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Zhang S, Xiong X, Xie N, Zheng W, Li Y, Lin T, Wei Q, Tan P. The efficacy and safety of stereotactic body radiotherapy combined with systematic therapy for metastatic renal cell carcinoma: a systematic review and meta-analysis. MedComm (Beijing) 2024; 5:e544. [PMID: 38660686 PMCID: PMC11042534 DOI: 10.1002/mco2.544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 03/20/2024] [Accepted: 03/20/2024] [Indexed: 04/26/2024] Open
Abstract
There is considerable interest in the potential of stereotactic body radiation therapy (SBRT) combined with systemic therapy such as tyrosine kinase inhibitors (TKIs) or immune checkpoint inhibitors (ICIs). However, its efficacy and safety remain unclear. The purpose of this study was to evaluate the efficacy and safety of conducting SBRT during ICI or TKI treatment in different disease settings for patients with metastatic renal cell carcinoma (mRCC). A total of 16 studies were ultimately included. Under the random effects model, the pooled 1-year local control rate (1-yr LCR) and objective response rate (ORR) were 90% (95% confidence interval [CI]: 80%-95%, I 2 = 67%) and 52% (95% CI: 37%-67%, I 2 = 90%), respectively. SBRT concomitant with different systemic therapy yield significant different 1-yr LCR (p < 0.01) and ORR (p = 0.02). Regarding survival benefits, the pooled 1-year progression-free survival (1-yr PFS) and 1-year overall survival (1-yr OS) rates were 45% (95% CI: 29%-62%, I 2 = 91%) and 85% (95% CI: 76%-91%, I 2 = 66%), respectively. 1-yr PFS and 1-yr OS in different disease settings demonstrated significant difference (p < 0.01). As for toxicity, the pooled incidence of grade 3-4 adverse events was 14% (95% CI: 5%-26%, I 2 = 90%). This study highlights the feasibility of utilizing these strategies in mRCC patients, especially those with a low metastatic tumor burden.
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Affiliation(s)
- Shiyu Zhang
- Department of UrologyWest China Hospital, Sichuan UniversityChengduChina
| | - Xingyu Xiong
- Department of UrologyWest China Hospital, Sichuan UniversityChengduChina
| | - Nan Xie
- Emergency Department of West China Hospital, West China School of Nursing, Sichuan universityChengduChina
- Nursing Key Laboratory of Sichuan ProvinceSichuan UniversityChengduChina
| | - Weitao Zheng
- Department of UrologyWest China Hospital, Sichuan UniversityChengduChina
| | - Yongjun Li
- West China School of MedicineWest China HospitalSichuan UniversityChengduChina
| | - Tianhai Lin
- Department of UrologyWest China Hospital, Sichuan UniversityChengduChina
| | - Qiang Wei
- Department of UrologyWest China Hospital, Sichuan UniversityChengduChina
| | - Ping Tan
- Department of UrologyWest China Hospital, Sichuan UniversityChengduChina
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2
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Prebble AR, Latka B, Burdekin B, Leary D, Harris M, Regan D, Boss MK. Investigation of Gastrointestinal Toxicities Associated with Concurrent Abdominal Radiation Therapy and the Tyrosine Kinase Inhibitor Sunitinib in a Mouse Model. Int J Mol Sci 2024; 25:1838. [PMID: 38339116 PMCID: PMC10855812 DOI: 10.3390/ijms25031838] [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: 12/22/2023] [Revised: 01/26/2024] [Accepted: 01/30/2024] [Indexed: 02/12/2024] Open
Abstract
Tyrosine kinase inhibitors (TKIs) may be combined with radiation therapy (RT) to enhance tumor control; however, increased incidences of gastrointestinal (GI) toxicity have been reported with this combination. We hypothesize that toxicity is due to compromised intestinal healing caused by inhibition of vascular repair and proliferation pathways. This study explores underlying tissue toxicity associated with abdominal RT and concurrent sunitinib in a mouse model. Four groups of CD-1 mice were treated with 12 Gy abdominal RT, oral sunitinib, abdominal RT + sunitinib, or sham treatment. Mice received oral sunitinib or the vehicle via gavage for 14 days. On day 7, mice were irradiated with 12 Gy abdominal RT or sham treated. Mice were euthanized on day 14 and intestinal tract was harvested for semiquantitative histopathologic evaluation and immunohistochemical quantification of proliferation (Ki67) and vascular density (CD31). Non-irradiated groups had stable weights while abdominal irradiation resulted in weight loss, with mice receiving RT + SUN having greater weight loss than mice receiving RT alone. Semiquantitative analysis showed significant increases in inflammation in irradiated groups. The difference in the density of CD31+ cells was significantly increased in RT alone compared to SUN alone. Ki67+ density was not significant. In summary, we identify a lack of angiogenic response in irradiated GI tissues when abdominal RT is combined with a TKI, which may correlate with clinical toxicities seen in canine and human patients receiving combined treatment.
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Affiliation(s)
- Amber R. Prebble
- Veterinary Teaching Hospital, Colorado State University, Fort Collins, CO 80523, USA;
| | - Bailey Latka
- Department of Clinical Sciences, Colorado State University, Fort Collins, CO 80523, USA (B.B.)
| | - Braden Burdekin
- Department of Clinical Sciences, Colorado State University, Fort Collins, CO 80523, USA (B.B.)
| | - Del Leary
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO 80523, USA;
| | - Mac Harris
- Department of Microbiology, Immunology, and Pathology, Colorado State University, Fort Collins, CO 80523, USA; (M.H.); (D.R.)
| | - Daniel Regan
- Department of Microbiology, Immunology, and Pathology, Colorado State University, Fort Collins, CO 80523, USA; (M.H.); (D.R.)
| | - Mary-Keara Boss
- Department of Clinical Sciences, Colorado State University, Fort Collins, CO 80523, USA (B.B.)
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3
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Guninski RS, Cuccia F, Alongi F, Andratschke N, Belka C, Bellut D, Dahele M, Josipovic M, Kroese TE, Mancosu P, Minniti G, Niyazi M, Ricardi U, Munck Af Rosenschold P, Sahgal A, Tsang Y, Verbakel WFAR, Guckenberger M. Efficacy and safety of SBRT for spine metastases: A systematic review and meta-analysis for preparation of an ESTRO practice guideline. Radiother Oncol 2024; 190:109969. [PMID: 37922993 DOI: 10.1016/j.radonc.2023.109969] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 10/18/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND AND PURPOSE Advances in characterizing cancer biology and the growing availability of novel targeted agents and immune therapeutics have significantly changed the prognosis of many patients with metastatic disease. Palliative radiotherapy needs to adapt to these developments. In this study, we summarize the available evidence for stereotactic body radiotherapy (SBRT) in the treatment of spinal metastases. MATERIALS AND METHODS A systematic review and meta-analysis was performed using PRISMA methodology, including publications from January 2005 to September 2021, with the exception of the randomized phase III trial RTOG-0631 which was added in April 2023. Re-irradiation was excluded. For meta-analysis, a random-effects model was used to pool the data. Heterogeneity was assessed with the I2-test, assuming substantial and considerable as I2 > 50 % and I2 > 75 %, respectively. A p-value < 0.05 was considered statistically significant. RESULTS A total of 69 studies assessing the outcomes of 7236 metastases in 5736 patients were analyzed. SBRT for spine metastases showed high efficacy, with a pooled overall pain response rate of 83 % (95 % confidence interval [CI] 68 %-94 %), pooled complete pain response of 36 % (95 % CI: 20 %-53 %), and 1-year local control rate of 94 % (95 % CI: 86 %-99 %), although with high levels of heterogeneity among studies (I2 = 93 %, I2 = 86 %, and 86 %, respectively). Furthermore, SBRT was safe, with a pooled vertebral fracture rate of 9 % (95 % CI: 4 %-16 %), pooled radiation induced myelopathy rate of 0 % (95 % CI 0-2 %), and pooled pain flare rate of 6 % (95 % CI: 3 %-17 %), although with mixed levels of heterogeneity among the studies (I2 = 92 %, I2 = 0 %, and 95 %, respectively). Only 1.7 % of vertebral fractures required surgical stabilization. CONCLUSION Spine SBRT is characterized by a favorable efficacy and safety profile, providing durable results for pain control and disease control, which is particularly relevant for oligometastatic patients.
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Affiliation(s)
- R S Guninski
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
| | - F Cuccia
- ARNAS Civico Hospital, Radiation Oncology Unit, Palermo, Italy
| | - F Alongi
- Advanced Radiation Department, IRCCS Ospedale Sacro Cuore Don Calabria, Negrar-Verona, Italy. University of Brescia, Italy
| | - N Andratschke
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - C Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany. German Cancer Consortium (DKTK), partner site Munich, Munich, Germany. Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - D Bellut
- University Hospital Zurich, University of Zurich, Department of Neurosurgery. Zurich, Switzerland
| | - M Dahele
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Radiation Oncology and Cancer Center Amsterdam, de Boelelaan 1117, Amsterdam, The Netherlands
| | - M Josipovic
- Department of Oncology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark; Department of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
| | - T E Kroese
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - P Mancosu
- IRCCS Humanitas Research Hospital, Medical Physics Unit, Radiation Oncology department, via Manzoni 56, I-20089 Rozzano, Milan, Italy
| | - G Minniti
- Department of Radiological Sciences, Oncology and Anatomical PathologySapienza University of Rome, Rome; IRCCS Neuromed, Pozzilli, IS, Italy
| | - M Niyazi
- Department of Radiation Oncology, University hospital Tübingen, Tübingen, Germany
| | - U Ricardi
- University of Turin, Department of Oncology, Turin, Italy
| | - P Munck Af Rosenschold
- Radiation Physics, Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden; Medical Radiation Physics, Lund University, Lund, Sweden
| | - A Sahgal
- Odette Cancer Center of the Sunnybrook Health Sciences Center, Department of Radiation Oncology, Toronto, Canada
| | - Y Tsang
- Princess Margaret Cancer Centre, Radiation Medicine Program, Toronto, Canada
| | - W F A R Verbakel
- Amsterdam University Medical Center, Department of Radiation Oncology, Amsterdam, The Netherlands
| | - M Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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4
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Thirunavu V, Larkin CJ, Drumm M, Ellis EM, Roumeliotis AG, Shlobin NA, Abecassis ZA, Karras CL, Dahdaleh NS. Impact of Postoperative Stereotactic Body Radiation Therapy on Survival of Patients with Spinal Metastases in the Context of Additional Systemic Adjuvant Therapy. World Neurosurg 2023; 173:e787-e799. [PMID: 36907267 DOI: 10.1016/j.wneu.2023.03.018] [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: 02/11/2023] [Accepted: 03/04/2023] [Indexed: 03/12/2023]
Abstract
BACKGROUND Stereotactic body radiotherapy (SBRT) has been established as a safe and effective treatment modality for control of long-term pain and tumor growth. However, few studies have investigated the efficacy of postoperative SBRT versus conventional external beam radiation therapy (EBRT) in extending survival within the context of systemic therapy. METHODS A retrospective chart review of patients who underwent surgery for spinal metastasis at our institution was conducted. Demographic, treatment, and outcome data were collected. SBRT was compared with EBRT and non-SBRT, and analyses were stratified by whether patients received systemic therapy. Survival analysis was conducted using propensity score matching. RESULTS Bivariate analysis in the nonsystemic therapy group revealed longer survival with SBRT compared with EBRT and non-SBRT. Further analysis also showed that primary cancer type and preoperative mRS significantly affected survival. Within patients who received systemic therapy, overall median survival for patients receiving SBRT was 22.7 months (95% confidence interval [CI] 12.1-52.3) versus 16.1 months (95% CI 12.7-44.0; P = 0.28) for patients who received EBRT and 16.1 months (95% CI: 12.2-21.9; P = 0.07) for patients without SBRT. Within patients who did not receive systemic therapy, overall median survival for patients with SBRT was 62.1 months (95% CI 18.1-unknown) versus 5.3 months (95% CI 2.8-unknown; P = 0.08) for patients with EBRT and 6.9 months (95% CI 5.0-45.6; P = 0.02) for patients without SBRT. CONCLUSIONS In patients who do not receive systemic therapy, treatment with postoperative SBRT may increase survival time compared with patients not receiving SBRT.
