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Hernando-Requejo O, Olombrada MVT, Bravo IA, Moreno LA, López-Campos F, Gonzalez ML, Martín MM, Macías VM, De la Pinta C. Current landscape of gastrointestinal radiation oncology in Spain: a multicenter real-life survey and comparison with key clinical guidelines. Rep Pract Oncol Radiother 2024; 29:340-347. [PMID: 39144273 PMCID: PMC11321793 DOI: 10.5603/rpor.101096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 05/31/2024] [Indexed: 08/16/2024] Open
Abstract
Background The GI Tumors Workgroup, a division of the Spanish Society of Radiation Therapy, conducted a survey in December 2020 to assess the adherence of radiation oncologists in Spain to international guidelines for gastrointestinal tumors. Materials and methods Using Google Forms, we designed a survey covering treatments for esophageal, gastric, pancreatic, and rectal cancers. Results In esophageal cancer treatment, neoadjuvant chemoradiation was the standard in 76.7% of institutions. Radiation doses range from 41.1 to 50.4 Gy in conventional fractionation. Planning positron emission tomography-computed tomography (PET-CT) was performed in 83.3% of centers, and intensity-modulated radiation therapy/volumetric-arc radiation therapy (IMRT/VMAT) was the preferred technique in 86.7% of institutions. For gastric cancer, 71.4% followed perioperative chemotherapy guidelines. In the case of adjuvant radiotherapy, the majority prescribed 45-50.4 Gy, and 82.1% used IMRT/VMAT for treatment. For pancreas cancer, neoadjuvant chemotherapy followed by surgery in borderline resectable tumors and induction chemotherapy followed by radical radiotherapy for non-resectable tumors were the most frequent approaches. IMRT/VMAT was the primary technique. Locally advanced rectal cancer treatment is mainly based on neoadjuvant radiotherapy in all institutions. The preferred radiation doses typically range from 45 to 50 Gy in conventional fractionation. IMRT/VMAT was standard in most Institutions. Conclusions Spain's radiotherapy practices among respondents generally align with international guidelines for GI tumors highlighting Spain's commitment to evidence-based medical practice.
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Affiliation(s)
| | | | - Irene Alda Bravo
- Radiation Oncology Department, 12 de Octubre University Hospital, Madrid, Spain
| | - Leire Arbea Moreno
- Radiation Oncology Department, Clínica Universidad de Navarra, Pamplona, Spain
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Wang K, Karalis JD, Elamir A, Bifolco A, Wachsmann M, Capretti G, Spaggiari P, Enrico S, Balasubramanian K, Fatimah N, Pontecorvi G, Nebbia M, Yopp A, Kaza R, Pedrosa I, Zeh H, Polanco P, Zerbi A, Wang J, Aguilera T, Ligorio M. Delta Radiomic Features Predict Resection Margin Status and Overall Survival in Neoadjuvant-Treated Pancreatic Cancer Patients. Ann Surg Oncol 2024; 31:2608-2620. [PMID: 38151623 PMCID: PMC10908610 DOI: 10.1245/s10434-023-14805-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 12/06/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Neoadjuvant therapy (NAT) emerged as the standard of care for patients with pancreatic ductal adenocarcinoma (PDAC) who undergo surgery; however, surgery is morbid, and tools to predict resection margin status (RMS) and prognosis in the preoperative setting are needed. Radiomic models, specifically delta radiomic features (DRFs), may provide insight into treatment dynamics to improve preoperative predictions. METHODS We retrospectively collected clinical, pathological, and surgical data (patients with resectable, borderline, locally advanced, and metastatic disease), and pre/post-NAT contrast-enhanced computed tomography (CT) scans from PDAC patients at the University of Texas Southwestern Medical Center (UTSW; discovery) and Humanitas Hospital (validation cohort). Gross tumor volume was contoured from CT scans, and 257 radiomics features were extracted. DRFs were calculated by direct subtraction of pre/post-NAT radiomic features. Cox proportional models and binary prediction models, including/excluding clinical variables, were constructed to predict overall survival (OS), disease-free survival (DFS), and RMS. RESULTS The discovery and validation cohorts comprised 58 and 31 patients, respectively. Both cohorts had similar clinical characteristics, apart from differences in NAT (FOLFIRINOX vs. gemcitabine/nab-paclitaxel; p < 0.05) and type of surgery resections (pancreatoduodenectomy, distal or total pancreatectomy; p < 0.05). The model that combined clinical variables (pre-NAT carbohydrate antigen (CA) 19-9, the change in CA19-9 after NAT (∆CA19-9), and resectability status) and DRFs outperformed the clinical feature-based models and other radiomics feature-based models in predicting OS (UTSW: 0.73; Humanitas: 0.66), DFS (UTSW: 0.75; Humanitas: 0.64), and RMS (UTSW 0.73; Humanitas: 0.69). CONCLUSIONS Our externally validated, predictive/prognostic delta-radiomics models, which incorporate clinical variables, show promise in predicting the risk of predicting RMS in NAT-treated PDAC patients and their OS or DFS.
