI: 10.1055/a-2286-1995] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 03/21/2024] [Indexed: 07/12/2024] Open
Abstract
Background and study aims The proximity of a pancreas head tumor to the duodenum often limits delivery of an ablative dose of radiation therapy. This study evaluated the feasibility and safety of using an injectable polyethylene glycol (PEG) hydrogel between the head of the pancreas and duodenum. Patients and methods In a multi-site feasibility cohort study of patients with localized pancreatic cancer, PEG hydrogel was injected under endoscopic ultrasound guidance to temporarily position the duodenum away from the pancreas. Procedure characteristics were recorded, including hydrogel volume and space created. Patients were monitored for adverse events (AEs) and radiotherapy toxicity. Results In all six intent-to-treat patients (four with borderline resectable, two with locally advanced disease), the ability to place and visualize PEG hydrogel and create space between the duodenum and the head of the pancreas was successful. There were no procedure-related AEs resulting in radiotherapy delay. There were no device-related AEs and no reports of pancreatitis. Conclusions PEG hydrogel was successfully placed, created space between the duodenum and the head of the pancreas, and was not associated with major toxicity. Enhancing radiotherapy for pancreatic cancer by using PEG hydrogel to create peri-duodenal space could have beneficial implications for treatment and warrants more exploration.
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Affiliation(s)
- Manoop S Bhutani
- Department of Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, Houston, United States
| | - Amol K Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, United States
| | - Kai Ding
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, United States
| | - Brenna Casey
- Interventional Gastroenterology, Massachusetts General Hospital Harvard Medical School, Boston, United States
| | - Kumar Krishnan
- Gastroenterology, Massachusetts General Hospital, Boston, United States
| | - Eugene J Koay
- Department of GI Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, United States
| | - Theodore S Hong
- Radiation Oncology, Massachusetts General Hospital, Boston, United States
| | - Joseph M Herman
- Department of Radiation Medicine, Northwell, New Hyde Park, United States
| | | | - Eun Ji Shin
- Internal Medicine, Johns Hopkins Medicine, Baltimore, United States
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2
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Greenwood H, Hassan J, Fife K, Ajithkumar TV, Thippu Jayaprakash K. Single-Fraction Stereotactic Ablative Body Radiotherapy for Primary and Extracranial Oligometastatic Cancers. Clin Oncol (R Coll Radiol) 2023; 35:773-786. [PMID: 37852814 DOI: 10.1016/j.clon.2023.10.049] [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: 05/26/2023] [Revised: 09/14/2023] [Accepted: 10/04/2023] [Indexed: 10/20/2023]
Abstract
Stereotactic ablative body radiotherapy (SABR) consists of delivering high doses of ionising radiation, typically across three to eight fractions with high precision and conformity. SABR has become increasingly commonplace throughout the last quarter of a century and is offered for the treatment of various primary and metastatic tumour types. Delivering SABR in a single fraction has arisen as an appealing possibility for several reasons. These include fewer hospital visits, greater patient convenience, improved sustainability and lower costs. However, these factors must be balanced against considerations such as toxicity, side-effects and, most importantly, progression-free and overall survival. In this review we seek to analyse the results of studies looking at the efficacy of single-fraction SABR for lung, prostate, renal and pancreas primary tumours, as well as oligometastases. The tumour type to be most widely treated with single-fraction SABR is lung, but its remit continues to expand. We also look at the biological rationale underpinning SABR and how this can be extended to single-fraction regimens. Finally, we turn our attention towards the future directions of SABR and specifically single-fraction regimens. These include the possibility of combining SABR with immunotherapy and technological advances in the field, which could serve to expand the scope of SABR. We conclude by summarising the current clinical studies of single-fraction SABR.
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Affiliation(s)
- H Greenwood
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - J Hassan
- University College London Medical School, London, UK
| | - K Fife
- Oncology Centre, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - T V Ajithkumar
- Oncology Centre, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - K Thippu Jayaprakash
- Oncology Centre, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; Department of Oncology, The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust, King's Lynn, UK.
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Ursino S, Gadducci G, Giannini N, Gonnelli A, Fuentes T, Di Martino F, Paiar F. New insights on clinical perspectives of FLASH radiotherapy: from low- to very high electron energy. Front Oncol 2023; 13:1254601. [PMID: 37936603 PMCID: PMC10626470 DOI: 10.3389/fonc.2023.1254601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 09/25/2023] [Indexed: 11/09/2023] Open
Abstract
Radiotherapy (RT) is performed in approximately 75% of patients with cancer, and its efficacy is often hampered by the low tolerance of the surrounding normal tissues. Recent advancements have demonstrated the potential to widen the therapeutic window using "very short" radiation treatment delivery (from a conventional dose rate between 0.5 Gy/min and 2 Gy/min to more than 40 Gy/s) causing a significant increase of normal tissue tolerance without varying the tumor effect. This phenomenon is called "FLASH Effect (FE)" and has been discovered by using electrons. Although several physical, dosimetric, and radiobiological aspects need to be clarified, current preclinical "in vivo" studies have reported a significant protective effect of FLASH RT on neurocognitive function, skin toxicity, lung fibrosis, and bowel injury. Therefore, the current radiobiological premises lay the foundation for groundbreaking potentials in clinical translation, which could be addressed to an initial application of Low Energy Electron FLASH (LEE) for the treatment of superficial tumors to a subsequent Very High Energy Electron FLASH (VHEE) for the treatment of deep tumors. Herein, we report a clinical investigational scenario that, if supported by preclinical studies, could be drawn in the near future.