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Affiliation(s)
- Vineeth Thirunavu
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
| | - Collin J Larkin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Michael Drumm
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Erin M Ellis
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Anastasios G Roumeliotis
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Zachary A Abecassis
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Constantine L Karras
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Nader S Dahdaleh
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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5
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Kroeze SGC, Pavic M, Stellamans K, Lievens Y, Becherini C, Scorsetti M, Alongi F, Ricardi U, Jereczek-Fossa BA, Westhoff P, But-Hadzic J, Widder J, Geets X, Bral S, Lambrecht M, Billiet C, Sirak I, Ramella S, Giovanni Battista I, Benavente S, Zapatero A, Romero F, Zilli T, Khanfir K, Hemmatazad H, de Bari B, Klass DN, Adnan S, Peulen H, Salinas Ramos J, Strijbos M, Popat S, Ost P, Guckenberger M. Metastases-directed stereotactic body radiotherapy in combination with targeted therapy or immunotherapy: systematic review and consensus recommendations by the EORTC-ESTRO OligoCare consortium. Lancet Oncol 2023; 24:e121-e132. [PMID: 36858728 DOI: 10.1016/s1470-2045(22)00752-5] [Citation(s) in RCA: 50] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/07/2022] [Accepted: 12/08/2022] [Indexed: 03/02/2023]
Abstract
Stereotactic body radiotherapy (SBRT) for patients with metastatic cancer, especially when characterised by a low tumour burden (ie, oligometastatic disease), receiving targeted therapy or immunotherapy has become a frequently practised and guideline-supported treatment strategy. Despite the increasing use in routine clinical practice, there is little information on the safety of combining SBRT with modern targeted therapy or immunotherapy and a paucity of high-level evidence to guide clinical management. A systematic literature review was performed to identify the toxicity profiles of combined metastases-directed SBRT and targeted therapy or immunotherapy. These results served as the basis for an international Delphi consensus process among 28 interdisciplinary experts who are members of the European Society for Radiotherapy and Oncology (ESTRO) and European Organisation for Research and Treatment of Cancer (EORTC) OligoCare consortium. Consensus was sought about risk mitigation strategies of metastases-directed SBRT combined with targeted therapy or immunotherapy; a potential need for and length of interruption to targeted therapy or immunotherapy around SBRT delivery; and potential adaptations of radiation dose and fractionation. Results of this systematic review and consensus process compile the best available evidence for safe combination of metastases-directed SBRT and targeted therapy or immunotherapy for patients with metastatic or oligometastatic cancer and aim to guide today's clinical practice and the design of future clinical trials.
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Affiliation(s)
- Stephanie G C Kroeze
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland; Centre for Radiation Oncology KSA-KSB, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Matea Pavic
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Karin Stellamans
- Department of Radiation Oncology, AZ Groeninge Campus Kennedylaan, Kortrijk, Belgium
| | - Yolande Lievens
- Department of Radiation Oncology, Ghent University Hospital and Ghent University, Gent, Belgium
| | - Carlotta Becherini
- Department of Radiation Oncology, Careggi University Hospital, Florence, Italy
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Filippo Alongi
- Advanced Radiation Oncology department, IRCCS Sacro Cuore don Calabria Hospital, Negrar di Valpolicella, Italy; Department of Radiation Oncology, University of Brescia, Brescia, Italy
| | | | - Barbara Alicja Jereczek-Fossa
- Department of Radiation Oncology, European Institute of Oncology, IRCCS, Milan, Italy; Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy; Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Paulien Westhoff
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Jasna But-Hadzic
- Department of Radiation Oncology, Institute of Oncology, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Joachim Widder
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Xavier Geets
- Department of Radiation Oncology, Cliniques universitaires Saint-Luc, MIRO-IREC Lab, Université catholique de Louvain, Brussels, Belgium
| | - Samuel Bral
- Department of Radiation Oncology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium
| | - Maarten Lambrecht
- Department of Radiotherapy-Oncology, Leuvens Kanker Instituut, Universitair Ziekenhuis Leuven, Leuven, Belgium
| | | | - Igor Sirak
- Department of Oncology and Radiotherapy, University Hospital, Hradec Králové, Czech Republic
| | - Sara Ramella
- Department of Radiation Oncology, Campus Bio-Medico University of Rome, Rome, Italy
| | | | - Sergi Benavente
- Department of Radiation Oncology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Almudena Zapatero
- Department of Radiation Oncology, Hospital Universitario de La Princesa, Health Research Institute, Madrid, Spain
| | - Fabiola Romero
- Department of Radiation Oncology, Hospital Universitario Reina Sofia, Cordoba, Spain
| | - Thomas Zilli
- Department of Radiation Oncology, Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland; Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Kaouthar Khanfir
- Department of Radiation Oncology, Hôpital Valais, Sion, Switzerland
| | - Hossein Hemmatazad
- Department of Radiation Oncology, Inselspital University Hospital, Bern, Switzerland; Department of Radiation Oncology, University of Bern, Bern, Switzerland
| | - Berardino de Bari
- Service Radio-Oncologie Neuchåtel Hôpital Network, La Chaux-de-Fonds, Switzerland
| | - Desiree N Klass
- Institute of Radiation Oncology, Cantonal Hospital Graubünden, Chur, Switzerland
| | - Shaukat Adnan
- Department of Oncology, Aberdeen Royal Infirmary, UK
| | - Heike Peulen
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, Netherlands
| | - Juan Salinas Ramos
- Radiation Oncology Department, Santa Lucia General University Hospital, Cartagena, Spain
| | - Michiel Strijbos
- Department of Oncology, GasthuisZusters Antwerpen, Antwerpen, Belgium
| | | | - Piet Ost
- Department of Radiation Oncology, Iridium Netwerk, Antwerp, Belgium
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Fomchenko EI, Bayley JC, Alvarez-Breckenridge C, Rhines LD, Tatsui CE. Spinal Metastases and the Evolving Role of Molecular Targeted Therapy, Chemotherapy, and Immunotherapy. Neurospine 2022; 19:978-993. [PMID: 36597635 PMCID: PMC9816609 DOI: 10.14245/ns.2244290.145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 07/13/2022] [Indexed: 12/27/2022] Open
Abstract
Metastatic involvement of the spine is a common complication of systemic cancer progression. Surgery and external beam radiotherapy are palliative treatment modalities aiming to preserve neurological function, control pain and maintain functional status. More recently, with development of image guidance and stereotactic delivery of high doses of conformal radiation, local tumor control has improved; however recurrent or radiation refractory disease remains a significant clinical problem with limited treatment options. This manuscript represents a narrative overview of novel targeted molecular therapies, chemotherapies, and immunotherapy treatments for patients with breast, lung, melanoma, renal cell, prostate, and thyroid cancers, which resulted in improved responses compared to standard chemotherapy. We present clinical examples of excellent responses in spinal metastatic disease which have not been specifically documented in the literature, as most clinical trials evaluate treatment response based on visceral disease. This review is useful for the spine surgeons treating patients with metastatic disease as knowledge of these responses could help with timing and planning of surgical interventions, as well as promote multidisciplinary discussions, allowing development of an individualized treatment strategy to patients presenting with widespread multifocal progressive disease, where surgery could lead to suboptimal results.
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Affiliation(s)
| | - James C. Bayley
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | | | | | - Claudio E. Tatsui
- Department of Neurosurgery, MD Anderson Cancer Center, Houston, TX, USA,Corresponding Author Claudio E. Tatsui Department of Neurosurgery, MD Anderson Cancer Center, Houston, 1515 Holcombe Blvd, Houston, TX, USA
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7
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Loo Gan C, Huang J, Pan E, Xie W, Schmidt AL, Labaki C, Meza L, Bouchard G, Li H, Jackson-Spence F, Sánchez-Ruiz C, Powles T, Kumar SA, Weise N, Hall WA, Rose BS, Beuselinck B, Suarez C, Pal SK, Choueiri TK, Heng DY, McKay RR. Real-world Practice Patterns and Safety of Concurrent Radiotherapy and Cabozantinib in Metastatic Renal Cell Carcinoma: Results from the International Metastatic Renal Cell Carcinoma Database Consortium. Eur Urol Oncol 2022; 6:204-211. [PMID: 36328934 DOI: 10.1016/j.euo.2022.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/26/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND There is a paucity of data on the safety of cabozantinib use in combination with radiotherapy. OBJECTIVE To report the practice patterns, safety, and efficacy of cabozantinib with radiotherapy in metastatic renal cell carcinoma (mRCC). DESIGN, SETTING, AND PARTICIPANTS An international multicenter retrospective study was conducted. Patients with mRCC treated with cabozantinib at any line of therapy and who received radiotherapy between 30 d prior to the start date of cabozantinib and 30 d following discontinuation of cabozantinib, from 2014 to 2020, were included. Concurrent use was defined as the use of cabozantinib on radiotherapy treatment days during any course of radiotherapy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary outcomes of interest were the rate of grade ≥3 adverse events (AEs) occurring within 90 d of receipt of radiotherapy. Secondary outcomes included hospitalization rate and patterns of cabozantinib and radiotherapy use. Baseline characteristics and AEs were presented descriptively. RESULTS AND LIMITATIONS A total of 127 consecutive patients were included. Most patients had clear cell histology (88%), had International Metastatic Renal Cell Carcinoma Database Consortium intermediate-risk disease (57%), and had received at least one prior line of therapy (93%). Of 127 patients, 67 (53%) received concurrent cabozantinib with radiotherapy, while the remaining held cabozantinib on radiotherapy days. Overall, grade 3-4 AEs occurred in 6.3% (n = 8/127) of patients. No grade 5 events were observed. In patients treated with conventional palliative radiotherapy (n = 88), the rate of grade 3-4 AEs in those who had concurrent versus those who had nonconcurrent cabozantinib was 6.3% (n = 3/48) versus 5.0% (n = 2/40). No patient was hospitalized due to radiotherapy-related toxicity. In patients treated with stereotactic ablative body radiotherapy (SABR; n = 50), the rate of grade 3-4 AEs in those who had concurrent versus those who had nonconcurrent cabozantinib was 3.6% (n = 1/28) versus 9.1% (n = 2/22). One patient in the nonconcurrent group was hospitalized due to muscle weakness suspected to be related to associated vasogenic edema 19 d after SABR for multiple brain metastases. CONCLUSIONS In this real-world study of patients with mRCC treated with cabozantinib, 53% of patients received radiotherapy concurrently, with few grade 3-4 AEs reported within 90 d of receiving radiotherapy. The use of radiotherapy and cabozantinib requires a risk-benefit assessment of patient and disease characteristics to optimize therapy regimens. PATIENT SUMMARY Our study reports the real-world experience of using radiotherapy in patients receiving cabozantinib for metastatic kidney cancer. Over half of the patients continued taking cabozantinib while receiving radiotherapy, and few patients developed serious side effects. The combined use of radiotherapy and cabozantinib requires a careful risk-benefit assessment to achieve optimal treatment outcomes.
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8
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Radiation myelopathy following stereotactic body radiation therapy for spine metastases. J Neurooncol 2022; 159:23-31. [PMID: 35737172 DOI: 10.1007/s11060-022-04037-0] [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: 04/22/2022] [Accepted: 05/13/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE Stereotactic body radiation therapy (SBRT) is now considered a standard of care treatment option in the management of spine metastases. One of the most feared complications of spine SBRT is radiation myelopathy (RM). METHODS We provided a narrative review of RM following spine SBRT based on review of the published literature, including data on spinal cord dose constraints associated with the risk of RM, strategies to mitigate the risk, and management options for RM. RESULTS There are limited published data of cases of RM following spine SBRT with detailed spinal cord dosimetry. The HyTEC report provided recommendations for the point maximal dose (Dmax) for the spinal cord that is associated with a < 5% risk of RM for 1-5 fractions spine SBRT. In the setting of spine SBRT reirradiation after previous conventional external beam radiation therapy (cEBRT), factors associated with RM are: SBRT spinal cord Dmax, cumulative spinal cord Dmax, and the time interval between previous RT and SBRT reirradiation. There are various strategies to mitigate the risk of RM, including accurate delineation of the spinal cord (or thecal sac), strict adherence to the recommended spinal cord dose constraints, and robust treatment immobilisation set-up and delivery. Limited effective treatment options are available for patients who develop RM, and these include corticosteroids, hyperbaric oxygen, and bevacizumab; however, none have been supported by high quality evidence. CONCLUSION RM is a rare but devastating complication following SBRT for spine metastases. There are strategies to minimise the risk of RM to ensure safe delivery of spine SBRT.
