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Ramireddy JK, Sathya A, Sasidharan BK, Varghese AJ, Sathyamurthy A, John NO, Chandramohan A, Singh A, Joel A, Mittal R, Masih D, Varghese K, Rebekah G, Ram TS, Thomas HMT. Can Pretreatment MRI and Planning CT Radiomics Improve Prediction of Complete Pathological Response in Locally Advanced Rectal Cancer Following Neoadjuvant Treatment? J Gastrointest Cancer 2024:10.1007/s12029-024-01073-z. [PMID: 38856797 DOI: 10.1007/s12029-024-01073-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2024] [Indexed: 06/11/2024]
Abstract
OBJECTIVE(S) The treatment response to neoadjuvant chemoradiation (nCRT) differs largely in individuals treated for rectal cancer. In this study, we investigated the role of radiomics to predict the pathological response in locally advanced rectal cancers at different treatment time points: (1) before the start of any treatment using baseline T2-weighted MRI (T2W-MR) and (2) at the start of radiation treatment using planning CT. METHODS Patients on nCRT followed by surgery between June 2017 to December 2019 were included in the study. Histopathological tumour response grading (TRG) was used for classification, and gross tumour volume was defined by the radiation oncologists. Following resampling, 100 and 103 pyradiomic features were extracted from T2W-MR and planning CT images, respectively. Synthetic minority oversampling technique (SMOTE) was used to address class imbalance. Four machine learning classifiers built clinical, radiomic, and merged models. Model performances were evaluated on a held-out test dataset following 3-fold cross-validation using area under the receiver operator characteristic curves (AUC) with bootstrap 95% confidence intervals. RESULTS One hundred and fifty patients were included; 58/150 with TRG 1 were classified as complete responders, and rest were incomplete responders (IR). Clinical models performed better (AUC = 0.68) compared to radiomics models (AUC = 0.62). Overall, the clinical + T2W-MR model showed best performance (AUC = 0.72) in predicting the pathological response prior to therapy. Clinical + Planning CT-merged models could only achieve the highest AUC of 0.66. CONCLUSION Merging clinical and baseline T2W-MR radiomics enhances predicting pathological response in rectal cancer. Validation in larger cohorts is warranted, especially for watch and wait strategies.
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Grants
- Fluid research major grant Christian Medical College, Vellore
- Fluid research major grant Christian Medical College, Vellore
- Fluid research major grant Christian Medical College, Vellore
- Fluid research major grant Christian Medical College, Vellore
- Fluid research major grant Christian Medical College, Vellore
- Fluid research major grant Christian Medical College, Vellore
- Fluid research major grant Christian Medical College, Vellore
- Fluid research major grant Christian Medical College, Vellore
- Fluid research major grant Christian Medical College, Vellore
- Fluid research major grant Christian Medical College, Vellore
- Fluid research major grant Christian Medical College, Vellore
- Fluid research major grant Christian Medical College, Vellore
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Affiliation(s)
- Jeba Karunya Ramireddy
- Quantitative Imaging Research and Artificial Intelligence Lab, Department of Radiation Oncology, Unit 2, Dr Ida B Scudder Cancer Centre, Christian Medical College, Vellore, Tamil Nadu, 632004, India
| | - A Sathya
- Quantitative Imaging Research and Artificial Intelligence Lab, Department of Radiation Oncology, Unit 2, Dr Ida B Scudder Cancer Centre, Christian Medical College, Vellore, Tamil Nadu, 632004, India
| | - Balu Krishna Sasidharan
- Quantitative Imaging Research and Artificial Intelligence Lab, Department of Radiation Oncology, Unit 2, Dr Ida B Scudder Cancer Centre, Christian Medical College, Vellore, Tamil Nadu, 632004, India
| | - Amal Joseph Varghese
- Quantitative Imaging Research and Artificial Intelligence Lab, Department of Radiation Oncology, Unit 2, Dr Ida B Scudder Cancer Centre, Christian Medical College, Vellore, Tamil Nadu, 632004, India
| | - Arvind Sathyamurthy
- Quantitative Imaging Research and Artificial Intelligence Lab, Department of Radiation Oncology, Unit 2, Dr Ida B Scudder Cancer Centre, Christian Medical College, Vellore, Tamil Nadu, 632004, India
| | - Neenu Oliver John
- Quantitative Imaging Research and Artificial Intelligence Lab, Department of Radiation Oncology, Unit 2, Dr Ida B Scudder Cancer Centre, Christian Medical College, Vellore, Tamil Nadu, 632004, India
| | | | - Ashish Singh
- Department of Medical Oncology, Christian Medical College, Vellore, India
| | - Anjana Joel
- Department of Medical Oncology, Christian Medical College, Vellore, India
| | - Rohin Mittal
- Department of General Surgery, Christian Medical College, Vellore, India
| | - Dipti Masih
- Department of Pathology, Christian Medical College, Vellore, India
| | - Kripa Varghese
- Department of Pathology, Christian Medical College, Vellore, India
| | - Grace Rebekah
- Department of Biostatistics, Christian Medical College, Vellore, India
| | - Thomas Samuel Ram
- Quantitative Imaging Research and Artificial Intelligence Lab, Department of Radiation Oncology, Unit 2, Dr Ida B Scudder Cancer Centre, Christian Medical College, Vellore, Tamil Nadu, 632004, India
| | - Hannah Mary T Thomas
- Quantitative Imaging Research and Artificial Intelligence Lab, Department of Radiation Oncology, Unit 2, Dr Ida B Scudder Cancer Centre, Christian Medical College, Vellore, Tamil Nadu, 632004, India.
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2
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Chiloiro G, Romano A, Cusumano D, Boldrini L, Panza G, Placidi L, Meldolesi E, Nardini M, Meffe G, Nicolini G, Votta C, Indovina L, Gambacorta MA. THeragnostic utilities for neoplastic DisEases of the rectum by MRI guided radiotherapy (THUNDER 2) phase II trial: interim safety analysis. Radiat Oncol 2023; 18:163. [PMID: 37803322 PMCID: PMC10557246 DOI: 10.1186/s13014-023-02353-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/19/2023] [Indexed: 10/08/2023] Open
Abstract
BACKGROUND The THUNDER-2 phase II single institutional trial investigates the benefits of MRI-guided radiotherapy (MRIgRT) in treating locally advanced rectal cancer (LARC). This study focuses on evaluating the impact of escalating radiation therapy dose in non-responder patients using the Early Tumour Regression Index (ERI) for predicting complete response (CR). The trial's primary endpoint is to increase the CR rate in non-responders by 10% and assess the feasibility of the delta radiomics-based MRIgRT predictive model. This interim analysis assesses the feasibility and safety of the proposed MRIgRT dose escalation strategy in terms of acute toxicity (gastrointestinal, genitourinary and haematological) and treatment adherence. METHODS Stage cT2-3, N0-2, or cT4 patients with anal sphincter involvement, N0-2a, M0, but without high-risk features were enrolled. MRIgRT treatment consisted of a standard dose of 55 Gy to the Gross Tumor Volume (GTV) and mesorectum, and 45 Gy to the mesorectum and drainage nodes in 25 fractions with concomitant chemotherapy. 0.35 T MRI was used for simulation imaging and daily alignment. ERI was calculated at the 10th fraction. Non-responders with an ERI above 13.1 received intensified dose escalation from the 11th fraction, resulting in a total dose of 60.1 Gy. Acute toxicity was assessed using the CTCAE v.5 scale. RESULTS From March 2021 to November 2022, 33 out of the total number of 63 patients to be enrolled (52.4%) were included, with one withdrawal unrelated to treatment. Sixteen patients (50%) underwent dose escalation. Treatment was well tolerated, with only one patient (3.1%) in the standard treatment group experiencing acute Grade 3 diarrhea, proctitis, and cystitis. No significant differences in toxicity were observed between the two groups (p = 0.5463). CONCLUSIONS MRIgRT treatment with dose escalation up to 60.1 Gy is well tolerated in LARC patients predicted as non-responders by ERI, confirming the feasibility and safety of this approach. The THUNDER-2 trial's primary and secondary endpoints will be fully analyzed when all planned patients will be enrolled.