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Affiliation(s)
- Stefano Ursino
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
- Centro Pisano Multidisciplinare sulla Ricerca e implementazione clinica della Flash Radiotherapy (CPFR), University of Pisa, Pisa, Italy
- Center for Instrument Sharing University of Pisa (CISUP), University of Pisa, Pisa, Italy
| | - Giovanni Gadducci
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
- Centro Pisano Multidisciplinare sulla Ricerca e implementazione clinica della Flash Radiotherapy (CPFR), University of Pisa, Pisa, Italy
| | - Noemi Giannini
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
- Centro Pisano Multidisciplinare sulla Ricerca e implementazione clinica della Flash Radiotherapy (CPFR), University of Pisa, Pisa, Italy
| | - Alessandra Gonnelli
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
- Centro Pisano Multidisciplinare sulla Ricerca e implementazione clinica della Flash Radiotherapy (CPFR), University of Pisa, Pisa, Italy
| | - Taiushia Fuentes
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
- Centro Pisano Multidisciplinare sulla Ricerca e implementazione clinica della Flash Radiotherapy (CPFR), University of Pisa, Pisa, Italy
| | - Fabio Di Martino
- Centro Pisano Multidisciplinare sulla Ricerca e implementazione clinica della Flash Radiotherapy (CPFR), University of Pisa, Pisa, Italy
- Unit of Medical Physics, S. Chiara University Hospital, Pisa, Italy
| | - Fabiola Paiar
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
- Centro Pisano Multidisciplinare sulla Ricerca e implementazione clinica della Flash Radiotherapy (CPFR), University of Pisa, Pisa, Italy
- Center for Instrument Sharing University of Pisa (CISUP), University of Pisa, Pisa, Italy
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Kamel R, Dennis K, Doody J, Pantarotto J. Ablative vs. Non-Ablative Radiotherapy in Palliating Locally Advanced Pancreatic Cancer: A Single Institution Experience and a Systematic Review of the Literature. Cancers (Basel) 2023; 15:cancers15113016. [PMID: 37296977 DOI: 10.3390/cancers15113016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/28/2023] [Accepted: 05/29/2023] [Indexed: 06/12/2023] Open
Abstract
We studied the dose-local control (LC) relationship in ablative vs. non-ablative radiotherapy in a non-radical treatment setting of "locally advanced pancreatic cancer (LAPC)" by comparing our patients (n = 89) treated with SBRT on the CyberKnife unit vs. conventional radiation between January 2005 and January 2021, and by reviewing the literature. A systematic search was performed leveraging Medline for references on SBRT use in pancreatic cancer without date terms or language restrictions. A total of 3702 references were identified and the search was then repeated in Embase and the Cochrane database. Ultimately, 12 studies were eligible for inclusion, which either compared SBRT to conventional radiation, or SBRT use in dose escalation for primary LAPC in a non-neoadjuvant setting. Our cohort's median overall survival was 152 days (CI 95%, 118-185); including 371 days (CI 95%, 230-511) vs. 126 days (CI 95%, 90-161) favoring SBRT, p = 0.004. The median time to local progression was 170 days (48-923) for SBRT vs. 107 days (27-489) for the non-ablative group. In our SBRT patients, no local progressions were seen with BED10 > 60 Gy. Even when palliating LAPC, SBRT should be considered as an alternative to conventional radiation, especially in patients with a low disease burden. BED10 ≥ 60-70 Gy offers better local control without increasing toxicity rates. Less local progression may provide a better quality of life to those patients who already have a short life expectancy.
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Affiliation(s)
- Randa Kamel
- Department of Radiation Oncology, UZ Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Brussel, Belgium
| | - Kristopher Dennis
- Department of Radiation Oncology, The Ottawa Hospital, Smyth Road 501, Ottawa, ON K1H 8L6, Canada
| | - Janice Doody
- Department of Radiation Oncology, The Ottawa Hospital, Smyth Road 501, Ottawa, ON K1H 8L6, Canada
| | - Jason Pantarotto
- Department of Radiation Oncology, The Ottawa Hospital, Smyth Road 501, Ottawa, ON K1H 8L6, Canada
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Takanen S, Pinnarò P, Farina I, Sperati F, Botti C, Vici P, Soriani A, Marucci L, Sanguineti G. Stereotactic partial breast irradiation in primary breast cancer: A comprehensive review of the current status and future directions. Front Oncol 2022; 12:953810. [PMID: 36313648 PMCID: PMC9606691 DOI: 10.3389/fonc.2022.953810] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 09/26/2022] [Indexed: 11/13/2022] Open
Abstract
In selected low-risk breast cancer patients, accelerated partial breast irradiation (APBI) may represent an alternative option to the whole breast irradiation to reduce the volume of irradiated breast and total treatment duration. In the last few years, preliminary data from clinical trials showed that stereotactic partial breast radiotherapy may have the advantage to be less invasive compared to other APBI techniques, with preliminary good results in terms of local toxicity and cosmesis: the use of magnetic resonance, fiducial markers in the tumor bed, and new breast devices support both a precise definition of the target and radiation planning.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021257856, identifier CRD42021257856.