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9
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Schoenhals JE, Mohamad O, Christie A, Zhang Y, Li D, Singla N, Bowman I, Arafat W, Hammers H, Courtney K, Cole S, Bagrodia A, Margulis V, Desai N, Garant A, Choy H, Timmerman R, Brugarolas J, Hannan R. Stereotactic Ablative Radiation Therapy for Oligoprogressive Renal Cell Carcinoma. Adv Radiat Oncol 2021; 6:100692. [PMID: 34646963 PMCID: PMC8498727 DOI: 10.1016/j.adro.2021.100692] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/09/2021] [Accepted: 03/11/2021] [Indexed: 12/26/2022] Open
Abstract
PURPOSE Oligoprogression, defined as limited sites of progression on systemic therapy, in patients with metastatic renal cell carcinoma (mRCC) is not uncommon, possibly because of inter- and intratumoral heterogeneity. We evaluated the effect of stereotactic ablative radiation therapy (SAbR) for longitudinal control of oligoprogressive mRCC. METHODS AND MATERIALS Patients with extracranial mRCC were included in this retrospective analysis if they progressed in ≤3 sites on systemic therapy while demonstrating response/stability at other sites and received SAbR to all progressing sites without switching systemic therapy. Our primary endpoint was modified progression-free survival (mPFS), which we calculated from the start of SAbR to the start of a subsequent systemic therapy, death, or loss to follow-up. RESULTS We identified 36 patients with a median follow-up of 20.4 months (interquartile range, 10.9-29.4). Forty-three sites were treated with SAbR with a median dose of 36 Gy (range, 18-50) in 3 fractions (range, 1-5). Median time to SAbR from the start of systemic therapy was 11.4 months (interquartile range, 6.1-17.1). Median mPFS was 9.2 months (95% confidence interval [CI], 5.9-13.2). Patients receiving SAbR while on immunotherapy exhibited a longer median mPFS (>28.4 months, log-rank P = .0001) than patients not on immunotherapy (9.2 months). Median overall survival from SAbR administration was 43.4 months (95% CI, 21.5-not Reached). The 1-year local control rate was 93% (95% CI, 78.7-97.5). Most SAbR-related toxicities were grade 1 to 2 (33% of patients), with one grade 5 hemoptysis event possibly related to SAbR or disease progression. CONCLUSIONS SAbR has the potential to extend the the duration of current systemic therapy for selected patients with mRCC, preserving subsequent therapies for later administration possibly enabling longer treatment duration.
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Affiliation(s)
| | - Osama Mohamad
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Alana Christie
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, Dallas, Texas
| | - Yuanyuan Zhang
- Department of Radiation Oncology, Simmons Comprehensive Cancer Center, Dallas, Texas
| | - Daniel Li
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, Dallas, Texas
| | - Nirmish Singla
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, Dallas, Texas
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Isaac Bowman
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, Dallas, Texas
- Department of Internal Medicine, Hematology-Oncology Division, Simmons Comprehensive Cancer Center, Dallas, Texas
| | - Waddah Arafat
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, Dallas, Texas
- Department of Internal Medicine, Hematology-Oncology Division, Simmons Comprehensive Cancer Center, Dallas, Texas
| | - Hans Hammers
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, Dallas, Texas
- Department of Internal Medicine, Hematology-Oncology Division, Simmons Comprehensive Cancer Center, Dallas, Texas
| | - Kevin Courtney
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, Dallas, Texas
- Department of Internal Medicine, Hematology-Oncology Division, Simmons Comprehensive Cancer Center, Dallas, Texas
| | - Suzanne Cole
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, Dallas, Texas
- Department of Internal Medicine, Hematology-Oncology Division, Simmons Comprehensive Cancer Center, Dallas, Texas
| | - Aditya Bagrodia
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, Dallas, Texas
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Vitaly Margulis
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, Dallas, Texas
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Neil Desai
- Department of Radiation Oncology, Simmons Comprehensive Cancer Center, Dallas, Texas
| | - Aurelie Garant
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, Dallas, Texas
- Department of Radiation Oncology, Simmons Comprehensive Cancer Center, Dallas, Texas
| | - Hak Choy
- Department of Radiation Oncology, Simmons Comprehensive Cancer Center, Dallas, Texas
| | - Robert Timmerman
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, Dallas, Texas
- Department of Radiation Oncology, Simmons Comprehensive Cancer Center, Dallas, Texas
| | - James Brugarolas
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, Dallas, Texas
- Department of Internal Medicine, Hematology-Oncology Division, Simmons Comprehensive Cancer Center, Dallas, Texas
| | - Raquibul Hannan
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, Dallas, Texas
- Department of Radiation Oncology, Simmons Comprehensive Cancer Center, Dallas, Texas
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10
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Massaad E, Saylor PJ, Hadzipasic M, Kiapour A, Oh K, Schwab JH, Schoenfeld AJ, Shankar GM, Shin JH. The effectiveness of systemic therapies after surgery for metastatic renal cell carcinoma to the spine: a propensity analysis controlling for sarcopenia, frailty, and nutrition. J Neurosurg Spine 2021; 35:356-365. [PMID: 34171829 DOI: 10.3171/2020.12.spine201896] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 12/09/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The effectiveness of starting systemic therapies after surgery for spinal metastases from renal cell carcinoma (RCC) has not been evaluated in randomized controlled trials. Agents that target tyrosine kinases, mammalian target of rapamycin signaling, and immune checkpoints are now commonly used. Variables like sarcopenia, nutritional status, and frailty may impact recovery from spine surgery and are considered when evaluating a patient's candidacy for such treatments. A better understanding of the significance of these variables may help improve patient selection for available treatment options after surgery. The authors used comparative effectiveness methods to study the treatment effect of postoperative systemic therapies (PSTs) on survival. METHODS Univariable and multivariable Cox regression analyses were performed to determine factors associated with overall survival (OS) in a retrospective cohort of adult patients who underwent spine surgery for metastatic RCC between 2010 and 2019. Propensity score-matched (PSM) analysis and inverse probability weighting (IPW) were performed to determine the treatment effect of PST on OS. To address confounding and minimize bias in estimations, PSM and IPW were adjusted for covariates, including age, sex, frailty, sarcopenia, nutrition, visceral metastases, International Metastatic RCC Database Consortium (IMDC) risk score, and performance status. RESULTS In total, 88 patients (73.9% male; median age 62 years, range 29-84 years) were identified; 49 patients (55.7%) had an intermediate IMDC risk, and 29 (33.0%) had a poor IMDC risk. The median follow-up was 17 months (range 1-104 months) during which 57 patients (64.7%) died. Poor IMDC risk (HR 3.2 [95% CI 1.08-9.3]), baseline performance status (Eastern Cooperative Oncology Group score 3 or 4; HR 2.7 [95% CI 1.5-4.7]), and nutrition (prognostic nutritional index [PNI] first tertile, PNI < 40.74; HR 2.69 [95% CI 1.42-5.1]) were associated with worse OS. Sarcopenia and frailty were not significantly associated with poor survival. PST was associated with prolonged OS, demonstrated by similar effects from multivariable Cox analysis (HR 0.55 [95% CI 0.30-1.00]), PSM (HR 0.53 [95% CI 0.29-0.93]), IPW (HR 0.47 [95% CI 0.24-0.94]), and comparable confidence intervals. The median survival for those receiving PST was 28 (95% CI 19-43) months versus 12 (95% CI 4-37) months for those who only had surgery (log-rank p = 0.027). CONCLUSIONS This comparative analysis demonstrated that PST is associated with improved survival in specific cohorts with metastatic spinal RCC after adjusting for frailty, sarcopenia, and malnutrition. The marked differences in survival should be taken into consideration when planning for surgery.
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Affiliation(s)
| | | | | | | | | | | | - Andrew J Schoenfeld
- 5Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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11
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Spyropoulou D, Tsiganos P, Dimitrakopoulos FI, Tolia M, Koutras A, Velissaris D, Lagadinou M, Papathanasiou N, Gkantaifi A, Kalofonos H, Kardamakis D. Radiotherapy and Renal Cell Carcinoma: A Continuing Saga. In Vivo 2021; 35:1365-1377. [PMID: 33910814 PMCID: PMC8193295 DOI: 10.21873/invivo.12389] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 03/26/2021] [Accepted: 03/31/2021] [Indexed: 11/10/2022]
Abstract
Renal cell carcinoma (RCC) is one of the most aggressive malignancies of the genito-urinary tract, having a poor prognosis especially in patients with metastasis. Surgical resection remains the gold standard for localized renal cancer disease, with radiotherapy (RT) receiving much skepticism during the last decades. However, many studies have evaluated the role of RT, and although renal cancer is traditionally considered radio-resistant, technological advances in the RT field with regards to modern linear accelerators, as well as advanced RT techniques have resulted in breakthrough therapeutic outcomes. Additionally, the combination of RT with immune checkpoint inhibitors and targeted agents may maximize the clinical benefit. This review article focuses on the role of RT in the therapeutic management of renal cell carcinoma.
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Affiliation(s)
- Despoina Spyropoulou
- Department of Radiation Oncology, University of Patras Medical School, Patras, Greece;
| | - Panagiotis Tsiganos
- Clinical Radiology Laboratory, Department of Medicine, University of Patras, Patras, Greece
| | - Foteinos-Ioannis Dimitrakopoulos
- Division of Oncology, Department of Medicine, University Hospital of Patras, Patras, Greece
- Clinical and Molecular Oncology Laboratory, Medical School, University of Patras, Patras, Greece
| | - Maria Tolia
- Radiotherapy Department, University Hospital Heraklion, University of Crete Medical School, Heraklion, Greece
| | - Angelos Koutras
- Division of Oncology, Department of Medicine, University Hospital of Patras, Patras, Greece
| | - Dimitris Velissaris
- Emergency Department and Internal Medicine Department, University Hospital of Patras, Patras, Greece
| | - Maria Lagadinou
- Emergency Department University Hospital of Patras, Patras, Greece
| | | | - Areti Gkantaifi
- Radiotherapy Department, Interbalkan Medical Center, Thessaloniki, Greece
| | - Haralabos Kalofonos
- Division of Oncology, Department of Medicine, University Hospital of Patras, Patras, Greece
| | - Dimitrios Kardamakis
- Department of Radiation Oncology, University of Patras Medical School, Patras, Greece
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12
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Liu Y, Zhang Z, Han H, Guo S, Liu Z, Liu M, Zhou F, Dong P, He L. Survival After Combining Stereotactic Body Radiation Therapy and Tyrosine Kinase Inhibitors in Patients With Metastatic Renal Cell Carcinoma. Front Oncol 2021; 11:607595. [PMID: 33692951 PMCID: PMC7937906 DOI: 10.3389/fonc.2021.607595] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 01/07/2021] [Indexed: 12/09/2022] Open
Abstract
Background Stereotactic body radiation therapy (SBRT) and tyrosine kinase inhibitors (TKIs) are effective treatments for metastatic renal cell carcinoma, but data on combining these two modalities are scarce. We aimed to investigate the survival outcomes of SBRT plus TKIs. Methods Data of patients treated with TKIs from December 2007 to June 2019 were collected. Patients received SBRT plus TKIs (TKI + SBRT group) or TKIs alone (TKI alone group). Local control (LC), time to change of systemic therapy (TTS), and overall survival (OS) were assessed. Results A total of 190 patients were included, and 85 patients received TKI + SBRT. The 2-year LC rate was 92.8%. The median OS in the TKI + SBRT group was significantly longer than that of the TKI alone group (63.2 vs 29.8 months; P < 0.001). In multivariate analysis, IMDC intermediate (HR 1.96; 95% CI 1.10-3.48; P = 0.022) and poor risk (HR 2.43; 95% CI 1.25-4.75; P = 0.009), oligometastasis (HR 0.41; 95% CI 0.26-0.65; P < 0.001), and the addition of SBRT (HR 0.48; 95% CI 0.31-0.75; P = 0.001) were prognostic factors for OS. Patients with oligometastasis (P = 0.009) and those with IMDC favorable (P = 0.044) or intermediate (P = 0.002) risk had significantly longer OS with TKI + SBRT. The median TTS were 21.5, 6.4, and 9.0 months in patients receiving SBRT before first-line TKI failure, SBRT after first-line TKI failure, and first-line TKI alone (P < 0.001). Five patients (5.9%) experienced SBRT-related grade 3 toxicities. Conclusions Combining SBRT with TKIs is tolerable and associated with longer OS in selected patients, such as those with oligometastasis and favorable or intermediate risk.