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Affiliation(s)
- Giuditta Chiloiro
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Angela Romano
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy.
| | - Davide Cusumano
- Mater Olbia Hospital, Strada Statale Orientale Sarda 125, Olbia, 07026, Italy
| | - Luca Boldrini
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Giulia Panza
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Lorenzo Placidi
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Elisa Meldolesi
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Matteo Nardini
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Guenda Meffe
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Gianluca Nicolini
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Claudio Votta
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Luca Indovina
- Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
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3
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Castelluccia A, Marchesano D, Grimaldi G, Annessi I, Bianciardi F, Borrazzo C, Dipalma A, El Gawhary R, Masi M, Rago M, Valentino M, Verna L, Portaluri M, Gentile P. Stereotactic MR-guided adaptive radiotherapy (SMART) for primary rectal cancer: evaluation of early toxicity and pathological response. Rep Pract Oncol Radiother 2023; 28:437-444. [PMID: 37795221 PMCID: PMC10547417 DOI: 10.5603/rpor.a2023.0051] [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: 04/15/2023] [Accepted: 07/17/2023] [Indexed: 10/06/2023] Open
Abstract
Background The purpose of this study is to measure the effects of stereotactic MR-guided adaptive radiotherapy (SMART) for rectal cancer patients in terms of early toxicity and pathological response. Materials and methods For this prospective pilot study, patients diagnosed with locally advanced rectal cancer (LARC) with positive lymph node clinical staging underwent SMART on rectal lesion and mesorectum using hybrid MR-Linac (MRIdian ViewRay). Dose prescription at 80% isodose for the rectal lesion and mesorectum was 40 Gy (8 Gy/fr) and 25 Gy (5 Gy/fr), respectively, delivered on 5 days (3 fr/week). Response assessment by MRI was performed 3 weeks after SMART, then patients fit for surgery underwent total mesorectal excision. Primary endpoint was evaluation of adverse effect of radiotherapy. Secondary endpoint was pathological complete response rate. Early toxicity was graded according to the Common Terminology Criteria for Adverse Events (CTCAE v5.0). Results From October 2020 to January 2022, twenty patients underwent rectal SMART. No grade 3-5 toxicity was recorded. Twelve patients were eligible for total mesorectal excision (TME). Mean interval between the completion of SMART and surgery was 4 weeks. Pathological downstaging occurred in all patients; rate of pathological complete response (pCR) was 17%. pCR occurred with a prolonged time to surgery (> 7 weeks). Conclusion To our knowledge, this is the first study to use stereotactic radiotherapy for primary rectal cancer. SMART for rectal cancer is well tolerated and effective in terms of tumor regression, especially if followed by delayed surgery.
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Affiliation(s)
| | - Domenico Marchesano
- Radiation Oncology, Provincia Religiosa di San Pietro Fatebenefratelli, Roma, Italy
| | - Gianmarco Grimaldi
- Radiation Oncology, Provincia Religiosa di San Pietro Fatebenefratelli, Roma, Italy
| | - Ivan Annessi
- Radiation Oncology, Provincia Religiosa di San Pietro Fatebenefratelli, Roma, Italy
| | - Federico Bianciardi
- Radiation Oncology, Provincia Religiosa di San Pietro Fatebenefratelli, Roma, Italy
- Radiation Oncology, UPMC Hillman Cancer Center San Pietro FBF, Rome, Italy
| | - Cristian Borrazzo
- Radiation Oncology, Provincia Religiosa di San Pietro Fatebenefratelli, Roma, Italy
| | - Annamaria Dipalma
- Radiation Oncology, Provincia Religiosa di San Pietro Fatebenefratelli, Roma, Italy
| | - Randa El Gawhary
- Radiation Oncology, Provincia Religiosa di San Pietro Fatebenefratelli, Roma, Italy
| | - Marica Masi
- Radiation Oncology, Provincia Religiosa di San Pietro Fatebenefratelli, Roma, Italy
| | - Maria Rago
- Radiation Oncology, Provincia Religiosa di San Pietro Fatebenefratelli, Roma, Italy
| | - Maria Valentino
- Radiation Oncology, Provincia Religiosa di San Pietro Fatebenefratelli, Roma, Italy
| | - Laura Verna
- Radiation Oncology, Provincia Religiosa di San Pietro Fatebenefratelli, Roma, Italy
| | | | - PierCarlo Gentile
- Radiation Oncology, Provincia Religiosa di San Pietro Fatebenefratelli, Roma, Italy
- Radiation Oncology, UPMC Hillman Cancer Center San Pietro FBF, Rome, Italy
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4
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Guido A, Cuicchi D, Castellucci P, Cellini F, Di Fabio F, Llimpe FLR, Strigari L, Buwenge M, Cilla S, Deodato F, Macchia G, Galietta E, Golfieri R, Ardizzoni A, Zagari RM, Fanti S, Poggioli G, Fuccio L, Morganti AG. Adaptive Individualized high-dose preoperAtive (AIDA) chemoradiation in high-risk rectal cancer: a phase II trial. Eur J Nucl Med Mol Imaging 2023; 50:572-580. [PMID: 36127416 PMCID: PMC9816267 DOI: 10.1007/s00259-022-05944-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 08/12/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE To evaluate the pathological complete response (pCR) rate of locally advanced rectal cancer (LARC) after adaptive high-dose neoadjuvant chemoradiation (CRT) based on 18 F-fluorodeoxyglucose positron emission tomography/computed tomography (18 F-FDG-PET/CT). METHODS The primary endpoint was the pCR rate. Secondary endpoints were the predictive value of 18 F-FDG-PET/CT on pathological response and acute and late toxicity. All patients performed 18 F-FDG-PET/CT at baseline (PET0) and after 2 weeks during CRT (PET1). The metabolic PET parameters were calculated both at the PET0 and PET1. The total CRT dose was 45 Gy to the pelvic lymph nodes and 50 Gy to the primary tumor, corresponding mesorectum, and to metastatic lymph nodes. Furthermore, a sequential boost was delivered to a biological target volume defined by PET1 with an additional dose of 5 Gy in 2 fractions. Capecitabine (825 mg/m2 twice daily orally) was prescribed for the entire treatment duration. RESULTS Eighteen patients (13 males, 5 females; median age 55 years [range, 41-77 years]) were enrolled in the trial. Patients underwent surgical resection at 8-9 weeks after the end of neoadjuvant CRT. No patient showed grade > 1 acute radiation-induced toxicity. Seven patients (38.8%) had TRG = 0 (complete regression), 5 (27.0%) showed TRG = 2, and 6 (33.0%) had TRG = 3. Based on the TRG results, patients were classified in two groups: TRG = 0 (pCR) and TRG = 1, 2, 3 (non pCR). Accepting p < 0.05 as the level of significance, at the Kruskal-Wallis test, the medians of baseline-MTV, interim-SUVmax, interim-SUVmean, interim-MTV, interim-TLG, and the MTV reduction were significantly different between the two groups. 18 F-FDG-PET/CT was able to predict the pCR in 77.8% of cases through compared evaluation of both baseline PET/CT and interim PET/CT. CONCLUSIONS Our results showed that a dose escalation on a reduced target in the final phase of CRT is well tolerated and able to provide a high pCR rate.