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Affiliation(s)
- Silvia Takanen
- Radiation Oncology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Regina Elena National Cancer Institute, Rome, Italy
- *Correspondence: Silvia Takanen, ; Ilaria Farina,
| | - Paola Pinnarò
- Radiation Oncology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Regina Elena National Cancer Institute, Rome, Italy
| | - Ilaria Farina
- Radiation Oncology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Regina Elena National Cancer Institute, Rome, Italy
- *Correspondence: Silvia Takanen, ; Ilaria Farina,
| | - Francesca Sperati
- Biostatistics, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Regina Elena National Cancer Institute, Rome, Italy
| | - Claudio Botti
- Surgery, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Regina Elena National Cancer Institute, Rome, Italy
| | - Patrizia Vici
- Phase IV Studies, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Regina Elena National Cancer Institute, Rome, Italy
| | - Antonella Soriani
- Physics, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Regina Elena National Cancer Institute, Rome, Italy
| | - Laura Marucci
- Radiation Oncology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Regina Elena National Cancer Institute, Rome, Italy
| | - Giuseppe Sanguineti
- Radiation Oncology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Regina Elena National Cancer Institute, Rome, Italy
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Tanaka O, Taniguchi T, Adachi K, Nakaya S, Kiryu T, Ukai A, Makita C, Matsuo M. Effect of stomach size on organs at risk in pancreatic stereotactic body radiotherapy. Radiat Oncol 2022; 17:136. [PMID: 35909121 PMCID: PMC9339195 DOI: 10.1186/s13014-022-02107-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In clinical practice, the organs at risk (OARs) should be carefully determined when performing pancreatic stereotactic body radiotherapy (SBRT). We conducted a simulation study to examine the effect of the stomach size on the radiation dose to the OARs when performing pancreatic SBRT. METHODS Twenty-five cases were included in this study. Pancreatic head and body tumors were 2-cm-sized pseudotumors, which were included as gross target volume (GTV) contours. The stomach, pancreas, small intestine, liver, kidneys, and spinal cord were considered as the OARs. The prescription dose for planning target volume (PTV) was 40 Gy/5fx, and the dose limit for the OARs was determined. The dose to X% of the OAR volume at X values of 0.1, 5.0, and 10.0 cc (DX) and the percentage of the OAR volume that received more than X Gy were recorded. RESULTS In terms of the radiation dose to the pancreatic body tumors, the stomach size was positively correlated with a dose of D10cc [correlation coefficient (r) = 0.5516) to the stomach. The r value between the radiation dose to the pancreatic head tumor and the stomach size was 0.3499. The stomach size and radiation dose to the head and body of the pancreas were positively correlated (pancreatic head D10cc: r = 0.3979, pancreatic body D10cc: r = 0.3209). The larger the stomach, the larger the radiation dose to the healthy portion of the pancreas outside the PTV. CONCLUSIONS When performing pancreatic SBRT, the dose to the OARs depends on the stomach size. Reducing the dose to the stomach and pancreas can be achieved by shrinking the stomach.
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Affiliation(s)
- Osamu Tanaka
- Department of Radiation Oncology, Asahi University Hospital, 3-23 Hashimoto-cho, Gifu City, Gifu, 500-8523, Japan.
| | - Takuya Taniguchi
- Department of Radiation Oncology, Asahi University Hospital, 3-23 Hashimoto-cho, Gifu City, Gifu, 500-8523, Japan
| | - Kousei Adachi
- Department of Radiation Oncology, Asahi University Hospital, 3-23 Hashimoto-cho, Gifu City, Gifu, 500-8523, Japan
| | - Shuto Nakaya
- Department of Radiation Oncology, Asahi University Hospital, 3-23 Hashimoto-cho, Gifu City, Gifu, 500-8523, Japan
| | - Takuji Kiryu
- Department of Radiation Oncology, Asahi University Hospital, 3-23 Hashimoto-cho, Gifu City, Gifu, 500-8523, Japan
| | - Akira Ukai
- Department of Oral and Maxillofacial Surgery, Asahi University Hospital, 3-23 Hashimoto-cho, Gifu City, Gifu, 500-8523, Japan
| | - Chiyoko Makita
- Department of Radiology, Gifu University Hospital, 1-1 Yanagido, Gifu City, Gifu, 501-1194, Japan
| | - Masayuki Matsuo
- Department of Radiology, Gifu University Hospital, 1-1 Yanagido, Gifu City, Gifu, 501-1194, Japan
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Ji X, Zhou B, Ding W, Wang J, Jiang W, Li Y, Hu J, Sun X. Efficacy of stereotactic body radiation therapy for locoregional recurrent pancreatic cancer after radical resection. Front Oncol 2022; 12:925043. [PMID: 35936670 PMCID: PMC9353056 DOI: 10.3389/fonc.2022.925043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 06/27/2022] [Indexed: 11/25/2022] Open
Abstract
Objective This study aimed to analyze the efficacy and toxicity of stereotactic body radiotherapy (SBRT) for locoregional recurrent pancreatic cancer after radical resection. Methods Patients with locoregional recurrent pancreatic cancer after surgery treated with SBRT in our institution were retrospectively investigated from January 2010 to January 2020. Absolute neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) recorded at pretreatment were analyzed. Endpoints included overall survival (OS), progression-free survival (PFS) and cumulative incidences of local failure (LF) and metastatic failure (MF). Results A total of 22 patients received SBRT with a median prescribed dose of 40 Gy (range of 30-50 Gy)/4 to 7 fractions. The median OS of all patients was 13.6 months (95% CI, 9.6-17.5 months). 0-1 performance status (HR 12.10, 95% CI 2.04-71.81, P=0.006) and ≤2.1 pre-SBRT NLR (HR 4.05, 95% CI 1.21-13.59, P=0.023) were significant predictors of higher OS on multivariable analysis. The median progression-free survival (PFS) of the cohort was 7.5 months (95% CI, 6.5-8.5 months). The median time to LF and MF were 15.6 months and 6.4 months, respectively. The rate of MF as a first event was higher than that of first event LF. Pain relief was observed in all patients (100%) 6 weeks after SBRT. In terms of acute toxicity, grade 1 including fatigue (6, 27.3%), anorexia (6, 27.3%), nausea (4, 18.2%) and leukopenia (4, 18.2%) was often observed. No acute toxicity of grade 4 or 5 was observed. In terms of late toxicity, no treatment-related toxicity was found during follow-up. Conclusion This study showed that SBRT can significantly reduce pain, effectively control local tumor progression, and have acceptable toxicity for patients with locoregional recurrence after radical resection of primary pancreatic cancer. Good performance status and lower pre-SBRT NLR were associated with improved overall survival.