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Affiliation(s)
- Yang Liu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Zhiling Zhang
- Department of Urology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Hui Han
- Department of Urology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Shengjie Guo
- Department of Urology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Zhuowei Liu
- Department of Urology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Mengzhong Liu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Fangjian Zhou
- Department of Urology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Pei Dong
- Department of Urology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Liru He
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
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13
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Ingrosso G, Becherini C, Francolini G, Lancia A, Alì E, Caini S, Teriaca MA, Marchionni A, Filippi AR, Livi L, Sanguineti G, Aristei C, Detti B. Stereotactic body radiotherapy (SBRT) in combination with drugs in metastatic kidney cancer: A systematic review. Crit Rev Oncol Hematol 2021; 159:103242. [PMID: 33545356 DOI: 10.1016/j.critrevonc.2021.103242] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 01/15/2021] [Accepted: 01/20/2021] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE To conduct a systematic review and meta-analysis of the role of SBRTdrug combination in patients affected by mRCC and associated oncologic outcomes and toxicity profiles. EVIDENCE ACQUISITION We performed a critical review of the Pubmed, Medline, and Embase databases from January 1, 2000 through April 30, 2020 according to the Preferred Reporting Items and Meta-Analyses statement. To assess the overall quality of the literature reviewed, we used a modified Delphi tool. EVIDENCE SYNTHESIS A total of 6 studies were included, corresponding to a cohort of 216 patients. Tyrosine Kinases Inhibitors were the most widely used drugs in combination with SBRT, being administered in 93% patients. No study reported an increase of radiation-induced toxicity. CONCLUSIONS SBRT resulted to be safe, without increase in terms of drugs-related adverse events in this setting. Moreover, this approach showed promising clinical outcomes in terms of LC and OS.
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Affiliation(s)
- Gianluca Ingrosso
- Radiation Oncology Section, Department of Surgical and Biomedical Science, University of Perugia, Italy
| | - Carlotta Becherini
- Radiation Oncology, A.O.U. Careggi, University of Florence, Largo Brambilla, 3, 50134 Florence, Italy
| | - Giulio Francolini
- Radiation Oncology, A.O.U. Careggi, University of Florence, Largo Brambilla, 3, 50134 Florence, Italy
| | - Andrea Lancia
- Radiation Oncology, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Emanuele Alì
- Radiation Oncology Section, Department of Surgical and Biomedical Science, University of Perugia, Italy
| | - Saverio Caini
- Cancer Risk Factors and Lifestyle Epidemiology Unit, Institute for Cancer Research, Prevention and Clinical Networking, Florence, Italy
| | - Maria Ausilia Teriaca
- Radiation Oncology, A.O.U. Careggi, University of Florence, Largo Brambilla, 3, 50134 Florence, Italy
| | - Alessandro Marchionni
- Radiation Oncology Section, Department of Surgical and Biomedical Science, University of Perugia, Italy
| | | | - Lorenzo Livi
- Radiation Oncology, A.O.U. Careggi, University of Florence, Largo Brambilla, 3, 50134 Florence, Italy
| | - Giuseppe Sanguineti
- Department of Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Cynthia Aristei
- Radiation Oncology Section, Department of Surgical and Biomedical Science, University of Perugia, Italy
| | - Beatrice Detti
- Radiation Oncology, A.O.U. Careggi, University of Florence, Largo Brambilla, 3, 50134 Florence, Italy.
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14
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Glicksman RM, Tjong MC, Neves-Junior WFP, Spratt DE, Chua KLM, Mansouri A, Chua MLK, Berlin A, Winter JD, Dahele M, Slotman BJ, Bilsky M, Shultz DB, Maldaun M, Szerlip N, Lo SS, Yamada Y, Vera-Badillo FE, Marta GN, Moraes FY. Stereotactic Ablative Radiotherapy for the Management of Spinal Metastases: A Review. JAMA Oncol 2020; 6:567-577. [PMID: 31895403 DOI: 10.1001/jamaoncol.2019.5351] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Rising cancer incidence combined with improvements in systemic and local therapies extending life expectancy are translating into more patients with spinal metastases. This makes the multidisciplinary management of spinal metastases and development of new therapies increasingly important. Spinal metastases may cause significant pain and reduced quality of life and lead to permanent neurological disability if compression of the spinal cord and/or nerve root occurs. Until recently, treatments for spinal metastases were not optimal and provided temporary local control and pain relief. Spinal stereotactic ablative radiotherapy (SABR) is an effective approach associated with an improved therapeutic ratio, with evolving clinical application. Objective To review the literature of spinal SABR for spinal metastases, discuss a multidisciplinary approach to appropriate patient selection and technical considerations, and summarize current efforts to combine spinal SABR with systemic therapies. Evidence Review The MEDLINE database was searched to identify articles reporting on spinal SABR to September 30, 2018. Articles including clinical trials, prospective and retrospective studies, systematic reviews, and consensus recommendations were selected for relevance to multidisciplinary management of spinal metastases. Results Fifty-nine unique publications with 5655 patients who underwent SABR for spinal metastases were included. Four comprehensive frameworks for patient selection were discussed. Spinal SABR was associated with 1-year local control rates of approximately 80% to 90% in the de novo setting, greater than 80% in the postoperative setting, and greater than 65% in the reirradiation setting. The most commonly discussed adverse effect was development of a vertebral compression fracture with variable rates, most commonly reported as approximately 10% to 15%. High-level data on the combination of SABR with modern therapies are still lacking. At present, 19 clinical trials are ongoing, mainly focusing on combined modality therapies, radiotherapy prescription dose, and oligometastic disease. Conclusions and Relevance These findings suggest that spinal SABR may be an effective treatment option for well-selected patients with spinal metastases, achieving high rates of local tumor control with moderate rates of adverse effects. Optimal management should include review by a multidisciplinary care team.
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Affiliation(s)
- Rachel M Glicksman
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Michael C Tjong
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | | | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Kevin L M Chua
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore.,Oncology Academic Programme, Duke University/National University of Singapore (NUS) Medical School, Singapore
| | - Alireza Mansouri
- Department of Neurosurgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Melvin L K Chua
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore.,Oncology Academic Programme, Duke University/National University of Singapore (NUS) Medical School, Singapore
| | - Alejandro Berlin
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Jeff D Winter
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Max Dahele
- Department of Radiation Oncology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Ben J Slotman
- Department of Radiation Oncology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Mark Bilsky
- Department of Neurosurgery, Multi-Disciplinary Spine Tumor Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - David B Shultz
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Marcos Maldaun
- Division of Neurosurgery, Hospital Sírio-Libanês, São Paulo, Brazil
| | | | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle
| | - Yoshiya Yamada
- Department of Radiation Oncology, Multi-Disciplinary Spine Tumor Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Gustavo N Marta
- Department of Radiation Oncology, Hospital Sírio-Libanês, São Paulo, Brazil.,Division of Radiation Oncology, Department of Radiology and Oncology, Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Fabio Y Moraes
- Division of Radiation Oncology, Department of Oncology, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
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15
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Abstract
PURPOSE OF REVIEW The role of metastasectomy in the management of metastatic renal cell carcinoma (mRCC) remains controversial. The aim of this review is to summarize and evaluate the recent findings about the surgical treatment of patients with mRCC focusing on the literature published in the last 2 years. RECENT FINDINGS Despite the lack of randomized controlled trials, the benefit of metastasectomy in term of cancer-specific and overall survival have been demonstrated in large observational studies. Results of ongoing clinical trials evaluating the impact of combination of surgical and systemic therapies are eagerly awaited and may shed the light on a new treatment armamentarium in this subset of patients. SUMMARY Several novel systemic agents have emerged and is continuously changing the treatment paradigm in patients with advanced RCC. However, surgical resection of the primary tumor and metastatic deposits represents a definitive cure option in well selected patients.
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16
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Kroeze SGC, Fritz C, Schaule J, Siva S, Kahl KH, Sundahl N, Blanck O, Kaul D, Adebahr S, Verhoeff JJC, Skazikis G, Roeder F, Geier M, Eckert F, Guckenberger M. Stereotactic radiotherapy combined with immunotherapy or targeted therapy for metastatic renal cell carcinoma. BJU Int 2020; 127:703-711. [PMID: 33113260 DOI: 10.1111/bju.15284] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To evaluate the safety and efficacy of stereotactic radiotherapy (SRT) in patients with metastatic renal cell carcinoma (mRCC) concurrently receiving targeted therapy (TT) or immunotherapy. PATIENTS AND METHODS Data on patients with mRCC were extracted from a retrospective international multicentre register study (TOaSTT), investigating SRT concurrent (≤30 days) with TT/immune checkpoint inhibitor (ICI) therapy. Overall survival (OS), progression-free survival (PFS), local metastasis control (LC) and time to systemic therapy switch were analysed using Kaplan-Meier curves and log-rank testing. Clinical and treatment factors influencing survival were analysed using multivariate Cox regression. Acute and late SRT-induced toxicity were defined according to the Common Terminology Criteria for Adverse Events v.4.03. RESULTS Fifty-three patients who underwent 128 sessions of SRT were included, of whom 58% presented with oligometastatic disease (OMD). ICIs and TT were received by 32% and 68% of patients, respectively. Twenty patients (37%) paused TT for a median (range) of 14 (2-21) days. ICI therapy was not paused in any patient. A median (range) of 1 (1-5) metastatic tumour was treated per patient, with a median (range) SRT dose of 65 (40-129.4) Gy (biologically effective dose). The OS, LC and PFS rates at 1 year were 71%, 75% and 25%, respectively. The median OS and PFS were not significantly different among patients receiving TT vs those receiving ICIs (P = 0.329). New lesions were treated with a repeat radiotherapy course in 46% of patients. After 1 year, 62% of patients remained on the same systemic therapy as at the time of SRT; this was more frequent for ICI therapy compared to TT (83% vs 36%; P = 0.035). OMD was an independent prognostic factor for OS (P = 0.004, 95% confidence interval [CI] 0.035-0.528) and PFS (P = 0.004; 95% CI 0.165-0.717) in multivariate analysis. Eastern Cooperative Oncology Group performance status (ECOG-PS) was the other independent prognostic factor for OS (P = 0.001, 95% CI 0.001-0.351). Acute grade 3 toxicity was observed in two patients, and late grade 3 toxicity in one patient. No grade 4 or 5 toxicity was observed. CONCLUSION Combined treatment with TT or immunotherapy and concurrent SRT was safe, without signals of increased severe toxicity. As we observed no signal of excess toxicity, full-dose SRT should be considered to achieve optimal metastasis control in patients receiving TT or immunotherapy. Favourable PFS and OS were observed for patients with oligometastatic RCC with a good ECOG-PS, which should form the basis for prospective testing of this treatment strategy in properly designed clinical trials.
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Affiliation(s)
- Stephanie G C Kroeze
- Department of Radiation Oncology, University Hospital Zürich, University of Zurich, Zurich, Switzerland
| | - Corinna Fritz
- Department of Radiation Oncology, University Hospital Zürich, University of Zurich, Zurich, Switzerland
| | - Jana Schaule
- Department of Radiation Oncology, University Hospital Zürich, University of Zurich, Zurich, Switzerland
| | - Shankar Siva
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Vic., Australia
| | - Klaus H Kahl
- Department of Radiation Oncology, University Hospital Augsburg, Augsburg, Germany
| | - Nora Sundahl
- Department of Radiation Oncology, University Hospital Ghent, Ghent, Belgium
| | - Oliver Blanck
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - David Kaul
- Department or Radiation Oncology, Charité-University Hospital Berlin, Berlin, Germany
| | - Sonja Adebahr
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, German Cancer Consortium (DKTK), Partner Site Freiburg, University of Freiburg, Freiburg, Germany
| | - Joost J C Verhoeff
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Georgios Skazikis
- Department of Radiation Oncology, Schwarzwald-Baar Klinikum, Villingen-Schwenningen, Germany
| | - Falk Roeder
- Department of Radiation Oncology, University Hospital Munich, Munich, Germany
| | - Michael Geier
- Department of Radiation Oncology, Ordensklinikum Linz, Linz, Austria
| | - Franziska Eckert
- Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zürich, University of Zurich, Zurich, Switzerland
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17
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Safaee MM, Shah V, Tenorio A, Uribe JS, Clark AJ. Minimally Invasive Pedicle Screw Fixation With Indirect Decompression by Ligamentotaxis in Pathological Fractures. Oper Neurosurg (Hagerstown) 2020; 19:210-217. [PMID: 32255471 DOI: 10.1093/ons/opaa045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Accepted: 01/13/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The spine is the most common site of bony metastases. Associated pathological fractures can result in pain, neurological deficit, biomechanical instability, and deformity. OBJECTIVE To present a minimally invasive technique for indirect decompression by ligamentotaxis in pathological fractures. METHODS A minimally invasive approach was utilized to perform percutaneous pedicle screw fixation in patients who required stabilization for pathological fractures. Preoperative and postoperative computed tomography and magnetic resonance imaging were used to compare spinal canal area and midsagittal canal diameter. RESULTS Two patients with newly diagnosed pathological fractures underwent minimally invasive treatment. Each presented with minimal epidural disease and a chief complaint of intractable back pain without neurological deficit. They underwent minimally invasive pedicle screw fixation with indirect decompression by ligamentotaxis. In each case, postoperative imaging demonstrated an increase in spinal canal area and midsagittal canal diameter by an independent neuroradiologist. There were no perioperative complications, and each patient was neurologically stable without evidence of hardware failure at their 5- and 6-mo follow-up visits. CONCLUSION Minimally invasive percutaneous fixation can be used to stabilize pathological fractures and provide indirect decompression by ligamentotaxis. This procedure is associated with minimal blood loss, low morbidity, and rapid initiation of radiation therapy. Only patients with minimal epidural disease, stenosis caused primarily by bony retropulsion, and mild-to-moderate deformity should be considered candidates for this approach.