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Affiliation(s)
- Alessandra Guido
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Dajana Cuicchi
- Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Paolo Castellucci
- Nuclear Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesco Cellini
- Dipartimento di Diagnostica per Immagini Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, UOC di Radioterapia Oncologica, Roma, Italy.
- Università Cattolica del Sacro Cuore, Dipartimento Universitario Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Largo Agostino Gemelli 8, 00168, Roma, Italy.
| | - Francesca Di Fabio
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Lidia Strigari
- Department of Medical Physics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Milly Buwenge
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Savino Cilla
- Medical Physics, Gemelli Molise Hospital-Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Francesco Deodato
- Università Cattolica del Sacro Cuore, Dipartimento Universitario Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Largo Agostino Gemelli 8, 00168, Roma, Italy
- Radiation Oncology, Gemelli Molise Hospital-Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Gabriella Macchia
- Radiation Oncology, Gemelli Molise Hospital-Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Erika Galietta
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Rita Golfieri
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andrea Ardizzoni
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Rocco Maurizio Zagari
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Gastroenterology Unit, Department of Medical and Surgical Sciences, Gastroenterology Unit, University of Bologna, Bologna, Italy
| | - Stefano Fanti
- Nuclear Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Gilberto Poggioli
- Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Digestive Medicine and Surgery, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Lorenzo Fuccio
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Gastroenterology Unit, Department of Medical and Surgical Sciences, Gastroenterology Unit, University of Bologna, Bologna, Italy
| | - Alessio G Morganti
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum University of Bologna, Bologna, Italy
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5
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Lo Russo M, Nachbar M, Barry A, Bhide S, Chang A, Hall W, Intven M, Marijnen C, Peters F, Minsky B, Romesser PB, Sarkar R, Tan A, Boeke S, Wegener D, Butzer S, Boldt J, Gatidis S, Nikolaou K, Thorwarth D, Zips D, Gani C. Impact of endorectal filling on interobserver variability of MRI based rectal primary tumor delineation. Clin Transl Radiat Oncol 2023; 38:1-5. [PMID: 36299279 PMCID: PMC9589000 DOI: 10.1016/j.ctro.2022.09.002] [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: 07/28/2022] [Revised: 09/08/2022] [Accepted: 09/18/2022] [Indexed: 11/29/2022] Open
Abstract
Background Online adaptive MR-guided radiotherapy allows for the reduction of safety margins in dose escalated treatment of rectal tumors. With the use of smaller margins, precise tumor delineation becomes more critical. In the present study we investigated the impact of rectal ultrasound gel filling on interobserver variability in delineation of primary rectal tumor volumes. Methods Six patients with locally advanced rectal cancer were scanned on a 1.5 T MRI-Linac without (MRI_e) and with application of 100 cc of ultrasound gel transanally (MRI_f). Eight international radiation oncologists expert in the treatment of gastrointestinal cancers delineated the gross tumor volume (GTV) on both MRI scans. MRI_f scans were provided to the participating centers after MRI_e scans had been returned. Interobserver variability was analyzed by either comparing the observers' delineations with a reference delineation (approach 1) and by building all possible pairs between observers (approach 2). Dice Similarity Index (DICE) and 95 % Hausdorff-Distance (95 %HD) were calculated. Results Rectal ultrasound gel filling was well tolerated by all patients. Overall, interobserver agreement was superior in MRI_f scans based on median DICE (0.81 vs 0.74, p < 0.005 for approach 1 and 0.76 vs 0.64, p < 0.0001 for approach 2) and 95 %HD (6.9 mm vs 4.2 mm for approach 1, p = 0.04 and 8.9 mm vs 6.1 mm, p = 0.04 for approach 2). Delineated median tumor volumes and inter-quartile ranges were 26.99 cc [18.01-50.34 cc] in MRI_e and 44.20 [19.72-61.59 cc] in MRI_f scans respectively, p = 0.012. Conclusions Although limited by the small number of patients, in this study the application of rectal ultrasound gel resulted in higher interobserver agreement in rectal GTV delineation. The endorectal gel filling might be a useful tool for future dose escalation strategies.
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Affiliation(s)
- Monica Lo Russo
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Germany
| | - Marcel Nachbar
- Section for Biomedical Physics, Department of Radiation Oncology, University Hospital Tübingen, Germany
| | - Aisling Barry
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Shree Bhide
- Radiotherapy and Imaging, The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, United Kingdom
| | - Amy Chang
- Hong Kong Sanatorium and Hospital, Hong Kong, China
| | - William Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Martijn Intven
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Corrie Marijnen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Femke Peters
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Bruce Minsky
- Department of Gastrointestinal Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paul B. Romesser
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Reith Sarkar
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Simon Boeke
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Germany
| | - Daniel Wegener
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Germany
| | - Sarah Butzer
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Germany
| | - Jessica Boldt
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Germany
| | - Sergios Gatidis
- Department of Radiology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Germany
| | - Konstantin Nikolaou
- Department of Radiology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Germany
| | - Daniela Thorwarth
- Section for Biomedical Physics, Department of Radiation Oncology, University Hospital Tübingen, Germany
- German Cancer Research Center (DKFZ) Heidelberg and German Consortium for Translational Cancer Research (DKTK), Partner Site Tübingen, Tübingen, Germany
| | - Daniel Zips
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Germany
- German Cancer Research Center (DKFZ) Heidelberg and German Consortium for Translational Cancer Research (DKTK), Partner Site Tübingen, Tübingen, Germany
| | - Cihan Gani
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Germany
- German Cancer Research Center (DKFZ) Heidelberg and German Consortium for Translational Cancer Research (DKTK), Partner Site Tübingen, Tübingen, Germany