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Gaudreault M, Siva S, Kron T, Hardcastle N. Assessing organ at risk position variation and its impact on delivered dose in kidney SABR. Radiat Oncol 2022; 17:112. [PMID: 35761291 PMCID: PMC9235197 DOI: 10.1186/s13014-022-02041-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 03/23/2022] [Indexed: 11/10/2022] Open
Abstract
Background Delivered organs at risk (OARs) dose may vary from planned dose due to interfraction and intrafraction motion during kidney SABR treatment. Cases of bowel stricture requiring surgery post SABR treatment were reported in our institution. This study aims to provide strategies to reduce dose deposited to OARs during SABR treatment and mitigate risk of gastrointestinal toxicity.
Methods Small bowel (SB), large bowel (LB) and stomach (STO) were delineated on the last cone beam CT (CBCT) acquired before any dose had been delivered (PRE CBCT) and on the first CBCT acquired after any dose had been delivered (MID CBCT). OAR interfraction and intrafraction motion were estimated from the shortest distance between OAR and the internal target volume (ITV). Adaptive radiation therapy (ART) was used if dose limits were exceeded by projecting the planned dose on the anatomy of the day. Results In 36 patients, OARs were segmented on 76 PRE CBCTs and 30 MID CBCTs. Interfraction motion was larger than intrafraction motion in STO (p-value = 0.04) but was similar in SB (p-value = 0.8) and LB (p-value = 0.2). LB was inside the planned 100% isodose in all PRE CBCTs and MID CBCTs in the three patients that suffered from bowel stricture. SB D0.03cc was exceeded in 8 fractions (4 patients). LB D1.5cc was exceeded in 4 fractions (2 patients). Doses to OARs were lowered and limits were all met with ART on the anatomy of the day. Conclusions Interfraction motion was responsible for OARs overdosage. Dose limits were respected by using ART with the anatomy of the day. Supplementary Information The online version contains supplementary material available at 10.1186/s13014-022-02041-2.
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Affiliation(s)
- Mathieu Gaudreault
- Department of Physical Sciences, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC, 3000, Australia. .,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, 3000, Australia.
| | - Shankar Siva
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, 3000, Australia.,Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, 3000, Australia
| | - Tomas Kron
- Department of Physical Sciences, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC, 3000, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, 3000, Australia
| | - Nicholas Hardcastle
- Department of Physical Sciences, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC, 3000, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, 3000, Australia.,Centre for Medical Radiation Physics, University of Wollongong, Wollongong, NSW, 2522, Australia
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Kaučić H, Kosmina D, Schwarz D, Mack A, Šobat H, Čehobašić A, Leipold V, Andrašek I, Avdičević A, Mlinarić M. Stereotactic Ablative Radiotherapy Using CALYPSO ® Extracranial Tracking for Intrafractional Tumor Motion Management-A New Potential Local Treatment for Unresectable Locally Advanced Pancreatic Cancer? Results from a Retrospective Study. Cancers (Basel) 2022; 14:cancers14112688. [PMID: 35681668 PMCID: PMC9179494 DOI: 10.3390/cancers14112688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/24/2022] [Accepted: 05/27/2022] [Indexed: 11/16/2022] Open
Abstract
(1) Background: The aim of this study was to evaluate the efficacy and safety of SABR for LAPC using Calypso® Extracranial Tracking for intrafractional, fiducial-based motion management, to present this motion management technique, as there are yet no published data on usage of Calypso® during SABR for LAPC, and to report on our clinical outcomes. (2) Methods: Fifty-four patients were treated with SABR in one, three, or five fractions, receiving median BED10 = 112.5 Gy. Thirty-eight patients received systemic treatment. End points were OS, FFLP, PFS, and toxicity. Actuarial survival analysis and univariate analysis were investigated. (3) Results: Median follow-up was 20 months. Median OS was 24 months. One-year FFLP and one-year OS were 100% and 90.7%, respectively. Median PFS was 18 months, and one-year PFS was 72.2%. Twenty-five patients (46.3%) were alive at the time of analysis, and both median FU and OS for this subgroup were 26 months. No acute/late toxicity > G2 was reported. (4) Conclusions: SABR for LAPC using Calypso® presented as an effective and safe treatment and could be a promising local therapeutic option with very acceptable toxicity, either as a single treatment or in a multimodality regimen. Dose escalation to the tumor combined with systemic treatment could yield better clinical outcomes.