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Affiliation(s)
- Michael M Safaee
- Department of Neurological Surgery, University of California-San Francisco, San Francisco, California
| | - Vinil Shah
- Division of Neuroradiology, Department of Radiology, University of California-San Francisco, San Francisco, California
| | - Alexander Tenorio
- Department of Neurological Surgery, University of California-San Francisco, San Francisco, California
| | | | - Aaron J Clark
- Department of Neurological Surgery, University of California-San Francisco, San Francisco, California
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Spencer KL, van der Velden JM, Wong E, Seravalli E, Sahgal A, Chow E, Verlaan JJ, Verkooijen HM, van der Linden YM. Systematic Review of the Role of Stereotactic Radiotherapy for Bone Metastases. J Natl Cancer Inst 2020; 111:1023-1032. [PMID: 31119273 PMCID: PMC6792073 DOI: 10.1093/jnci/djz101] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 04/07/2019] [Accepted: 05/15/2019] [Indexed: 01/07/2023] Open
Abstract
Background Stereotactic radiotherapy (SBRT) might improve pain and local control in patients with bone metastases compared to conventional radiotherapy, although an overall estimate of these outcomes is currently unknown. Methods A systematic review was carried out following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Pubmed, Embase, and Cochrane databases were systematically searched to identify studies reporting pain response and local control among patients with bone metastases from solid-organ tumors who underwent SBRT in 1–6 fractions. All studies prior to April 15, 2017, were included. Study quality was assessed by predefined criteria, and pain response and local control rates were extracted. Results A total of 2619 studies were screened; 57 were included (reporting outcomes for 3995 patients) of which 38 reported pain response and 45 local control rates. Local control rates were high with pain response rates above those previously reported for conventional radiotherapy. Marked heterogeneity in study populations and delivered treatments were identified such that quantitative synthesis was not appropriate. Reported toxicity was limited. Of the pain response studies, 73.7% used a retrospective cohort design and only 10.5% used the international consensus endpoint definitions of pain response. The median survival within the included studies ranged from 8 to 30.4 months, suggesting a high risk of selection bias in the included observational studies. Conclusions This review demonstrates the potential benefit of SBRT over conventional palliative radiotherapy in improving pain due to bone metastases. Given the methodological limitations of the published literature, however, large randomized trials are now urgently required to better quantify this benefit.
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Affiliation(s)
- Katie L Spencer
- Correspondence to: Katie Spencer, MB, BChir, FRCR, Cancer Epidemiology Group, Level 11 Worsley Building, Clarendon Way, University of Leeds, Leeds LS2 9NL, West Yorkshire, UK (e-mail: )
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19
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Miccio JA, Oladeru OT, Jun Ma S, Johung KL. Radiation Therapy for Patients with Advanced Renal Cell Carcinoma. Urol Clin North Am 2020; 47:399-411. [PMID: 32600541 DOI: 10.1016/j.ucl.2020.04.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Stereotactic radiosurgery and stereotactic body radiation therapy (SBRT) have led to a resurgence of the use of radiotherapy in the management of advanced renal cell carcinoma (RCC). These techniques provide excellent local control and palliation of metastatic sites of disease with minimal toxicity. Additionally, SBRT to the primary tumor may be efficacious and well tolerated in select patients that are not surgical candidates. Emerging data suggest that SBRT may potentiate the immune response, and current and future study will evaluate if SBRT can improve survival outcomes in patients with metastatic RCC.
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Affiliation(s)
- Joseph A Miccio
- Department of Therapeutic Radiology, Yale School of Medicine, 35 Park Street, New Haven, CT 06519, USA
| | | | - Sung Jun Ma
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY 14263, USA
| | - Kimberly L Johung
- Department of Therapeutic Radiology, Yale School of Medicine, 35 Park Street, New Haven, CT 06519, USA.
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20
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Mazzola R, Jereczek-Fossa BA, Franceschini D, Tubin S, Filippi AR, Tolia M, Lancia A, Minniti G, Corradini S, Arcangeli S, Scorsetti M, Alongi F. Oligometastasis and local ablation in the era of systemic targeted and immunotherapy. Radiat Oncol 2020; 15:92. [PMID: 32366258 PMCID: PMC7197157 DOI: 10.1186/s13014-020-01544-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/22/2020] [Indexed: 12/13/2022] Open
Abstract
Background During these last years, new agents have dramatically improved the survival of the metastatic patients. Oligometastases represent a continuous field of interest in which the integration of metastases-directed therapy and drugs could further improve the oncologic outcomes. Herein a narrative review is performed regarding the main rationale in combining immunotherapy and target therapies with SBRT looking at the available clinical data in case of oligometastatic NSCLC, Melanoma and Kidney cancer. Material and method Narrative Review regarding retrospective and prospective studies published between January 2009 to November 2019 with at least 20 patients analyzed. Results Concerning the combination between SBRT and Immunotherapy, the correct sequence of remains uncertain, and seems to be drug-dependent. The optimal patients’ selection is crucial to expect substantial benefits to SBRT/Immunotherapy combination and, among several factors. A potential field of interest is represented by the so-called oligoprogressed disease, in which SBRT could improve the long-term efficacy of the existing target therapy. Conclusions A low tumor burden seems to be the most relevant, thus making the oligometastatic disease represent the ideal setting for the use of combination therapies with immunological drugs.
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Affiliation(s)
- Rosario Mazzola
- IRCCS, Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy
| | - Barbara Alicja Jereczek-Fossa
- Department of Radiation Oncology IEO, European Institute of Oncology IRCCS, Milan, Italy.,Department of Oncology and Hemato-oncology University of Milan, Milan, Italy
| | - Davide Franceschini
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, Rozzano, Milan, Italy
| | - Slavisa Tubin
- KABEG Klinikum Klagenfurt, Institute of Radiation Oncology, Klagenfurt am Wörthersee, Austria
| | | | - Maria Tolia
- Faculty of Medicine, School of Health Sciences, University of Thessaly, University Hospital of Larissa, Biopolis, Larisa, Greece
| | - Andrea Lancia
- Radiation Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giuseppe Minniti
- Radiation Oncology Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Stefano Arcangeli
- Department of Radiation Oncology, Policlinico S. Gerardo and University of Milan "Bicocca", Milan, Italy
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, Rozzano, Milan, Italy
| | - Filippo Alongi
- IRCCS, Advanced Radiation Oncology Department, Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy. .,University of Brescia, Brescia, Italy.
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Survival Outcomes After Adding Stereotactic Body Radiotherapy to Metastatic Renal Cell Carcinoma Patients Treated With Tyrosine Kinase Inhibitors. Am J Clin Oncol 2020; 43:58-63. [PMID: 31651452 PMCID: PMC6922069 DOI: 10.1097/coc.0000000000000622] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Long-lasting control is rarely achieved with tyrosine kinase inhibitors (TKI) alone in metastatic renal cell carcinoma (mRCC). Our study aimed to investigate the survival outcomes of adding stereotactic body radiotherapy (SBRT) to TKI in mRCC. MATERIALS AND METHODS From September 2015 to September 2018, 56 patients treated with TKI received SBRT for 103 unresectable lesions. A total of 24 and 32 patients were irradiated before and after TKI failure, respectively. Overall survival (OS) was calculated from metastases. Progression-free survival (PFS) was calculated from SBRT. RESULTS Overall, 10, 32, and 12 patients had International Metastatic Renal Cell Carcinoma Database Consortium favorable, intermediate, and poor risk. Median follow-up was 21.7 months (range, 5.1 to 110.6 mo). Median OS was 61.2 months. The median PFS was 11.5 months, while the 2-year LC rate was 94%. Sixteen (34%) lesions achieved complete response (CR) in patients irradiated before TKI failure, whereas only 4 (7%) lesions yielded CR in those irradiated after TKI failure (P=0.001). The median PFS in CR group was significantly longer than that of non-CR group (18.9 vs. 7.1 mo; P=0.003). The 5-year OS in CR group was 86%, compared with 48% in non-CR group (P=0.010). Four (7%) patients experienced Grade 3 toxicity. CONCLUSIONS Adding SBRT to TKI is safe and seems to improve survival in mRCC. Patients irradiated before TKI failure have higher CR rate, and the favorable local response might turn into survival benefit.
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22
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Moraes FY, Chen X, Yan M, Spratt DE, Redmond K, Jackson WC, Yamada YJ. Evolving Role of Stereotactic Body Radiation Therapy in the Management of Spine Metastases: Defining Dose and Dose Constraints. Neurosurg Clin N Am 2020; 31:167-189. [PMID: 32147009 DOI: 10.1016/j.nec.2019.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
When treating solid tumor spine metastases, stereotactic high-dose-per-fraction radiation, given in a single fraction or in a hypofractionated approach, has proved to be a highly effective and safe therapeutic option for any tumor histology, in the setting of de novo therapy, as salvage treatment of local progression after previous radiation, and in the postoperative setting. There are variations in practice based on the clinical presentation, goals of therapy, as well as institutional preferences. As a biologically potent therapy, a thoughtful and careful attention to detail with patient selection, treatment planning, and delivery is crucial for treatment success.
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Affiliation(s)
- Fabio Y Moraes
- Department of Oncology, Division of Radiation Oncology, Queen's University, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Xuguang Chen
- Department of Radiation Oncology, Johns Hopkins University, Baltimore, MD, USA
| | - Michael Yan
- Department of Oncology, Division of Radiation Oncology, Queen's University, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Kristen Redmond
- Department of Radiation Oncology, Johns Hopkins University, Baltimore, MD, USA
| | - William C Jackson
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Yoshiya Josh Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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23
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Xu K, Li J, Hu M, Zhang H, Yang J, Gong H, Li B, Wan W, Xiao J. Prognostic Significance of Preoperative Inflammatory Biomarkers and Traditional Clinical Parameters in Patients with Spinal Metastasis from Clear Cell Renal Cell Carcinoma: A Retrospective Study of 95 Patients in a Single Center. Cancer Manag Res 2020; 12:59-70. [PMID: 32021423 PMCID: PMC6954859 DOI: 10.2147/cmar.s228570] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 12/07/2019] [Indexed: 12/12/2022] Open
Abstract
Purpose The purpose of this retrospective study was to identify preoperative inflammatory biomarkers and clinical parameters and evaluate their prognostic significance in patients with spinal metastasis from clear cell renal cell carcinoma (CCRCC). Patients and methods Correlations of overall survival (OS) with traditional clinical parameters and inflammatory indicators including the neutrophil–lymphocyte ratio (NLR), platelet–lymphocyte ratio (PLR), lymphocyte–monocyte ratio (LMR), albumin–globulin ratio (AGR), and C-reactive protein to albumin ratio (CRP/Alb ratio) were analyzed in 95 patients with spinal metastasis from CCRCA using the Kaplan–Meier method to identify potential prognostic factors. Factors with P values ≤ 0.1 were subjected to multivariate analysis by Cox regression analysis. P values ≤ 0.05 were considered statistically significant. Results The 95 patients included in this study were followed up by a mean of 48.8 months (median 51 months; range 6–132 months), during which 21 patients died, with a death rate of 22.1%. The statistical results indicated that patients with total piecemeal spondylectomy (TPS), targeted therapy, NLR < 3.8 and PLR < 206.9 had a significantly longer OS rate. Conclusion TPS and targeted therapy could significantly prolong the OS of patients with spinal metastasis from CCRCC. In addition, NLR and PLR are robust and convenient prognostic indicators that have a discriminatory ability superior to other inflammatory biomarkers.