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Fahy MR, Kelly ME, Aalbers AGJ, Abdul Aziz N, Abecasis N, Abraham-Nordling M, Akiyoshi T, Alberda W, Albert M, Andric M, Angeles MA, Angenete E, Antoniou A, Auer R, Austin KK, Aytac E, Aziz O, Bacalbasa N, Baker RP, Bali M, Baransi S, Baseckas G, Bebington B, Bedford M, Bednarski BK, Beets GL, Berg PL, Bergzoll C, Beynon J, Biondo S, Boyle K, Bordeianou L, Brecelj E, Bremers AB, Brunner M, Buchwald P, Bui A, Burgess A, Burger JWA, Burling D, Burns E, Campain N, Carvalhal S, Castro L, Caycedo-Marulanda A, Ceelan W, Chan KKL, Chang GJ, Chang M, Chew MH, Chok AY, Chong P, Clouston H, Codd M, Collins D, Colquhoun AJ, Constantinides J, Corr A, Coscia M, Cosimelli M, Cotsoglou C, Coyne PE, Croner RS, Damjanovich L, Daniels IR, Davies M, Delaney CP, de Wilt JHW, Denost Q, Deutsch C, Dietz D, Domingo S, Dozois EJ, Drozdov E, Duff M, Eglinton T, Enriquez-Navascues JM, Espín-Basany E, Evans MD, Eyjólfsdóttir B, Fearnhead NS, Ferron G, Flatmark K, Fleming FJ, Flor B, Folkesson J, Frizelle FA, Funder J, Gallego MA, Gargiulo M, García-Granero E, García-Sabrido JL, Gargiulo M, Gava VG, Gentilini L, George ML, George V, Georgiou P, Ghosh A, Ghouti L, Gil-Moreno A, Giner F, Ginther DN, Glyn T, Glynn R, Golda T, Griffiths B, Harris DA, Hagemans JAW, Hanchanale V, Harji DP, Helewa RM, Hellawell G, Heriot AG, Hochman D, Hohenberger W, Holm T, Hompes R, Hornung B, Hurton S, Hyun E, Ito M, Iversen LH, Jenkins JT, Jourand K, Kaffenberger S, Kandaswamy GV, Kapur S, Kanemitsu Y, Kazi M, Kelley SR, Keller DS, Ketelaers SHJ, Khan MS, Kiran RP, Kim H, Kim HJ, Koh CE, Kok NFM, Kokelaar R, Kontovounisios C, Kose F, Koutra M, Kristensen HØ, Kroon HM, Kumar S, Kusters M, Lago V, Lampe B, Lakkis Z, Larach JT, Larkin JO, Larsen SG, Larson DW, Law WL, Lee PJ, Limbert M, Loria A, Lydrup ML, Lyons A, Lynch AC, Maciel J, Manfredelli S, Mann C, Mantyh C, Mathis KL, Marques CFS, Martinez A, Martling A, Mehigan BJ, Meijerink WJHJ, Merchea A, Merkel S, Mehta AM, Mikalauskas S, McArthur DR, McCormick JJ, McCormick P, McDermott FD, McGrath JS, Malde S, Mirnezami A, Monson JRT, Navarro AS, Negoi I, Neto JWM, Ng JL, Nguyen B, Nielsen MB, Nieuwenhuijzen GAP, Nilsson PJ, Nordkamp S, Nugent T, Oliver A, O’Dwyer ST, O’Sullivan NJ, Paarnio K, Palmer G, Pappou E, Park J, Patsouras D, Peacock O, Pellino G, Peterson AC, Pinson J, Poggioli G, Proud D, Quinn M, Quyn A, Rajendran N, Radwan RW, Rajendran N, Rao C, Rasheed S, Rausa E, Regenbogen SE, Reims HM, Renehan A, Rintala J, Rocha R, Rochester M, Rohila J, Rothbarth J, Rottoli M, Roxburgh C, Rutten HJT, Safar B, Sagar PM, Sahai A, Saklani A, Sammour T, Sayyed R, Schizas AMP, Schwarzkopf E, Scripcariu D, Scripcariu V, Selvasekar C, Shaikh I, Simpson A, Skeie-Jensen T, Smart NJ, Smart P, Smith JJ, Solbakken AM, Solomon MJ, Sørensen MM, Sorrentino L, Steele SR, Steffens D, Stitzenberg K, Stocchi L, Stylianides NA, Swartling T, Spasojevic M, Sumrien H, Sutton PA, Swartking T, Takala H, Tan EJ, Taylor C, Tekin A, Tekkis PP, Teras J, Thaysen HV, Thurairaja R, Thorgersen EB, Toh EL, Tsarkov P, Tsukada Y, Tsukamoto S, Tuech JJ, Turner WH, Tuynman JB, Valente M, van Ramshorst GH, van Zoggel D, Vasquez-Jimenez W, Vather R, Verhoef C, Vierimaa M, Vizzielli G, Voogt ELK, Uehara K, Urrejola G, Wakeman C, Warrier SK, Wasmuth HH, Waters PS, Weber K, Weiser MR, Wheeler JMD, Wild J, Williams A, Wilson M, Wolthuis A, Yano H, Yip B, Yip J, Yoo RN, Zappa MA, Winter DC. Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline. Br J Surg 2022; 109:1251-1263. [PMID: 36170347 DOI: 10.1093/bjs/znac317] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 07/18/2022] [Accepted: 08/18/2022] [Indexed: 12/31/2022]
Abstract
This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.
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More Is Not Better When It Comes to Treating Rectal Cancer With Multimodal Chemoradiation Beyond the Standard Radiation Dose of 5040 cGy. Dis Colon Rectum 2022; 65:692-701. [PMID: 34082437 DOI: 10.1097/dcr.0000000000001986] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Radiation dose schedules for neoadjuvant chemoradiation for rectal cancers differ, with the most common dose schedule using 5040 cGy in 28 fractions. OBJECTIVES The aim of this retrospective study was to assess the benefit of higher radiation doses beyond 5040 cGy in the context of pathological response and follow-up events. SETTING The database from a provincial tertiary cancer center in Canada was the source of information for this study. PATIENTS Included in this study were 508 consecutive patients with rectal cancer with locally advanced disease (clinical T3/T4 or N1/N2) who received neoadjuvant chemoradiation followed by surgery. Of the 508 patients, 281 received the standard radiation dose of 4500 to 5040 cGy and 227 received a dose >5040 cGy. MAIN OUTCOME MEASURE The postsurgical pathology, late toxicities, and follow-up outcomes were analyzed. The outcomes were evaluated in relation to the dose of radiation received. RESULTS Data regarding the clinical outcomes were comparable between the 4500 to 5040 cGy and >5040 cGy radiation groups with pathological complete response rates of 20.9% and 15.4% (p = 0.104); distant recurrence rates of 17.4% and 19.4% (p = 0.36); local recurrence rates of 3.2% and 3.5% (p = 0.36); and the median overall survival rates of 61 and 60.5 months (p = 0.8). No statistically significant correlation of improvement in outcomes was noted with radiation doses beyond 5040 cGy. LIMITATIONS This is a retrospective study. CONCLUSION Our study showed that dose escalation beyond the standard dose of 4500 to 5040cGy failed to achieve meaningful clinical outcomes. See Video Abstract at http://links.lww.com/DCR/B633. MS NO ES MEJOR CUANDO SE TRATA DE TRATAR EL CNCER DE RECTO CON QUIMIORRADIACIN MULTIMODAL MS ALL DE LA DOSIS DE RADIACIN ESTNDAR DE CGY ANTECEDENTES:En neoadyuvancia de cáncer rectal es posible encontrar muchas variaciones, en radioterapia la dosis más común que usa 5040 cGy en 28 fracciones.OBJETIVOS:El objetivo de este estudio retrospectivo fue evaluar el beneficio de dosis de radiación más altas más allá de 5040cGy en el contexto de la respuesta patológica y en su seguimiento.AJUSTE:Base de datos de un centro de cáncer terciario provincial en Canadá.PACIENTES:Se incluyeron en este estudio quinientos ocho pacientes consecutivos con cáncer de recto y enfermedad localmente avanzada (clínica T3 / T4 o N1 / N2) que recibieron quimiorradiación neoadyuvante seguida de cirugía. De los 508 pacientes, 281 recibieron la dosis de radiación estándar de 4500-5040 cGy y 227 recibieron una dosis > 5040 cGy.PRINCIPAL MEDIDA DE RESULTADO:Se analizo evolucion posquirúrgica, toxicidad tardía y seguimiento. Los resultados se evaluaron en relación con la dosis de radiación recibida.RESULTADOS:Los datos con respecto a los resultados clínicos fueron comparables entre los grupos de radiación de 4500-5040 cGy y> 5040 cGy con tasas de respuesta patológica completa de 20,9% y 15,4% respectivamente (p = 0,104); tasas de recurrencia a distancia de 17,4% y 19,4%, respectivamente (p = 0,36); tasas de recurrencia local de 3,2% y 3,5%, respectivamente (p = 0,36); y la mediana de las tasas de supervivencia global de 61 y 60,5 meses, respectivamente (p = 0,8). No se observó una correlación estadísticamente significativa de mejoría en los resultados con dosis de radiación superiores a 5040 cGy.LIMITACIONES:Este es un estudio retrospectivo.CONCLUSIONES:Nuestro estudio mostró que el aumento de la dosis más allá de la dosis estándar de 4500-5040cGy no logró resultados clínicos significativos. Consulte Video Resumen en http://links.lww.com/DCR/B633. (Traducción-Dr. Gunther Bocic).