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Affiliation(s)
- Hrvoje Kaučić
- Specijalna bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia; (D.K.); (D.S.); (H.Š.); (A.Č.); (V.L.); (I.A.); (A.A.); (M.M.)
- Sveučilište Josipa Jurja Strossmayera u Osijeku—Medicinski Fakultet Osijek, Josipa Huttlera 4, 31000 Osijek, Croatia
- Correspondence: ; Tel.: +385-91-5622-191
| | - Domagoj Kosmina
- Specijalna bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia; (D.K.); (D.S.); (H.Š.); (A.Č.); (V.L.); (I.A.); (A.A.); (M.M.)
| | - Dragan Schwarz
- Specijalna bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia; (D.K.); (D.S.); (H.Š.); (A.Č.); (V.L.); (I.A.); (A.A.); (M.M.)
- Medicinski Fakultet Sveučilišta u Rijeci, Braće Branchetta 20/1, 51000 Rijeka, Croatia
- Sveučilište Josipa Jurja Strossmayera u Osijeku—Fakultet za Dentalnu Medicinu i Zdravstvo Osijek, Crkvena Ulica 21, 31000 Osijek, Croatia
| | - Andreas Mack
- Swiss NeuroRadiosurgery Center, Bürglistrasse 29, 8002 Zürich, Switzerland;
| | - Hrvoje Šobat
- Specijalna bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia; (D.K.); (D.S.); (H.Š.); (A.Č.); (V.L.); (I.A.); (A.A.); (M.M.)
| | - Adlan Čehobašić
- Specijalna bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia; (D.K.); (D.S.); (H.Š.); (A.Č.); (V.L.); (I.A.); (A.A.); (M.M.)
- Sveučilište Josipa Jurja Strossmayera u Osijeku—Medicinski Fakultet Osijek, Josipa Huttlera 4, 31000 Osijek, Croatia
| | - Vanda Leipold
- Specijalna bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia; (D.K.); (D.S.); (H.Š.); (A.Č.); (V.L.); (I.A.); (A.A.); (M.M.)
- Sveučilište Josipa Jurja Strossmayera u Osijeku—Medicinski Fakultet Osijek, Josipa Huttlera 4, 31000 Osijek, Croatia
| | - Iva Andrašek
- Specijalna bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia; (D.K.); (D.S.); (H.Š.); (A.Č.); (V.L.); (I.A.); (A.A.); (M.M.)
| | - Asmir Avdičević
- Specijalna bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia; (D.K.); (D.S.); (H.Š.); (A.Č.); (V.L.); (I.A.); (A.A.); (M.M.)
| | - Mihaela Mlinarić
- Specijalna bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia; (D.K.); (D.S.); (H.Š.); (A.Č.); (V.L.); (I.A.); (A.A.); (M.M.)
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Ermongkonchai T, Khor R, Muralidharan V, Tebbutt N, Lim K, Kutaiba N, Ng SP. Stereotactic radiotherapy and the potential role of magnetic resonance-guided adaptive techniques for pancreatic cancer. World J Gastroenterol 2022; 28:745-754. [PMID: 35317275 PMCID: PMC8891728 DOI: 10.3748/wjg.v28.i7.745] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 11/11/2021] [Accepted: 01/22/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pancreatic cancer is a malignancy with one of the poorest prognoses amongst all cancers. Patients with unresectable tumours either receive palliative care or undergo various chemoradiotherapy regimens. Conventional techniques are often associated with acute gastrointestinal toxicities, as adjacent critical structures such as the duodenum ultimately limits delivered doses. Stereotactic body radiotherapy (SBRT) is an advanced radiation technique that delivers highly ablative radiation split into several fractions, with a steep dose fall-off outside target volumes.
AIM To discuss the latest data on SBRT and whether there is a role for magnetic resonance-guided techniques in multimodal management of locally advanced, unresectable pancreatic cancer.
METHODS We conducted a search on multiple large databases to collate the latest records on radiotherapy techniques used to treat pancreatic cancer. Out of 1229 total records retrieved from our search, 36 studies were included in this review.
RESULTS Studies indicate that SBRT is associated with improved clinical efficacy and toxicity profiles compared to conventional radiotherapy techniques. Further dose escalation to the tumour with SBRT is limited by the poor soft-tissue visualisation of computed tomography imaging during radiation planning and treatment delivery. Magnetic resonance-guided techniques have been introduced to improve imaging quality, enabling treatment plan adaptation and re-optimisation before delivering each fraction.
CONCLUSION Therefore, SBRT may lead to improved survival outcomes and safer toxicity profiles compared to conventional techniques, and the addition of magnetic resonance-guided techniques potentially allows dose escalation and conversion of unresectable tumours to operable cases.