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Affiliation(s)
- Kehan Xu
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai 200003, People's Republic of China
| | - Jialin Li
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai 200003, People's Republic of China
| | - Mengzi Hu
- Department of Orthopedics, Xuzhou Central Hospital, Xuzhou, Jiangsu 221009, People's Republic of China
| | - Hao Zhang
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai 200003, People's Republic of China
| | - Jian Yang
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai 200003, People's Republic of China
| | - Haiyi Gong
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai 200003, People's Republic of China
| | - Bo Li
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai 200003, People's Republic of China
| | - Wei Wan
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai 200003, People's Republic of China
| | - Jianru Xiao
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai 200003, People's Republic of China
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Juloori A, Miller JA, Parsai S, Kotecha R, Ahluwalia MS, Mohammadi AM, Murphy ES, Suh JH, Barnett GH, Yu JS, Vogelbaum MA, Rini B, Garcia J, Stevens GH, Angelov L, Chao ST. Overall survival and response to radiation and targeted therapies among patients with renal cell carcinoma brain metastases. J Neurosurg 2020; 132:188-196. [PMID: 30660120 DOI: 10.3171/2018.8.jns182100] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 08/14/2018] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The object of this retrospective study was to investigate the impact of targeted therapies on overall survival (OS), distant intracranial failure, local failure, and radiation necrosis among patients treated with radiation therapy for renal cell carcinoma (RCC) metastases to the brain. METHODS All patients diagnosed with RCC brain metastasis (BM) between 1998 and 2015 at a single institution were included in this study. The primary outcome was OS, and secondary outcomes included local failure, distant intracranial failure, and radiation necrosis. The timing of targeted therapies was recorded. Multivariate Cox proportional-hazards regression was used to model OS, while multivariate competing-risks regression was used to model local failure, distant intracranial failure, and radiation necrosis, with death as a competing risk. RESULTS Three hundred seventy-six patients presented with 912 RCC BMs. Median OS was 9.7 months. Consistent with the previously validated diagnosis-specific graded prognostic assessment (DS-GPA) for RCC BM, Karnofsky Performance Status (KPS) and number of BMs were the only factors prognostic for OS. One hundred forty-seven patients (39%) received vascular endothelial growth factor receptor (VEGFR) tyrosine kinase inhibitors (TKIs). Median OS was significantly greater among patients receiving TKIs (16.8 vs 7.3 months, p < 0.001). Following multivariate analysis, KPS, number of metastases, and TKI use remained significantly associated with OS.The crude incidence of local failure was 14.9%, with a 12-month cumulative incidence of 13.4%. TKIs did not significantly decrease the 12-month cumulative incidence of local failure (11.4% vs 14.5%, p = 0.11). Following multivariate analysis, age, number of BMs, and lesion size remained associated with local failure. The 12-month cumulative incidence of radiation necrosis was 8.0%. Use of TKIs within 30 days of SRS was associated with a significantly increased 12-month cumulative incidence of radiation necrosis (10.9% vs 6.4%, p = 0.04). CONCLUSIONS Use of targeted therapies in patients with RCC BM treated with intracranial SRS was associated with improved OS. However, the use of TKIs within 30 days of SRS increases the rate of radiation necrosis without improving local control or reducing distant intracranial failure. Prospective studies are warranted to determine the optimal timing to reduce the rate of necrosis without detracting from survival.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Glen H Stevens
- 4Neurology, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
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Hadzipasic M, Giantini-Larsen AM, Tatsui CE, Shin JH. Emerging Percutaneous Ablative and Radiosurgical Techniques for Treatment of Spinal Metastases. Neurosurg Clin N Am 2020; 31:141-150. [DOI: 10.1016/j.nec.2019.08.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Delgado-López PD, Roldán-Delgado H, Corrales-García EM. Stereotactic body radiation therapy and minimally invasive surgery in the management of spinal metastases: a change in the paradigm. Neurocirugia (Astur) 2019; 31:119-131. [PMID: 31668627 DOI: 10.1016/j.neucir.2019.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/26/2019] [Accepted: 08/26/2019] [Indexed: 11/25/2022]
Abstract
The main goal of treatment in spinal metastatic patients is local control of the disease, pain relief and the maintenance of ambulation. Traditionally, wide surgical resection of the tumour followed by adjuvant radiation and/or chemotherapy has been recommended. Currently, single-fraction or hypofractionated stereotactic body radiation therapy (SBRT) yields a one-year local control rate of over 95% with minimum morbidity, even for tumours previously considered radioresistant. In addition, by posterolateral and circumferential decompression and stabilisation of the spinal cord, it is feasible to create a 2 to 3 mm epidural margin between the dura mater and the tumour (separation surgery), enough to deliver safe and ablative doses of SBRT to the vertebrae. As these patients tend to be frail, such interventions should ideally be minimally invasive, thereby reducing surgical aggressiveness and helping to minimise the delay of any systemic therapies.
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Affiliation(s)
| | - Héctor Roldán-Delgado
- Servicio de Neurocirugía, Complejo Hospitalario Universitario de Canarias, Tenerife, España
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27
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Laufer I, Bilsky MH. Advances in the treatment of metastatic spine tumors: the future is not what it used to be. J Neurosurg Spine 2019; 30:299-307. [PMID: 30835704 DOI: 10.3171/2018.11.spine18709] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 11/06/2018] [Indexed: 11/06/2022]
Abstract
An improved understanding of tumor biology, the ability to target tumor drivers, and the ability to harness the immune system have dramatically improved the expected survival of patients diagnosed with cancer. However, many patients continue to develop spine metastases that require local treatment with radiotherapy and surgery. Fortunately, the evolution of radiation delivery and operative techniques permits durable tumor control with a decreased risk of treatment-related toxicity and a greater emphasis on restoration of quality of life and daily function. Stereotactic body radiotherapy allows delivery of ablative radiation doses to the majority of spine tumors, reducing the need for surgery. Among patients who still require surgery for decompression of the spinal cord or spinal column stabilization, minimal access approaches and targeted tumor excision and ablation techniques minimize the surgical risk and facilitate postoperative recovery. Growing interdisciplinary collaboration among scientists and clinicians will further elucidate the synergistic possibilities among systemic, radiation, and surgical interventions for patients with spinal tumors and will bring many closer to curative therapies.
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Belgioia L, Desideri I, Errico A, Franzese C, Daidone A, Marino L, Fiore M, Borghetti P, Greto D, Fiorentino A. Safety and efficacy of combined radiotherapy, immunotherapy and targeted agents in elderly patients: A literature review. Crit Rev Oncol Hematol 2018; 133:163-170. [PMID: 30661652 DOI: 10.1016/j.critrevonc.2018.11.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 09/11/2018] [Accepted: 11/23/2018] [Indexed: 01/31/2023] Open
Abstract
PURPOSE Aim of the present review is to assess present data about the use of the association of Radiotherapy (RT) and targeted therapy/immunotherapy (TT/IT) in elderly people. DESIGN PubMed database was searched for English literature published up to December 2017 using the keywords "radiotherapy" combined with "bevacizumab", "cetuximab", "trastuzumab", "erlotinib", "gefitinib", "sorafenib", "sunitinib", "vismodegib", "sonidegib", "ipilimumab", "pembrolizumab", "nivolumab". Studies performing RT and TT/IT in people aged >65-years were evaluated focusing on safety, toxicity and efficacy. Studies eligible for inclusion were: case reports, retrospective/prospective studies in which RT and new drugs were used concomitantly or sequentially, focusing on elderly sub-group. RESULTS The systematic search identified 626 records. After exclusion of duplicates, full-text review, cross-referencing and paper that did not respect the inclusion criteria, 81 studies were included in this review. In elderly patients the combination of RT with cetuximab or bevacizumab seems feasible but with higher reported side effects. Patients' age should not limit the association of trastuzumab and RT in HER2 positive breast cancer. The concurrent administration of TKIs and RT appears to be feasible and effective. Regarding the Immune Check Point inhibitors and RT, tolerance seems similar among older and younger people but definitive data are lacking. Instead, the association of RT and vismodegib/sonidegib remains investigational. CONCLUSION TT/IT in association of RT seems to be safe, but in elderly patients data concerning safety and toxicity are limited. Specific clinical trials on this population are encouraged.
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Affiliation(s)
- Liliana Belgioia
- Health Science Department (DISSAL) - University of Genoa and Radiation Oncology Department, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Isacco Desideri
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", Section of Radiation Oncology, University of Florence, Italy
| | - Angelo Errico
- Radiation Oncology Department, Mons. R. Dimiccoli Hospital - ASL BT, Barletta, Italy
| | - Ciro Franzese
- Department of Radiotherapy and Radiosurgery Istituto Clinico Humanitas "Humanitas Cancer Center", Rozzano, Italy
| | - Antonino Daidone
- U.O Radioterapia Oncologica, Ospedale A. Ajello, Mazara del Vallo, Trapani - Radioterapia Oncologica, Centro di Medicina Nucleare, San Gaetano, Bagheria, Palermo, Italy
| | | | - Michele Fiore
- Radiation Oncology, Campus Bio-Medico University, Rome, Italy
| | - Paolo Borghetti
- Radiation Oncology Department University and Spedali Civili, Brescia, Italy
| | - Daniela Greto
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", Section of Radiation Oncology, University of Florence, Italy
| | - Alba Fiorentino
- Radiation Oncology Department, General Regional Hospital "F. Miulli", Acquaviva delle fonti, BA, Italy.
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Buttigliero C, Allis S, Tucci M, Zichi C, Leone G, Di Stefano RF, Ruo Redda MG, Ricardi U, Scagliotti GV, Di Maio M, Filippi AR. Role of radiotherapy in improving activity of immune-modulating drugs in advanced renal cancer: Biological rationale and clinical evidences. Cancer Treat Rev 2018; 69:215-223. [PMID: 30096699 DOI: 10.1016/j.ctrv.2018.07.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 07/17/2018] [Accepted: 07/19/2018] [Indexed: 12/17/2022]
Abstract
In the last few years, immune checkpoint inhibitors have been extensively investigated in renal cell carcinoma and led to remarkable results. Radiation therapy may increase the activity of immune modulating agents through different mechanisms, priming the immune system, recruiting immune cells to the tumor environment, and altering the immunosuppressive effects of the tumor microenvironment. Preclinical studies reported increased loco-regional control when radiation is combined with immune-checkpoint blockade. Moreover, increased systemic disease control has been demonstrated when local radiation is combined with both anti-CTLA-4 and anti-PD-1/PD-L1 inhibitors. Actually, several trials are ongoing testing the activity of radiation therapy in combination with different immune-modulating agents for the treatment of metastatic renal cell carcinoma. The aim of this paper is to focus on the biological rationale of adding radiation therapy to immune-modulating agents in renal cell carcinoma and to review the currently available clinical evidence about the combination of radiotherapy and immunotherapy.