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Simultaneous Integrated Boost Volumetric Modulated Arc Therapy for Rectal Cancer: Long-Term Results after Protocol-Based Treatment. JOURNAL OF ONCOLOGY 2022; 2022:6986267. [PMID: 35437441 PMCID: PMC9012974 DOI: 10.1155/2022/6986267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 03/11/2022] [Indexed: 11/25/2022]
Abstract
Background Volumetric modulated arc therapy (VMAT) with simultaneous integrated boost (SIB) is an advanced form of radiotherapy (RT) technology. The purpose of this study was to report long-term treatment outcomes in patients with locally advanced rectal cancer undergoing VMAT-SIB based concurrent chemoradiotherapy (CRT). Methods Between January 2016 and January 2018, a total of 22 patients with operable stage II-III rectal adenocarcinoma were recruited for the pre-designed VMAT-SIB RT protocol. All patients underwent standard diagnostic and staging work-up. The RT target volumes included the following areas: PTV1 = mesorectum that contained gross tumors and enlarged lymph node regions and PTV2 = mesorectum and regional lymphatics from L4-5/S1 to 3-4 cm below the tumor or levator ani muscle, excluding PTV1. The VMAT-SIB dose prescription was as follows: PTV1 = 52.5 Gy/daily 2.1 Gy/25 fractions, PTV2 = 45 Gy/daily 1.8 Gy/25 fractions. Results The mean age of the study population was 64 (range, 18-84) years, and 15 (68.2%) patients were male. Radical operation (total mesorectal excision) was performed by either low anterior resection, ultralow anterior resection, or abdominal perineal resection. All five (22.7%) of the patients with confirmed increasing serum carcinoembryonic antigen (CEA) level at diagnosis showed normalization of serum CEA level after the planned treatment. Among 20 patients who underwent preoperative CRT and surgery, tumor down staging in T- and N-stages was achieved in 10 patients (50%) and 13 patients (65%), respectively, with 20% of ypT0/Tis. With a median follow-up of 54.2 (range, 22.6-61.1) months, the 5-year disease-free survival, overall survival, and local control rates were 64.6%, 81.8%, and 84.4%, respectively. Five patients developed distant metastasis and one developed local recurrence as a first event. Two cases with anastomosis site leakage, three with adhesive ileus, and two with abscess formation were observed during postoperative periods. Conclusions The current VMAT-SIB-based CRT protocol provided acceptable treatment and toxicity outcomes.
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Gordeyev S, Ivanov V, Fedianin M, Chernikh M, Kozlov N, Petrov L, Erygin D, Gridasov I, Kaushanskiy V, Feoktistov D, Mamedli Z. Neoadjuvant chemoradiotherapy for locally advanced rectal cancer with peritumoral abscesses and fistulas. Strahlenther Onkol 2021; 198:201-208. [PMID: 34825253 DOI: 10.1007/s00066-021-01878-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 11/01/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Rectal cancer patients who present with peritumoral abscesses and fistulas at the time of diagnosis may be denied chemoradiotherapy (CRT) as the safety is unknown. The aim of this study was to investigate the safety of preoperative CRT in this patient group. METHODS We performed a retrospective nested case-control study to compare outcomes between patients with locally advanced rectal cancer with peritumoral abscesses and fistulas (study group) and patients with T4 locally advanced rectal cancer with no evidence of abscesses and fistulas (control group). These groups were matched by treatment center and radiotherapy delivery method. All patients received 50-54 Gy of conventionally fractionated RT with concurrent chemotherapy. Primary endpoint was grade 3-5 toxicity (by National Cancer Institute Common Toxicity Criteria for Adverse Events (NCI CTCAE). Secondary endpoints included postoperative morbidity, pathologic complete response (pCR), disease-free survival (DFS), and overall survival (OS) at 2 years. RESULTS A total of 33 patients were included in each group. Grade 3 toxicity was observed in 2 (6.1%) patients in the study group and 4 (12.1%) patients in the control group (p = 0.672). No patients developed grade 4-5 toxicity. Grade 3-4 Clavien-Dindo complications were observed in 5 (15.2%) patients in the study group and in 6 (18.2%) patients in the control group (p = 1.0). Pathologic CR was achieved in 3 (9.1%) and 5 (15.2%) patients, respectively (p = 0.708). Two-year OS was 78.3% vs. 81.8% (p = 0.944), 2‑year DFS was 62.8% vs. 69.7% (p = 0.693), respectively. CONCLUSION The presence of peritumoral abscesses and fistulas in patients with locally advanced rectal cancer is not associated with increased toxicity or inferior clinical outcomes after preoperative CRT.
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Affiliation(s)
- Sergey Gordeyev
- N.N.Blokhin National Medical Research Center of Oncology, 23, Kashirskoe shosse, 115478, Moscow, Russian Federation.
| | - Valerii Ivanov
- "PET-technology" cancer center, 26, 50 let VLKSM st., 142110, Podolsk, Russian Federation
| | - Mikhail Fedianin
- N.N.Blokhin National Medical Research Center of Oncology, 23, Kashirskoe shosse, 115478, Moscow, Russian Federation.,Department of oncology and hematology at medical faculty of the Peoples' Friendship University of Russia (RUDN University), Moscow, Russian Federation
| | - Marina Chernikh
- N.N.Blokhin National Medical Research Center of Oncology, 23, Kashirskoe shosse, 115478, Moscow, Russian Federation.,"PET-technology" cancer center, 26, 50 let VLKSM st., 142110, Podolsk, Russian Federation.,I.M.Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Nikolay Kozlov
- N.N.Blokhin National Medical Research Center of Oncology, 23, Kashirskoe shosse, 115478, Moscow, Russian Federation
| | - Leonid Petrov
- A.F. Tsyb Medical Radiological Research Center, Zhukov st., 249031, Obninsk, Russian Federation
| | - Dmitriy Erygin
- Moscow city oncological hospital № 1, Baumanskaya 17/1, 105005, Moscow, Russian Federation
| | - Ivan Gridasov
- Stavropol regional oncological dispensary, 182A, Oktyabrskaya st., 355047, Stavropol, Russian Federation
| | - Valery Kaushanskiy
- Krasnodar regional oncological dispensary, 146, Dmitrova st., 350040, Krasnodar, Russian Federation
| | - Dmitry Feoktistov
- Bashkir regional oncological dispensary, 73/1, Prospekt Octyabrya, 450054, Ufa, Russian Federation
| | - Zaman Mamedli
- N.N.Blokhin National Medical Research Center of Oncology, 23, Kashirskoe shosse, 115478, Moscow, Russian Federation
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Assessment of MRI-Linac Economics under the RO-APM. J Clin Med 2021; 10:jcm10204706. [PMID: 34682829 PMCID: PMC8539760 DOI: 10.3390/jcm10204706] [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: 09/02/2021] [Accepted: 10/08/2021] [Indexed: 01/16/2023] Open
Abstract
The implementation of the radiation oncology alternative payment model (RO-APM) has raised concerns regarding the development of MRI-guided adaptive radiotherapy (MRgART). We sought to compare technical fee reimbursement under Fee-For-Service (FFS) to the proposed RO-APM for a typical MRI-Linac (MRL) patient load and distribution of 200 patients. In an exploratory aim, a modifier was added to the RO-APM (mRO-APM) to account for the resources necessary to provide this care. Traditional Medicare FFS reimbursement rates were compared to the diagnosis-based reimbursement in the RO-APM. Reimbursement for all selected diagnoses were lower in the RO-APM compared to FFS, with the largest differences in the adaptive treatments for lung cancer (−89%) and pancreatic cancer (−83%). The total annual reimbursement discrepancy amounted to −78%. Without implementation of adaptive replanning there was no difference in reimbursement in breast, colorectal and prostate cancer between RO-APM and mRO-APM. Accommodating online adaptive treatments in the mRO-APM would result in a reimbursement difference from the FFS model of −47% for lung cancer and −46% for pancreatic cancer, mitigating the overall annual reimbursement difference to −54%. Even with adjustment, the implementation of MRgART as a new treatment strategy is susceptible under the RO-APM.