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Affiliation(s)
- Tai Ermongkonchai
- Department of Radiation Oncology, Olivia Newton-John Cancer Centre at Austin Health, Heidelberg 3084, Victoria, Australia
| | - Richard Khor
- Department of Radiation Oncology, Olivia Newton-John Cancer Centre at Austin Health, Heidelberg 3084, Victoria, Australia
| | | | - Niall Tebbutt
- Department of Medical Oncology, Olivia Newton-John Cancer Centre at Austin Health, Heidelberg 3084, Victoria, Australia
| | - Kelvin Lim
- Department of Diagnostic Radiology, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Numan Kutaiba
- Department of Diagnostic Radiology, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Sweet Ping Ng
- Department of Radiation Oncology, Olivia Newton-John Cancer Centre at Austin Health, Heidelberg 3084, Victoria, Australia
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Shen Y, Zhu X, Cao F, Xie H, Ju X, Cao Y, Qing S, Jia Z, Gu L, Fang F, Zhang H. Re-Irradiation With Stereotactic Body Radiotherapy for In-Field Recurrence of Pancreatic Cancer After Prior Stereotactic Body Radiotherapy: Analysis of 24 Consecutive Cases. Front Oncol 2021; 11:729490. [PMID: 34796108 PMCID: PMC8593208 DOI: 10.3389/fonc.2021.729490] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 10/05/2021] [Indexed: 12/27/2022] Open
Abstract
Purpose/Objectives Locally recurrent pancreatic cancer is a therapeutic challenge, and aggressive approaches are needed to improve its clinical outcomes. Stereotactic body radiotherapy (SBRT) is a promising treatment for pancreatic cancer with an excellent local control and acceptable toxicity. However, the safety and efficacy of SBRT for in-field recurrence after initial SBRT remain unknown. The aim of the study was to investigate the feasibility of re-irradiation with SBRT for locally recurrent pancreatic cancer after prior definitive SBRT. Material/Methods Twenty-four consecutive patients with pancreatic cancer received two courses of SBRT in our center between January 2014 and December 2016. The median prescription dose of the initial and second courses of SBRT was 35.5 Gy/5–7f and 32 Gy/5–8f, respectively. Clinical outcomes including overall survival (OS), disease control, and toxicity were evaluated after treatment. Results The median interval between two courses of SBRT was 13 months (range: 6–29 months). From the first SBRT, the median OS of 18 patients with limited diseases was 26 months (95% CI: 19.1–32.95 months). The median OS of 12 patients without metastasis was 14 months (95% CI: 10.6–17.4 months) from re-irradiation of SBRT. The overall response rate and disease control rate were 50% and 13%, and 100% and 86.9% after each SBRT, respectively. Carbohydrate antigen 19-9 (CA19-9) levels declined dramatically after re-irradiation within 1 month (p = 0.002) and 3 months (p = 0.028). Twelve (75%) out of 16 patients had pain relief after re-irradiation. None of the patients experienced gastrointestinal toxicity. Conclusions Re-irradiation with SBRT can provide favorable outcomes and effective analgesia with mild toxicity after prior SBRT for in-field recurrent pancreatic cancer, which might be feasible for locally relapsed pancreatic cancer.
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Affiliation(s)
- Yuxin Shen
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Xiaofei Zhu
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Fei Cao
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Hongliang Xie
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Xiaoping Ju
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Yangsen Cao
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Shuiwang Qing
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Zhen Jia
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Lei Gu
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Fang Fang
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Huojun Zhang
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
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Georges P, Doussot A. Comment on: local control and survival after induction chemotherapy and ablative radiation versus resection for pancreatic ductal adenocarcinoma with vascular involvement. Hepatobiliary Surg Nutr 2021; 10:672-674. [PMID: 34760970 DOI: 10.21037/hbsn-21-336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 08/27/2021] [Indexed: 11/06/2022]
Affiliation(s)
- Pauline Georges
- Department of Digestive Surgical Oncology - Liver Transplantation Unit, CHU Besancon, Besancon, France
| | - Alexandre Doussot
- Department of Digestive Surgical Oncology - Liver Transplantation Unit, CHU Besancon, Besancon, France
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Achieving 'Marginal Gains' to Optimise Outcomes in Resectable Pancreatic Cancer. Cancers (Basel) 2021; 13:cancers13071669. [PMID: 33916294 PMCID: PMC8037133 DOI: 10.3390/cancers13071669] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/19/2021] [Accepted: 03/24/2021] [Indexed: 12/21/2022] Open
Abstract
Simple Summary Improving outcomes in pancreatic cancer is achievable through the accumulation of marginal gains. There exists evidence of variation and undertreatment in many areas of the care pathway. By fully realising the existing opportunities, there is the potential for immediate improvements in outcomes and quality of life. Abstract Improving outcomes among patients with resectable pancreatic cancer is one of the greatest challenges of modern medicine. Major improvements in survival will result from the development of novel therapies. However, optimising existing pathways, so that patients realise benefits of already proven treatments, presents a clear opportunity to improve outcomes in the short term. This narrative review will focus on treatments and interventions where there is a clear evidence base to improve outcomes in pancreatic cancer, and where there is also evidence of variation and under-treatment. Avoidance of preoperative biliary drainage, treatment of pancreatic exocrine insufficiency, prehabiliation and enhanced recovery after surgery, reducing perioperative complications, optimising opportunities for elderly patients to receive therapy, optimising adjuvant chemotherapy and regular surveillance after surgery are some of the strategies discussed. Each treatment or pathway change represents an opportunity for marginal gain. Accumulation of marginal gains can result in considerable benefit to patients. Given that these interventions already have evidence base, they can be realised quickly and economically.