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Affiliation(s)
- Consuelo Buttigliero
- Division of Medical Oncology, San Luigi Gonzaga Hospital, Department of Oncology, University of Turin, Regione Gonzole 10, 10043 Orbassano, Turin, Italy
| | - Simona Allis
- Radiation Oncology, San Luigi Gonzaga Hospital, Department of Oncology, University of Turin, Regione Gonzole 10, 10043 Orbassano, Turin, Italy
| | - Marcello Tucci
- Division of Medical Oncology, San Luigi Gonzaga Hospital, Department of Oncology, University of Turin, Regione Gonzole 10, 10043 Orbassano, Turin, Italy.
| | - Clizia Zichi
- Division of Medical Oncology, San Luigi Gonzaga Hospital, Department of Oncology, University of Turin, Regione Gonzole 10, 10043 Orbassano, Turin, Italy
| | - Gianmarco Leone
- Division of Medical Oncology, San Luigi Gonzaga Hospital, Department of Oncology, University of Turin, Regione Gonzole 10, 10043 Orbassano, Turin, Italy
| | - Rosario Francesco Di Stefano
- Division of Medical Oncology, San Luigi Gonzaga Hospital, Department of Oncology, University of Turin, Regione Gonzole 10, 10043 Orbassano, Turin, Italy
| | - Maria Grazia Ruo Redda
- Radiation Oncology, Ordine Mauriziano Hospital, Department of Oncology, University of Turin, Via Magellano 1, 10028 Turin, Italy
| | - Umberto Ricardi
- Radiation Oncology, Città della Salute e della Scienza di Torino, Department of Oncology, University of Turin, Via Genova 3, 10126 Turin, Italy
| | - Giorgio Vittorio Scagliotti
- Division of Medical Oncology, San Luigi Gonzaga Hospital, Department of Oncology, University of Turin, Regione Gonzole 10, 10043 Orbassano, Turin, Italy
| | - Massimo Di Maio
- Division of Medical Oncology, Ordine Mauriziano Hospital, Department of Oncology, University of Turin, Via Magellano 1, 10028 Turin, Italy
| | - Andrea Riccardo Filippi
- Radiation Oncology, San Luigi Gonzaga Hospital, Department of Oncology, University of Turin, Regione Gonzole 10, 10043 Orbassano, Turin, Italy
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Effectiveness of pazopanib and SBRT in metastatic renal cell carcinoma. World J Urol 2018; 36:1797-1798. [PMID: 29740689 DOI: 10.1007/s00345-018-2323-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 05/02/2018] [Indexed: 10/17/2022] Open
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31
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Psutka SP, Master VA. Role of metastasis-directed treatment in kidney cancer. Cancer 2018; 124:3641-3655. [PMID: 29689599 DOI: 10.1002/cncr.31341] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 02/05/2018] [Accepted: 02/09/2018] [Indexed: 12/12/2022]
Abstract
Despite the rapid elaboration of multiple, novel systemic agents introduced for metastatic renal cell carcinoma (mRCC) in recent years, a durable complete response remains elusive with systemic therapy alone. Definitive treatment of the metastatic deposit remains the sole potentially curative option and is a cornerstone of mRCC therapy, offering potential for both local control and palliation of tumor-related symptoms. In this review, the evidence supporting the definitive treatment of mRCC is examined and summarized, including the use of surgical metastasectomy, thermal ablation, radiotherapy, and other minimally invasive options. Multimodal approaches, including the combination of metastasectomy with novel systemic agents, are discussed. Finally, the authors review considerations for patient selection for this type of therapy and summarize available risk-stratification tools that may help guide shared decision making.
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Affiliation(s)
- Sarah P Psutka
- Division of Urology, John H. Stroger Jr. Hospital of Cook County, Chicago, Illinois.,Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Viraj A Master
- Department of Urology, Winship Cancer Institute, Emory University, Atlanta, Georgia
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32
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Verbiest A, De Meerleer G, Albersen M, Beuselinck B. Non-Surgical Ablative Treatment of Distant Extracranial Metastases for Renal Cell Carcinoma: A Systematic Review. KIDNEY CANCER 2018. [DOI: 10.3233/kca-170023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Annelies Verbiest
- Department of Oncology, Laboratory of Experimental Oncology, KU Leuven, Leuven, Belgium
- Department of General Medical Oncology, University Hospitals Leuven, Leuven Cancer Institute, Leuven, Belgium
| | - Gert De Meerleer
- Department of Radiotherapy, University Hospitals Leuven, Leuven, Belgium
| | - Maarten Albersen
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Benoit Beuselinck
- Department of Oncology, Laboratory of Experimental Oncology, KU Leuven, Leuven, Belgium
- Department of General Medical Oncology, University Hospitals Leuven, Leuven Cancer Institute, Leuven, Belgium
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33
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Barzilai O, Fisher CG, Bilsky MH. State of the Art Treatment of Spinal Metastatic Disease. Neurosurgery 2018; 82:757-769. [DOI: 10.1093/neuros/nyx567] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 10/23/2017] [Indexed: 12/25/2022] Open
Abstract
Abstract
Treatment paradigms for patients with spine metastases have evolved significantly over the past decade. Incorporating stereotactic radiosurgery into these paradigms has been particularly transformative, offering precise delivery of tumoricidal radiation doses with sparing of adjacent tissues. Evidence supports the safety and efficacy of radiosurgery as it currently offers durable local tumor control with low complication rates even for tumors previously considered radioresistant to conventional radiation. The role for surgical intervention remains consistent, but a trend has been observed toward less aggressive, often minimally invasive, techniques. Using modern technologies and improved instrumentation, surgical outcomes continue to improve with reduced morbidity. Additionally, targeted agents such as biologics and checkpoint inhibitors have revolutionized cancer care, improving both local control and patient survivals. These advances have brought forth a need for new prognostication tools and a more critical review of long-term outcomes. The complex nature of current treatment schemes necessitates a multidisciplinary approach including surgeons, medical oncologists, radiation oncologists, interventionalists, and pain specialists. This review recapitulates the current state-of-the-art, evidence-based data on the treatment of spinal metastases, integrating these data into a decision framework, NOMS, which integrates the 4 sentinel decision points in metastatic spine tumors: Neurologic, Oncologic, Mechanical stability, and Systemic disease and medical co-morbidities.
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Affiliation(s)
- Ori Barzilai
- Department of Neurosurgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Charles G Fisher
- Division of Spine, Department of Orthopedics, University of British Columbia, and the Combined Neurosurgical and Orthopedic Spine Program at Vancouver Coastal Health, Vancouver, British Columbia, Canada
| | - Mark H Bilsky
- Department of Neurosurgery, Memorial Sloan-Kettering Cancer Center, New York, New York
- Department of Neurological Surgery, Weill Cornell Medical College, New York, New York
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The Efficacy of Conventionally Fractionated Radiation in the Management of Osseous Metastases from Metastatic Renal Cell Carcinoma. JOURNAL OF ONCOLOGY 2018; 2018:6384253. [PMID: 29552034 PMCID: PMC5818960 DOI: 10.1155/2018/6384253] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 11/18/2017] [Accepted: 12/07/2017] [Indexed: 01/28/2023]
Abstract
Background There is little data regarding the effectiveness of palliative radiation with conventional fractionation for metastatic renal cell carcinoma (RCC), which has been described as radioresistant. We conducted a retrospective analysis of patients with metastatic bony disease from RCC treated with radiation therapy at our institution. Methods Forty patients with histologically confirmed RCC with a total of 53 treatment courses were included. Pain response after radiotherapy was recorded and freedom from progression was generated using posttreatment radiographs. Patient data was analyzed to assess influence on local control. Results Patients had a median age of 63. Median follow-up was 9.3 months. The most common radiation dose was 30 Gy in 10 fractions. Pain control after radiotherapy was achieved in 73.6% of patients. Increasing age was associated with nonresponse at the initial pain assessment post-RT (p = 0.02). In lesions with initial pain response, nonclear cell histology was associated with increased pain recurrence (p = 0.01) and a shorter duration to pain recurrence (p = 0.01). Radiographic control at 1 year was 62%. Conclusions Pain response and control rates for osseous metastatic disease in RCC are comparable to other histologies when treated with conventional fractionation. These appear to be inferior to reported control rates from stereotactic treatments.
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35
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Radiosurgery for Treatment of Renal Cell Metastases to Spine: A Systematic Review of the Literature. World Neurosurg 2018; 109:e502-e509. [DOI: 10.1016/j.wneu.2017.10.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 09/30/2017] [Accepted: 10/03/2017] [Indexed: 12/25/2022]
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36
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Emphasis on Repair, Not Just Avoidance of Injury, Facilitates Prudent Stereotactic Ablative Radiotherapy. Semin Radiat Oncol 2017; 27:378-392. [DOI: 10.1016/j.semradonc.2017.04.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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37
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Miller JA, Balagamwala EH, Berriochoa CA, Angelov L, Suh JH, Benzel EC, Mohammadi AM, Emch T, Magnelli A, Godley A, Qi P, Chao ST. The impact of decompression with instrumentation on local failure following spine stereotactic radiosurgery. J Neurosurg Spine 2017; 27:436-443. [DOI: 10.3171/2017.3.spine161015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVESpine stereotactic radiosurgery (SRS) is a safe and effective treatment for spinal metastases. However, it is unknown whether this highly conformal radiation technique is suitable at instrumented sites given the potential for microscopic disease seeding. The authors hypothesized that spinal decompression with instrumentation is not associated with increased local failure (LF) following SRS.METHODSA 2:1 propensity-matched retrospective cohort study of patients undergoing SRS for spinal metastasis was conducted. Patients with less than 1 month of radiographic follow-up were excluded. Each SRS treatment with spinal decompression and instrumentation was propensity matched to 2 controls without decompression or instrumentation on the basis of demographic, disease-related, dosimetric, and treatment-site characteristics. Standardized differences were used to assess for balance between matched cohorts.The primary outcome was the 12-month cumulative incidence of LF, with death as a competing risk. Lesions demonstrating any in-field progression were considered LFs. Secondary outcomes of interest were post-SRS pain flare, vertebral compression fracture, instrumentation failure, and any Grade ≥ 3 toxicity. Cumulative incidences analysis was used to estimate LF in each cohort, which were compared via Gray’s test. Multivariate competing-risks regression was then used to adjust for prespecified covariates.RESULTSOf 650 candidates for the control group, 166 were propensity matched to 83 patients with instrumentation. Baseline characteristics were well balanced. The median prescription dose was 16 Gy in each cohort. The 12-month cumulative incidence of LF was not statistically significantly different between cohorts (22.8% [instrumentation] vs 15.8% [control], p = 0.25). After adjusting for the prespecified covariates in a multivariate competing-risks model, decompression with instrumentation did not contribute to a greater risk of LF (HR 1.21, 95% CI 0.74–1.98, p = 0.45). The incidences of post-SRS pain flare (11% vs 14%, p = 0.55), vertebral compression fracture (12% vs 22%, p = 0.04), and Grade ≥ 3 toxicity (1% vs 1%, p = 1.00) were not increased at instrumented sites. No instrumentation failures were observed.CONCLUSIONSIn this propensity-matched analysis, LF and toxicity were similar among cohorts, suggesting that decompression with instrumentation does not significantly impact the efficacy or safety of spine SRS. Accordingly, spinal instrumentation may not be a contraindication to SRS. Future studies comparing SRS to conventional radiotherapy at instrumented sites in matched populations are warranted.