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Cuccia F, Rigo M, Gurrera D, Nicosia L, Mazzola R, Figlia V, Giaj-Levra N, Ricchetti F, Attinà G, Pastorello E, De Simone A, Naccarato S, Sicignano G, Ruggieri R, Alongi F. Mitigation on bowel loops daily variations by 1.5-T MR-guided daily-adaptive SBRT for abdomino-pelvic lymph-nodal oligometastases. J Cancer Res Clin Oncol 2021; 147:3269-3277. [PMID: 34268583 DOI: 10.1007/s00432-021-03739-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 06/30/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE We report preliminary dosimetric data concerning the use of 1.5-T MR-guided daily-adaptive radiotherapy for abdomino-pelvic lymph-nodal oligometastases. We aimed to assess the impact of this technology on mitigating daily variations for both target coverage and organs-at-risk (OARs) sparing. METHODS A total of 150 sessions for 30 oligometastases in 23 patients were analyzed. All patients were treated with MR-guided stereotactic body radiotherapy (SBRT) for a total dose of 35 Gy in five fractions. For each fraction, a quantitative analysis was performed for PTV volume, V35Gy and Dmean. Similarly, for OARs, we assessed daily variations of volume, Dmean, Dmax. Any potential statistically significant change between baseline planning and daily-adaptive sessions was assessed using the Wilcoxon signed-rank test, assuming a p value < 0.05 as significant. RESULTS Average baseline PTV, bowel, bladder, and single intestinal loop volumes were respectively 8.9 cc (range 0.7-41.2 cc), 1176 cc (119-3654 cc), 95 cc (39.7-202.9 cc), 18.3 cc (9.1-37.7 cc). No significant volume variations were detected for PTV (p = 0.21) bowel (p = 0.36), bladder (p = 0.47), except for single intestinal loops, which resulted smaller (p = 0.026). Average baseline V35Gy and Dmean for PTV were respectively 85.6% (72-98.8%) and 35.6 Gy (34.6-36.1 Gy). We recorded a slightly positive trend in favor of daily-adaptive strategy vs baseline planning for improved target coverage, although not reaching statistical significance (p = 0.11 and p = 0.18 for PTV-V35Gy and PTV-Dmean). Concerning OARs, a significant difference was observed in favor of daily-adapted treatments in terms of single intestinal loop Dmax [23.05 Gy (13.2-26.9 Gy) at baseline vs 20.5 Gy (12.1-24 Gy); p value = 0.0377] and Dmean [14.4 Gy (6.5-18 Gy) at baseline vs 13.0 Gy (6.7-17.6 Gy); p value = 0.0003]. Specifically for bladder, the average Dmax was 18.6 Gy (0.4-34.3 Gy) at baseline vs 18.3 Gy (0.7-34.3 Gy) for a p value = 0.28; the average Dmean was 7.0 Gy (0.2-16.6 Gy) at baseline vs 6.98 Gy (0.2-16.4 Gy) for a p value = 0.66. Concerning the bowel, no differences in terms of Dmean [4.78 Gy (1.3-10.9 Gy) vs 5.6 Gy (1.4-10.5 Gy); p value = 0.23] were observed between after daily-adapted sessions. A statistically significant difference was observed for bowel Dmax [26.4 Gy (7.7-34 Gy) vs 25.8 Gy (7.8-33.1 Gy); p value = 0.0086]. CONCLUSIONS Daily-adaptive MR-guided SBRT reported a significantly improved single intestinal loop sparing for lymph-nodal oligometastases. Also, bowel Dmax was significantly reduced with daily-adaptive strategy. A minor advantage was also reported in terms of PTV coverage, although not statistically significant.
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Affiliation(s)
- Francesco Cuccia
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, VR, Italy
| | - Michele Rigo
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, VR, Italy
| | - Davide Gurrera
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, VR, Italy
| | - Luca Nicosia
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, VR, Italy.
| | - Rosario Mazzola
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, VR, Italy
| | - Vanessa Figlia
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, VR, Italy
| | - Niccolò Giaj-Levra
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, VR, Italy
| | - Francesco Ricchetti
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, VR, Italy
| | - Giorgio Attinà
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, VR, Italy
| | - Edoardo Pastorello
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, VR, Italy
| | - Antonio De Simone
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, VR, Italy
| | - Stefania Naccarato
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, VR, Italy
| | - Gianluisa Sicignano
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, VR, Italy
| | - Ruggero Ruggieri
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, VR, Italy
| | - Filippo Alongi
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, VR, Italy.,University of Brescia, Brescia, Italy
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Bliggenstorfer JT, Bingmer K, Ofshteyn A, Stein SL, Charles R, Steinhagen E. Neoadjuvant radiation above NCCN guidelines for rectal cancer is associated with age under 50 and early clinical stage. Surg Endosc 2021; 36:2925-2935. [PMID: 34114070 DOI: 10.1007/s00464-021-08585-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 06/02/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Recent data suggest patients with early-onset rectal cancer (EORC) receive neoadjuvant radiation above recommended doses without oncologic benefit. The use of excessive radiation may lead to worse outcomes and patient harm. We sought to evaluate predictors of aggressive neoadjuvant radiation (A-XRT) use in EORC patients and compare this to late-onset rectal cancer (LORC) patients. METHODS The National Cancer Database from 2004 to 2014 was queried for rectal adenocarcinoma patients undergoing surgical resection. Patients with stage 0 or IV disease, positive margins, and incomplete data were excluded. Standard neoadjuvant radiation (S-XRT) was based upon NCCN guidelines: 25-50.4 Gray for stage II/III patients and none for stage I. Excess radiation was considered A-XRT. Patients diagnosed at age < 50 years were labeled EORC; those ≥ 50 years were LORC. Categorical data were analyzed with chi-square test. Logistic regression was used to analyze clinicodemographic associations with A-XRT. RESULTS 45,403 patients were included: 7999 (17.6%) EORC and 37,404 (82.4%) LORC. Multivariable logistic regression demonstrated that A-XRT use among stage I patient was associated with male gender, age under 50, urban location, mucinous histology, and poor tumor differentiation. Among stage II and III patients, A-XRT use was associated with male gender, age under 50, higher education and income, and urban location. Cox hazards did not demonstrate a significant association of A-XRT use with survival. CONCLUSION Our data reaffirm that EORC patients more frequently receive A-XRT and that use is based on demographic features independent of tumor characteristics. Reasons for A-XRT, particularly in EORC patients, should be clarified to promote adherence to guidelines and minimize patient harm.