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Son M, Kim H, Han D, Kim Y, Huh I, Han Y, Hong SM, Kwon W, Kim H, Jang JY, Kim Y. A Clinically Applicable 24-Protein Model for Classifying Risk Subgroups in Pancreatic Ductal Adenocarcinomas using Multiple Reaction Monitoring-Mass Spectrometry. Clin Cancer Res 2021; 27:3370-3382. [PMID: 33593883 DOI: 10.1158/1078-0432.ccr-20-3513] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 01/12/2021] [Accepted: 02/12/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE Pancreatic ductal adenocarcinoma (PDAC) subtypes have been identified using various methodologies. However, it is a challenge to develop classification system applicable to routine clinical evaluation. We aimed to identify risk subgroups based on molecular features and develop a classification model that was more suited for clinical applications. EXPERIMENTAL DESIGN We collected whole dissected specimens from 225 patients who underwent surgery at Seoul National University Hospital [Seoul, Republic of Korea (South)], between October 2009 and February 2018. Target proteins with potential relevance to tumor progression or prognosis were quantified with robust quality controls. We used hierarchical clustering analysis to identify risk subgroups. A random forest classification model was developed to predict the identified risk subgroups, and the model was validated using transcriptomic datasets from external cohorts (N = 700), with survival analysis. RESULTS We identified 24 protein features that could classify the four risk subgroups associated with patient outcomes: stable, exocrine-like; activated, and extracellular matrix (ECM) remodeling. The "stable" risk subgroup was characterized by proteins that were associated with differentiation and tumor suppressors. "Exocrine-like" tumors highly expressed pancreatic enzymes. Two high-risk subgroups, "activated" and "ECM remodeling," were enriched in terms such as cell cycle, angiogenesis, immunocompetence, tumor invasion metastasis, and metabolic reprogramming. The classification model that included these features made prognoses with relative accuracy and precision in multiple cohorts. CONCLUSIONS We proposed PDAC risk subgroups and developed a classification model that may potentially be useful for routine clinical implementations, at the individual level. This clinical system may improve the accuracy of risk prediction and treatment guidelines.See related commentary by Thakur and Singh, p. 3272.
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Affiliation(s)
- Minsoo Son
- Department of Biomedical Engineering, Seoul National University College of Medicine, Seoul, Republic of Korea (South)
| | - Hongbeom Kim
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea (South)
| | - Dohyun Han
- Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea (South)
| | - Yoseop Kim
- Department of Biomedical Engineering, Seoul National University College of Medicine, Seoul, Republic of Korea (South)
| | - Iksoo Huh
- College of Nursing and Research Institute of Nursing Science, Seoul National University, Seoul, Republic of Korea (South)
| | - Youngmin Han
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea (South)
| | - Seung-Mo Hong
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea (South)
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea (South)
| | - Haeryoung Kim
- Department of Pathology, Seoul National University College of Medicine, Seoul, Republic of Korea (South)
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea (South).
| | - Youngsoo Kim
- Department of Biomedical Engineering, Seoul National University College of Medicine, Seoul, Republic of Korea (South).
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Maximizing Tumor Control and Limiting Complications With Stereotactic Body Radiation Therapy for Pancreatic Cancer. Int J Radiat Oncol Biol Phys 2020; 110:206-216. [PMID: 33358561 DOI: 10.1016/j.ijrobp.2020.11.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/04/2020] [Accepted: 11/05/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE Stereotactic body radiation therapy (SBRT) and stereotactic ablative body radiation therapy is being increasingly used for pancreatic cancer (PCa), particularly in patients with locally advanced and borderline resectable disease. A wide variety of dose fractionation schemes have been reported in the literature. This HyTEC review uses tumor control probability models to evaluate the comparative effectiveness of the various SBRT treatment regimens used in the treatment of patients with localized PCa. METHODS AND MATERIALS A PubMed search was performed to review the published literature on the use of hypofractionated SBRT (usually in 1-5 fractions) for PCa in various clinical scenarios (eg, preoperative [neoadjuvant], borderline resectable, and locally advanced PCa). The linear quadratic model with α/β= 10 Gy was used to address differences in fractionation. Logistic tumor control probability models were generated using maximum likelihood parameter fitting. RESULTS After converting to 3-fraction equivalent doses, the pooled reported data and associated models suggests that 1-year local control (LC) without surgery is ≈79% to 86% after the equivalent of 30 to 36 Gy in 3 fractions, showing a dose response in the range of 25 to 36 Gy, and decreasing to less than 70% 1-year LC at doses below 24 Gy in 3 fractions. The 33 Gy in 5 fraction regimen (Alliance A021501) corresponds to 28.2 Gy in 3 fractions, for which the HyTEC pooled model had 77% 1-year LC without surgery. Above an equivalent dose of 28 Gy in 3 fractions, with margin-negative resection the 1-year LC exceeded 90%. CONCLUSIONS Pooled analyses of reported tumor control probabilities for commonly used SBRT dose-fractionation schedules for PCa suggests a dose response. These findings should be viewed with caution given the challenges and limitations of this review. Additional data are needed to better understand the dose or fractionation-response of SBRT for PCa.
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You MS, Ryu JK, Huh G, Chun JW, Paik WH, Lee SH, Kim YT. Comparison of efficacy between adjuvant chemotherapy and chemoradiation therapy for pancreatic cancer: AJCC stage-based approach. World J Clin Oncol 2020; 11:747-760. [PMID: 33033696 PMCID: PMC7522542 DOI: 10.5306/wjco.v11.i9.747] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 08/05/2020] [Accepted: 08/25/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The adjuvant treatment for patients with resected pancreatic cancer (PC) is not yet standardized. Because the prognosis differs according to the American Joint Committee on Cancer (AJCC) stage, a tailored approach to establish more aggressive treatment plans in high-risk patients is necessary. However, studies comparing the efficacy of adjuvant treatment modalities according to the AJCC stage are largely lacking.