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Affiliation(s)
- Jacob A. Miller
- 1Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic
| | | | | | - Lilyana Angelov
- 1Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic
- 3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic
- 4Department of Neurosurgery, Neurological Institute, Cleveland Clinic; and
| | - John H. Suh
- 1Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic
- 3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic
| | - Edward C. Benzel
- 1Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic
- 4Department of Neurosurgery, Neurological Institute, Cleveland Clinic; and
| | - Alireza M. Mohammadi
- 1Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic
- 3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic
- 4Department of Neurosurgery, Neurological Institute, Cleveland Clinic; and
| | - Todd Emch
- 1Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic
- 5Department of Diagnostic Radiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio
| | - Anthony Magnelli
- 2Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic
| | - Andrew Godley
- 2Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic
| | - Peng Qi
- 2Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic
| | - Samuel T. Chao
- 1Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic
- 3Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Taussig Cancer Institute, Cleveland Clinic
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38
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De Wolf K, Rottey S, Vermaelen K, Decaestecker K, Sundahl N, De Lobel L, Goetghebeur E, De Meerleer G, Lumen N, Fonteyne V, De Maeseneer D, Ost P. Combined high dose radiation and pazopanib in metastatic renal cell carcinoma: a phase I dose escalation trial. Radiat Oncol 2017; 12:157. [PMID: 28938918 PMCID: PMC5610443 DOI: 10.1186/s13014-017-0893-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 09/17/2017] [Indexed: 02/07/2023] Open
Abstract
Background The primary objective was to determine maximum tolerated radiation dose in patients with metastatic renal cell carcinoma on pazopanib treatment. Methods Treatment-naïve patients received pazopanib according to standard of care. Stereotactic body radiotherapy (SBRT) was delivered concurrently to the largest metastatic lesion at day 8, 10 and 12. SBRT doses were escalated in 3 dose levels (24 Gy/3, 30 Gy/3 and 36 Gy/3). Dose level was assigned using Time-to-Event Continual Reassessment Method with the target dose-limiting toxicity rate set to 0.25. Results Thirteen patients were included. One patient experienced dose limiting toxicity (DLT) at dose level 3 (grade 4 hypoglycemia). Maximum tolerated dose was not reached with a recommended dose of 36 Gy/3 having a probability of DLT of 11%. One-year local control was 83% (95% confidence interval 61–100) and 1-year progression-free survival was 28% (95% confidence interval 1–55). Conclusions SBRT in combination with pazopanib is well tolerated with good local control and response rates outside the radiation field. Trial registration This trial was retrospectively registered on clinicaltrials.gov(NCT02334709) on January 6th, 2015. Electronic supplementary material The online version of this article (10.1186/s13014-017-0893-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Katrien De Wolf
- Department of Radiation-Oncology, University Hospital Ghent, De Pintelaan 185, 9000, Ghent, Belgium.,Immuno-Oncology Network Ghent (ION Ghent), Ghent, Belgium
| | - Sylvie Rottey
- Department of Medical Oncology, University Hospital Ghent, De Pintelaan 185, 9000, Ghent, Belgium.,Cancer Research Institute Ghent (CRIG Ghent), Ghent, Belgium
| | - Karim Vermaelen
- Immuno-Oncology Network Ghent (ION Ghent), Ghent, Belgium.,Cancer Research Institute Ghent (CRIG Ghent), Ghent, Belgium.,Department of Internal Medicine, University Hospital Ghent, De Pintelaan 185, 9000, Ghent, Belgium
| | - Karel Decaestecker
- Department of Urology, University Hospital Ghent, De Pintelaan 185, 9000, Ghent, Belgium
| | - Nora Sundahl
- Department of Radiation-Oncology, University Hospital Ghent, De Pintelaan 185, 9000, Ghent, Belgium.,Immuno-Oncology Network Ghent (ION Ghent), Ghent, Belgium
| | - Lizzy De Lobel
- Department of Applied Mathematics, Computer Science and Statistics Ghent University, Ghent, Belgium
| | - Els Goetghebeur
- Department of Applied Mathematics, Computer Science and Statistics Ghent University, Ghent, Belgium
| | - Gert De Meerleer
- Department of Radiation-Oncology, University Hospital Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Nicolaas Lumen
- Cancer Research Institute Ghent (CRIG Ghent), Ghent, Belgium.,Department of Urology, University Hospital Ghent, De Pintelaan 185, 9000, Ghent, Belgium
| | - Valérie Fonteyne
- Department of Radiation-Oncology, University Hospital Ghent, De Pintelaan 185, 9000, Ghent, Belgium.,Cancer Research Institute Ghent (CRIG Ghent), Ghent, Belgium
| | - Daan De Maeseneer
- Department of Medical Oncology, University Hospital Ghent, De Pintelaan 185, 9000, Ghent, Belgium
| | - Piet Ost
- Department of Radiation-Oncology, University Hospital Ghent, De Pintelaan 185, 9000, Ghent, Belgium. .,Immuno-Oncology Network Ghent (ION Ghent), Ghent, Belgium. .,Cancer Research Institute Ghent (CRIG Ghent), Ghent, Belgium.
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Barzilai O, Laufer I, Yamada Y, Higginson DS, Schmitt AM, Lis E, Bilsky MH. Integrating Evidence-Based Medicine for Treatment of Spinal Metastases Into a Decision Framework: Neurologic, Oncologic, Mechanicals Stability, and Systemic Disease. J Clin Oncol 2017. [PMID: 28640703 DOI: 10.1200/jco.2017.72.7362] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Patients with cancer are frequently affected by spinal metastases. Treatment is palliative, with the principle goals of pain relief, preservation of neurologic function, and improvement in quality of life. In the past decade, we have witnessed a dramatic change in the treatment paradigms due to the development of improved surgical strategies and systemic and radiation therapy. The most important change to these paradigms has been the integration of spinal stereotactic radiosurgery (SSRS), allowing delivery of tumoricidal radiation doses with sparing of nearby organs at risk. High-dose SSRS provides durable tumor control when used either as definitive therapy or as a postoperative adjuvant therapy. Integration of SSRS has fundamentally changed the indications for and type of surgery performed for metastatic spine tumors. Although the role for surgical intervention is well established, a clear trend toward less-aggressive, often minimally invasive techniques has been observed. Targeted therapies are also rapidly changing the way cancer is being treated and have demonstrated improved survival for a number of malignancies. As these treatment decisions become more complex, a multidisciplinary approach including medical oncologists, radiation oncologists, surgeons, interventionalists, and pain specialists is required. In this article, the current evidence affecting the treatment of spinal metastases is integrated into a decision framework that considers four principal assessments of a patient's spine disease: NOMS (neurologic, oncologic, mechanical instability, and systemic disease).
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Affiliation(s)
- Ori Barzilai
- Ori Barzilai, Ilya Laufer, Yoshiya Yamada, Daniel S. Higginson, Adam M. Schmitt, Eric Lis, and Mark H. Bilsky, Memorial Sloan Kettering Cancer Center; Ilya Laufer and Mark H. Bilsky, Weill Cornell Medical College, New York, NY
| | - Ilya Laufer
- Ori Barzilai, Ilya Laufer, Yoshiya Yamada, Daniel S. Higginson, Adam M. Schmitt, Eric Lis, and Mark H. Bilsky, Memorial Sloan Kettering Cancer Center; Ilya Laufer and Mark H. Bilsky, Weill Cornell Medical College, New York, NY
| | - Yoshiya Yamada
- Ori Barzilai, Ilya Laufer, Yoshiya Yamada, Daniel S. Higginson, Adam M. Schmitt, Eric Lis, and Mark H. Bilsky, Memorial Sloan Kettering Cancer Center; Ilya Laufer and Mark H. Bilsky, Weill Cornell Medical College, New York, NY
| | - Daniel S Higginson
- Ori Barzilai, Ilya Laufer, Yoshiya Yamada, Daniel S. Higginson, Adam M. Schmitt, Eric Lis, and Mark H. Bilsky, Memorial Sloan Kettering Cancer Center; Ilya Laufer and Mark H. Bilsky, Weill Cornell Medical College, New York, NY
| | - Adam M Schmitt
- Ori Barzilai, Ilya Laufer, Yoshiya Yamada, Daniel S. Higginson, Adam M. Schmitt, Eric Lis, and Mark H. Bilsky, Memorial Sloan Kettering Cancer Center; Ilya Laufer and Mark H. Bilsky, Weill Cornell Medical College, New York, NY
| | - Eric Lis
- Ori Barzilai, Ilya Laufer, Yoshiya Yamada, Daniel S. Higginson, Adam M. Schmitt, Eric Lis, and Mark H. Bilsky, Memorial Sloan Kettering Cancer Center; Ilya Laufer and Mark H. Bilsky, Weill Cornell Medical College, New York, NY
| | - Mark H Bilsky
- Ori Barzilai, Ilya Laufer, Yoshiya Yamada, Daniel S. Higginson, Adam M. Schmitt, Eric Lis, and Mark H. Bilsky, Memorial Sloan Kettering Cancer Center; Ilya Laufer and Mark H. Bilsky, Weill Cornell Medical College, New York, NY
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40
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Siva S, Kothari G, Muacevic A, Louie AV, Slotman BJ, Teh BS, Lo SS. Radiotherapy for renal cell carcinoma: renaissance of an overlooked approach. Nat Rev Urol 2017. [PMID: 28631740 DOI: 10.1038/nrurol.2017.87] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Conventional radiotherapy previously had a limited role in the definitive treatment of renal cell carcinoma (RCC), owing to the disappointing outcomes of several trials and the perceived radioresistance of this type of cancer. In this context, radiotherapy has been relegated largely to the palliation of symptoms in patients with metastatic disease, with variable rates of response. Following the availability of newer technologies that enable safe delivery of high-dose radiotherapy, stereotactic ablative radiotherapy (SABR) has become increasingly used in patients with RCC. Preclinical evidence demonstrates that RCC cells are sensitive to ablative doses of radiotherapy (≥8-10 Gy). Trials in the setting of intracranial and extracranial oligometastases, as well as primary RCC, have demonstrated excellent tumour control using this approach. Additionally, an awareness of the capacity of high-dose radiation to stimulate antitumour immunity has resulted in novel combinations of SABR with immunotherapies. Here we describe the historical application of conventional radiotherapy, the current biological understanding of the effects of radiation, and the clinical evidence supporting the use of ablative radiotherapy in RCC. We also explore emerging opportunities to combine systemic targeted agents or immunotherapies with radiation. Radiotherapy, although once an overlooked approach, is moving towards the forefront of RCC treatment.
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Affiliation(s)
- Shankar Siva
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Grattan Street, Melbourne, Victoria 3000, Australia
| | - Gargi Kothari
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Grattan Street, Melbourne, Victoria 3000, Australia
| | - Alexander Muacevic
- European Cyberknife Center, Max-Lebsche-Platz 31, Munich D-81377, Germany
| | - Alexander V Louie
- Department of Radiation Oncology, London Health Sciences Centre, 800 Commissioners Road East, PO Box 5010, London, Ontario N6A 5W9, Canada
| | - Ben J Slotman
- Radiation Oncology, VU University Medical Center, De Boelelaan, PO Box 7057, Amsterdam, 1007 MB, Netherlands
| | - Bin S Teh
- Department of Radiation Oncology, Houston Methodist Hospital, 6565 Fannin, Ste#DB1-077, Houston, Texas 77030, USA
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356043, Seattle, Washington 98195-6043, USA
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41
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The risk of radiation necrosis following stereotactic radiosurgery with concurrent systemic therapies. J Neurooncol 2017; 133:357-368. [DOI: 10.1007/s11060-017-2442-8] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 04/15/2017] [Indexed: 12/19/2022]
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42
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Miller JA, Kotecha R, Ahluwalia MS, Mohammadi AM, Chao ST, Barnett GH, Murphy ES, Vogelbaum MA, Angelov L, Peereboom DM, Suh JH. Overall survival and the response to radiotherapy among molecular subtypes of breast cancer brain metastases treated with targeted therapies. Cancer 2017; 123:2283-2293. [PMID: 28192598 DOI: 10.1002/cncr.30616] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 12/08/2016] [Accepted: 01/18/2017] [Indexed: 11/12/2022]
Abstract
BACKGROUND The current study was conducted to investigate survival and the response to radiotherapy among patients with molecular subtypes of breast cancer brain metastases treated with or without targeted therapies. METHODS Patients diagnosed with breast cancer brain metastases at a single tertiary care institution were included. The primary outcome was overall survival, whereas secondary outcomes included the cumulative incidences of distant intracranial failure, local failure, and radiation necrosis. Competing risks regression was used to model secondary outcomes. RESULTS Within the study period, 547 patients presented with 3224 brain metastases and met inclusion criteria. Among patients with human epidermal growth factor receptor 2 (HER2)-amplified disease, 80% received HER2 antibodies and 38% received HER2/epidermal growth factor receptor tyrosine kinase inhibitors (TKIs). The median survival was significantly shorter in the basal cohort (8.4 months), and progressively increased in the luminal A (12.3 months), HER2-positive (15.4 months), and luminal B (18.8 months) cohorts (P<.001). Among patients with HER2-amplified disease, the median survival was extended with the use of both HER2 antibodies (17.9 months vs 15.1 months; P = .04) and TKIs (21.1 months vs 15.4 months; P = .03). The 12-month cumulative incidences of local failure among molecular subtypes were 6.0% in the luminal A cohort, 10.3% in the luminal B cohort, 15.4% in the HER2-positive cohort, and 9.9% in the basal cohort (P = .01). Concurrent HER2/epidermal growth factor receptor TKIs with stereotactic radiosurgery significantly decreased the 12-month cumulative incidence of local failure from 15.1% to 5.7% (P<.001). CONCLUSIONS Molecular subtypes appear to be prognostic for survival and predictive of the response to radiotherapy. TKIs were found to improve survival and local control, and may decrease the rate of distant failure. To preserve neurocognition, these results support a paradigm of upfront radiosurgery and HER2-directed therapy in the HER2-amplified population, reserving whole-brain radiotherapy for salvage. Cancer 2017;123:2283-2293. © 2017 American Cancer Society.
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Affiliation(s)
- Jacob A Miller
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio
| | - Rupesh Kotecha
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Manmeet S Ahluwalia
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Department of Hematology/Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alireza M Mohammadi
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Samuel T Chao
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Gene H Barnett
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Erin S Murphy
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Michael A Vogelbaum
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lilyana Angelov
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - David M Peereboom
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio.,Department of Hematology/Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - John H Suh
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio.,Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.,Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
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