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Affiliation(s)
- Jonathan T Bliggenstorfer
- Department of Surgery, UH-RISES: University Hospitals Research in Surgical Outcomes and Effectiveness, 11100 Euclid Avenue, Cleveland, OH, USA
| | - Katherine Bingmer
- Department of Surgery, UH-RISES: University Hospitals Research in Surgical Outcomes and Effectiveness, 11100 Euclid Avenue, Cleveland, OH, USA
| | - Asya Ofshteyn
- Department of Surgery, UH-RISES: University Hospitals Research in Surgical Outcomes and Effectiveness, 11100 Euclid Avenue, Cleveland, OH, USA
| | - Sharon L Stein
- Department of Surgery, UH-RISES: University Hospitals Research in Surgical Outcomes and Effectiveness, 11100 Euclid Avenue, Cleveland, OH, USA
| | - Ronald Charles
- Department of Surgery, UH-RISES: University Hospitals Research in Surgical Outcomes and Effectiveness, 11100 Euclid Avenue, Cleveland, OH, USA
| | - Emily Steinhagen
- Department of Surgery, UH-RISES: University Hospitals Research in Surgical Outcomes and Effectiveness, 11100 Euclid Avenue, Cleveland, OH, USA.
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Intven M, de Mol van Otterloo S, Mook S, Doornaert P, de Groot-van Breugel E, Sikkes G, Willemsen-Bosman M, van Zijp H, Tijssen R. Online adaptive MR-guided radiotherapy for rectal cancer; feasibility of the workflow on a 1.5T MR-linac: clinical implementation and initial experience. Radiother Oncol 2021; 154:172-178. [DOI: 10.1016/j.radonc.2020.09.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 09/13/2020] [Accepted: 09/14/2020] [Indexed: 10/23/2022]
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Li JL, Wang ZQ, Sun XL. MYL6B drives the capabilities of proliferation, invasion, and migration in rectal adenocarcinoma through the EMT process. Open Life Sci 2020; 15:522-531. [PMID: 33817240 PMCID: PMC7874597 DOI: 10.1515/biol-2020-0031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 02/04/2020] [Accepted: 02/11/2020] [Indexed: 12/12/2022] Open
Abstract
Objective This study was designed to explore the biological significance of myosin light chain 6B (MYL6B) in rectal adenocarcinoma. Methods Profiles on the Oncomine dataset, GEPIA website, and UALCAN-TCGA database were searched to assess the MYL6B expression level in rectal adenocarcinoma tissues and normal tissues. After MYL6B knockdown using siRNA strategy, cell counting kit-8 (CCK-8) and transwell assays were conducted to measure cell proliferation, migration and invasion, respectively. Flow cytometry analysis was conducted to assess cell apoptosis. Quantitative reverse transcription-polymerase chain reaction (qRT-PCR) and western blot were performed to detect the expression level of mRNAs and proteins. Results The data showed that overexpression of MYL6B was observed in rectal adenocarcinoma tissues and correlated with a poor prognosis of patients. Functional in vitro experiments revealed that MYL6B knockdown could inhibit proliferation, migration, and invasion of rectal adenocarcinoma cells, while promote cell apoptosis. Moreover, western blot analysis suggested that increased expression of E-cadherin and decreased expression of N-cadherin and Vimentin were induced by si-MYL6B. Conclusion In summary, this study elaborated on the promoting effect of MYL6B in rectal adenocarcinoma progression, thus providing novel insight for strategies of clinical diagnosis and drug application in the future clinical study.
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Affiliation(s)
- Jin-Liang Li
- Department of Anus & Intestine Surgery, The First People's Hospital of Jining, Jining, Shandong, 272100, P.R. China
| | - Zai-Qiu Wang
- Department of Anorectal Surgery, Yantai Yuhuangding Hospital, Yantai, 264000, P.R. China
| | - Xiao-Li Sun
- Department of Clinical Laboratory, Yantai Yuhuangding Hospital, Yantai, 264000, P.R. China
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15
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Bostel T, Dreher C, Wollschläger D, Mayer A, König F, Bickelhaupt S, Schlemmer HP, Huber PE, Sterzing F, Bäumer P, Debus J, Nicolay NH. Exploring MR regression patterns in rectal cancer during neoadjuvant radiochemotherapy with daily T2- and diffusion-weighted MRI. Radiat Oncol 2020; 15:171. [PMID: 32653003 PMCID: PMC7353746 DOI: 10.1186/s13014-020-01613-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 07/03/2020] [Indexed: 12/15/2022] Open
Abstract
Background To date, only limited magnetic resonance imaging (MRI) data are available concerning tumor regression during neoadjuvant radiochemotherapy (RCT) of rectal cancer patients, which is a prerequisite for adaptive radiotherapy (RT) concepts. This exploratory study prospectively evaluated daily fractional MRI during neoadjuvant treatment to analyze the predictive value of MR biomarkers for treatment response. Methods Locally advanced rectal cancer patients were examined with daily MRI during neoadjuvant RCT. Contouring of the tumor volume was performed for each MRI scan by using T2- and diffusion-weighted-imaging (DWI)-sequences. The daily apparent-diffusion coefficient (ADC) was calculated. Volumetric and functional tumor changes during RCT were analyzed and correlated with the pathological response after surgical resection. Results In total, 171 MRI scans of eight patients were analyzed regarding anatomical and functional dynamics during RCT. Pathological complete response (pCR) could be achieved in four patients, and four patients had a pathological partial response (pPR) following neoadjuvant treatment. T2- and DWI-based volumetry proved to be statistically significant in terms of therapeutic response, and volumetric thresholds at week two and week four during RCT were defined for the prediction of pCR. In contrast, the average tumor ADC values widely overlapped between both response groups during RCT and appeared inadequate to predict treatment response in our patient cohort. Conclusion This prospective exploratory study supports the hypothesis that MRI may be able to predict pCR of rectal cancers early during neoadjuvant RCT. Our data therefore provide a useful template to tailor future MR-guided adaptive treatment concepts.
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Affiliation(s)
- T Bostel
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany. .,Department of Radiation Oncology, University Medical Center Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany.
| | - C Dreher
- Division of Radiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,Department of Radiation Oncology, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - D Wollschläger
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center Mainz, Obere Zahlbacher Strasse 69, 55131, Mainz, Germany
| | - A Mayer
- Department of Radiation Oncology, University Medical Center Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - F König
- Division of Radiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - S Bickelhaupt
- Division of Medical Imaging and Radiology - Cancer Prevention, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,Institute of Radiology, Friedrich-Alexander-University Erlangen-Nürnberg, Maximiliansplatz 2, 91054, Erlangen, Germany
| | - H P Schlemmer
- Division of Radiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - P E Huber
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - F Sterzing
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Radiation Oncology, Kempten Clinic, Robert-Weixler-Strasse 50, 87439, Kempten, Germany
| | - P Bäumer
- Division of Radiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,dia.log, Altoetting Center for Radiology, Vinzenz-von-Paul-Strasse 10, 84503, Altoetting, Germany
| | - J Debus
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - N H Nicolay
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany. .,Department of Radiation Oncology, University of Freiburg Medical Center, Robert-Koch-Strasse 3, 79106, Freiburg, Germany.