AIM To compare the efficacy of chemotherapy and chemoradiation therapy according to AJCC 8th staging system in patients with PC who underwent surgical resection.
METHODS A total of 335 patients who underwent surgical resection and adjuvant treatment for PC were included. Patients were divided into three groups: Chemoradiation therapy (CRT) group, systemic chemotherapy (SCT) group and combined treatment of chemoradiation plus chemotherapy therapy (CRT-SCT) group. The primary outcomes were differences in overall survival (OS) between the three groups. The secondary outcomes were differences in recurrence-free survival, recurrence pattern and adverse events between the three groups.
RESULTS Patients received CRT (n = 65), SCT (n = 62) and CRT-SCT (n = 208). Overall median OS was 33.3 mo (95% confidence interval (CI): 27.4-38.6). In patients with stage I/II, the median OS was 27.0 mo (95%CI: 2.06-89.6) in the CRT group, 35.8 mo (95%CI: 26.9-NA) in the SCT group and 38.6 mo (95%CI: 33.3-55.7) in the CRT-SCT group. Among them, there was no significant difference in OS between the three groups. In 59 patients with stage III, median OS in the SCT group [19.0 mo (95%CI: 12.6-NA)] and the CRT-SCT group [23.4 mo (95%CI: 22.0-44.4)] was significantly longer than that in the CRT group [17.7 mo (95%CI: 6.8-NA); P = 0.011 and P < 0.001, respectively]. There were no significant differences in incidence of locoregional and distant recurrences between the three groups (P = 0.158 and P = 0.205, respectively). Incidences of grade 3 or higher hematologic adverse events were higher in the SCT and CRT-SCT groups than in the CRT group.
CONCLUSION SCT and CRT-SCT showed significantly longer OS and recurrence-free survival than CRT in patients with AJCC stage III, while there was no significant difference in OS between the CRT, SCT and CRT-SCT groups in patients with AJCC stage I/II. Different adjuvant therapy according to AJCC stage can be applied in patients with PC.
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Affiliation(s)
- Min Su You
- Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul 110-744, South Korea
| | - Ji Kon Ryu
- Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul 110-744, South Korea
| | - Gunn Huh
- Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul 110-744, South Korea
| | - Jung Won Chun
- Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul 110-744, South Korea
| | - Woo Hyun Paik
- Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul 110-744, South Korea
| | - Sang Hyub Lee
- Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul 110-744, South Korea
| | - Yong-Tae Kim
- Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul 110-744, South Korea
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Lymph node ratio as valuable predictor in pancreatic cancer treated with R0 resection and adjuvant treatment. BMC Cancer 2019; 19:952. [PMID: 31615457 PMCID: PMC6794802 DOI: 10.1186/s12885-019-6193-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 09/24/2019] [Indexed: 02/06/2023] Open
Abstract
Background Lymph-node (LN) metastasis is an important prognostic factor in resected pancreatic cancer. In this study, the prognostic value of American Joint Committee on Cancer (AJCC) 8th edition N stage, lymph-node ratio (LNR), and log odds of positive lymph nodes (LODDS) in resected pancreatic cancer was investigated. Methods Between January 2005 and December 2017, there were 351 patients with pancreatic cancer treated with R0 resection and adjuvant therapy at Seoul National University Hospital. Relationships between the three LN parameters and overall survival (OS) and recurrence-free survival (RFS) were evaluated using a log-rank test and Cox proportional hazard regression model. Each multivariate-adjusted LN parameter was internally validated by bootstrap-corrected Harrell’s C-index. Results The mean duration from surgery to adjuvant therapy was 47.6 ± 17.4 days. In total, the median OS and RFS was 31.7 (95% CI, 27.2-37.2) and 15.4 (95% CI, 13.5-17.7) months. The three LN classification systems were significantly correlated with OS and RFS in log-rank tests and multivariate-adjusted models (all p < 0.05). When internally validated, LNR showed the highest discrimination ability in predicting OS and RFS (each C–index = 0.65). LNR also showed the highest C-index in subgroup analysis, classified by adjuvant therapy modality. LNR and the AJCC 8th edition LN classification system were significantly associated with loco-regional recurrence (p = 0.026 and p = 0.027, respectively). Conclusions LNR, which showed the best prognostic performance and significant relationship with loco-regional recurrence, can help further stratify the patients and establish an active treatment plan.
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Novel treatment planning approaches to enhance the therapeutic ratio: targeting the molecular mechanisms of radiation therapy. Clin Transl Oncol 2019; 22:447-456. [PMID: 31254253 DOI: 10.1007/s12094-019-02165-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 06/16/2019] [Indexed: 12/16/2022]
Abstract
Radiation acts not only through cell death but has also angiogenic, immunomodulatory and bystander effects. The realization of its systemic implications has led to extensive research on the combination of radiotherapy with systemic treatments, including immunotherapy and antiangiogenic agents. Parameters such as dose, fractionation and sequencing of treatments are key determinants of the outcome. However, recent high-quality research indicates that these are not the only radiation therapy parameters that influence its systemic effect. To effectively integrate systemic agents with radiation therapy, these new aspects of radiation therapy planning will have to be taken into consideration in future clinical trials. Our aim is to review these new treatment planning parameters that can influence the balance between contradicting effects of radiation therapy so as to enhance the therapeutic ratio.
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