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16
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Microsatellite Instability (MSI) as an Independent Predictor of Pathologic Complete Response (PCR) in Locally Advanced Rectal Cancer: A National Cancer Database (NCDB) Analysis. Ann Surg 2020; 271:716-723. [PMID: 30216221 DOI: 10.1097/sla.0000000000003051] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The relationship between microsatellite instability (MSI) and response to neoadjuvant chemoradiation in rectal cancer is not well understood. BACKGROUND We utilized the National Cancer Database (NCDB) to investigate the association between MSI and pathologic complete response (pCR) in this patient population. METHODS We analyzed 5086 patients between 2010 and 2015 with locally advanced rectal cancer who were tested for MSI and treated definitively with chemoradiation followed by surgery. Primary comparison groups were between 4450 MSI-negative(-) and 636 MSI-positive(+) patients. Multivariable regression analysis was conducted to identify demographic, therapeutic, and clinical characteristics predictive of pCR. Cox proportional-hazard ratios were used for survival. RESULTS All patients were treated with definitive chemoradiation (median dose 50.4 Gy) followed by resection within 4 months. MSI(+) patients were associated with earlier year of diagnosis and higher-grade tumors (P < 0.05).The overall pCR rate was 8.6%, including 8.9% for MSI(-) and 5.9% for MSI(+) tumors (P = 0.01). Along with lower T stage, MSI(+) cases were significantly associated with a reduced pCR rate (odds ratio 0.65, 95% confidence interval 0.43-0.96) with multivariable analysis. The 5-year survival for patients with pCR was 93% compared with 73% without it (<0.001). CONCLUSION Microsatellite instability was independently associated with a reduction in pCR for locally advanced rectal cancer after neoadjuvant chemoradiation in this NCDB-based analysis.
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17
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Microsatellite Instability (MSI) as an Independent Predictor of Pathologic Complete Response (PCR) in Locally Advanced Rectal Cancer: A National Cancer Database (NCDB) Analysis. Ann Surg 2020. [PMID: 30216221 DOI: 10.1097/sla.00000000000030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
OBJECTIVE The relationship between microsatellite instability (MSI) and response to neoadjuvant chemoradiation in rectal cancer is not well understood. BACKGROUND We utilized the National Cancer Database (NCDB) to investigate the association between MSI and pathologic complete response (pCR) in this patient population. METHODS We analyzed 5086 patients between 2010 and 2015 with locally advanced rectal cancer who were tested for MSI and treated definitively with chemoradiation followed by surgery. Primary comparison groups were between 4450 MSI-negative(-) and 636 MSI-positive(+) patients. Multivariable regression analysis was conducted to identify demographic, therapeutic, and clinical characteristics predictive of pCR. Cox proportional-hazard ratios were used for survival. RESULTS All patients were treated with definitive chemoradiation (median dose 50.4 Gy) followed by resection within 4 months. MSI(+) patients were associated with earlier year of diagnosis and higher-grade tumors (P < 0.05).The overall pCR rate was 8.6%, including 8.9% for MSI(-) and 5.9% for MSI(+) tumors (P = 0.01). Along with lower T stage, MSI(+) cases were significantly associated with a reduced pCR rate (odds ratio 0.65, 95% confidence interval 0.43-0.96) with multivariable analysis. The 5-year survival for patients with pCR was 93% compared with 73% without it (<0.001). CONCLUSION Microsatellite instability was independently associated with a reduction in pCR for locally advanced rectal cancer after neoadjuvant chemoradiation in this NCDB-based analysis.
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18
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Jia RZ, Zhang JZ, Jing CQ, Li CS, Zhuo HQ. Fibroblast growth factor receptor-like-1: a new therapeutic target and unfavorable prognostic indicator for rectal adenocarcinoma. J Recept Signal Transduct Res 2020; 40:257-263. [PMID: 32098557 DOI: 10.1080/10799893.2020.1731534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Fibroblast growth factor receptor-like-1 (FGFRL1) is important to cell motility and links with tumorigenic potential in various types of cancers. To investigate the biological function and underlying mechanism of FGFRL1 in rectal adenocarcinoma, we conducted this study. TCGA and Oncomine databases were used to analyze FGFRL1 expression and its association with clinical characteristics or overall survival (OS) in rectal adenocarcinoma patients. siRNA strategy was implemented to knockdown FGFRL1 expression in rectal adenocarcinoma cells. CCK8, colony formation, wound healing, and transwell assays were implemented to measure cell behaviors. qRT-PCR and western blot were utilized to identify mRNA and protein expression levels. FGFRL1 was significantly increased in rectal adenocarcinoma tissue samples, either colon or rectum. High-regulation of FGFRL1 expression induced poorer outcome of rectal adenocarcinoma patients. Downregulation of FGFRL1 inhibited the proliferation, colony formation, migration, and invasion of SW837 cells. The MAPK pathway-related proteins, phosphorylation of MEK and ERK, were also decreased after si-FGFRL1 transfection. These findings demonstrated that FGFRL1, acting as a potential inducator, may promote the progression of rectal adenocarcinoma via activating the MAPK signaling pathway.
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Affiliation(s)
- Ru-Zhen Jia
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, PR China
| | - Ji-Zhun Zhang
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, PR China
| | - Chang-Qing Jing
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, PR China
| | - Chen-Sheng Li
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, PR China
| | - Hong-Qing Zhuo
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, PR China
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19
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Chiloiro G, Boldrini L, Meldolesi E, Re A, Cellini F, Cusumano D, Corvari B, Mantini G, Balducci M, Valentini V, Gambacorta MA. MR-guided radiotherapy in rectal cancer: First clinical experience of an innovative technology. Clin Transl Radiat Oncol 2019; 18:80-86. [PMID: 31341981 PMCID: PMC6630154 DOI: 10.1016/j.ctro.2019.04.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 04/03/2019] [Accepted: 04/05/2019] [Indexed: 12/15/2022] Open
Abstract
•This study represents one of the first reports of online MRgRT.•Integrated Low-field MR provides better anatomical visualization than CBCT or MVCT.•Better visualization of the target can help to reduce the margins from CTV to PTV.•MRgRT appears a feasible option in rectal cancer treatment offering potential benefits.•MRgRT represents a promising technology for rectal cancer management.
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Affiliation(s)
- Giuditta Chiloiro
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Roma, Italy
| | - Luca Boldrini
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Roma, Italy
| | - Elisa Meldolesi
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Roma, Italy
| | - Alessia Re
- Unità di Radioterapia Oncologica, Fondazione di Ricerca e Cura Giovanni Paolo II, Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Francesco Cellini
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Roma, Italy
| | - Davide Cusumano
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Fisica Sanitaria, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Roma, Italy
| | - Barbara Corvari
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Roma, Italy
| | - Giovanna Mantini
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Roma, Italy
- Università Cattolica del Sacro Cuore, Istituto di Radiologia, Roma, Italy
| | - Mario Balducci
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Roma, Italy
- Università Cattolica del Sacro Cuore, Istituto di Radiologia, Roma, Italy
| | - Vincenzo Valentini
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Roma, Italy
- Università Cattolica del Sacro Cuore, Istituto di Radiologia, Roma, Italy
| | - Maria Antonietta Gambacorta
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Roma, Italy
- Università Cattolica del Sacro Cuore, Istituto di Radiologia, Roma, Italy
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