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Affiliation(s)
- Kai Wang
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - John D Karalis
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ahmed Elamir
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Alessandro Bifolco
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Megan Wachsmann
- Department of Pathology, Veterans Affairs North Texas Health Care System, Dallas, TX, USA
| | - Giovanni Capretti
- Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Paola Spaggiari
- Department of Pathology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Sebastian Enrico
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Nafeesah Fatimah
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Giada Pontecorvi
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Martina Nebbia
- Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Adam Yopp
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ravi Kaza
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ivan Pedrosa
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Herbert Zeh
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Patricio Polanco
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Alessandro Zerbi
- Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Jing Wang
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Todd Aguilera
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Matteo Ligorio
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Tojjari A, Yu J, Saeed A. Immunotherapy and Radiation Therapy Combinatorial Approaches in Hepatocellular Carcinoma. Cancers (Basel) 2024; 16:1058. [PMID: 38473415 DOI: 10.3390/cancers16051058] [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: 01/27/2024] [Revised: 02/29/2024] [Accepted: 03/04/2024] [Indexed: 03/14/2024] Open
Abstract
Hepatocellular carcinoma (HCC), a prevalent and often fatal liver cancer, presents significant treatment challenges, especially in its advanced stages. This article delves into the promising approach of combining immunotherapy, particularly immune checkpoint inhibitors, with radiation therapy, a cornerstone of HCC management. Our review synthesizes current preclinical and clinical research, highlighting the potential synergistic effects of this combinational treatment. Emerging evidence suggests that this synergy enhances tumor control and improves patient survival rates. The combination leverages the localized, tumor-targeting ability of radiation therapy and the systemic, immune-boosting effects of immunotherapy, potentially overcoming the limitations inherent in each treatment modality when used separately. This integrative approach is especially promising in addressing the complex tumor microenvironment of HCC. However, the treatment landscape is nuanced, with challenges such as patient-specific response variability and potential resistance to therapies. Future research directions should focus on refining these combination strategies, tailoring them to individual patient profiles, and understanding the underlying mechanisms that govern the interaction between immunotherapy and radiation therapy. Such advancements could significantly improve HCC management, setting new standards for patient care and treatment efficacy.
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Affiliation(s)
- Alireza Tojjari
- Division of Hematology & Oncology, Department of Medicine, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA 15232, USA
| | - James Yu
- Division of Hematology and Medical Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Anwaar Saeed
- Division of Hematology & Oncology, Department of Medicine, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA 15232, USA
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Daamen LA, Parikh PJ, Hall WA. The Use of MR-Guided Radiation Therapy for Pancreatic Cancer. Semin Radiat Oncol 2024; 34:23-35. [PMID: 38105090 DOI: 10.1016/j.semradonc.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
The introduction of online adaptive magnetic resonance (MR)-guided radiation therapy (RT) has enabled safe treatment of pancreatic cancer with ablative doses. The aim of this review is to provide a comprehensive overview of the current literature on the use and clinical outcomes of MR-guided RT for treatment of pancreatic cancer. Relevant outcomes included toxicity, tumor response, survival and quality of life. The results of these studies support further investigation of the effectiveness of ablative MR-guided SBRT as a low-toxic, minimally-invasive therapy for localized pancreatic cancer in prospective clinical trials.
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Affiliation(s)
- Lois A Daamen
- Imaging & Oncology Division, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Parag J Parikh
- Department of Radiation Oncology, Henry Ford Medical Center, Henry Ford Health System, Detroit, MI
| | - William A Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI.
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Lu Q, Liang Y, Tian S, Jin J, Zhao Y, Fan H. Radiation-Induced Intestinal Injury: Injury Mechanism and Potential Treatment Strategies. TOXICS 2023; 11:1011. [PMID: 38133412 PMCID: PMC10747544 DOI: 10.3390/toxics11121011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/01/2023] [Accepted: 12/08/2023] [Indexed: 12/23/2023]
Abstract
Radiation-induced intestinal injury (RIII) is one of the most common intestinal complications caused by radiotherapy for pelvic and abdominal tumors and it seriously affects the quality of life of patients. However, the treatment of acute RIII is essentially symptomatic and nutritional support treatment and an ideal means of prevention and treatment is lacking. Researchers have conducted studies at the cellular and animal levels and found that some chemical or biological agents have good therapeutic effects on RIII and may be used as potential candidates for clinical treatment. This article reviews the injury mechanism and potential treatment strategies based on cellular and animal experiments to provide new ideas for the diagnosis and treatment of RIII in clinical settings.
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Affiliation(s)
- Qianying Lu
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin 300072, China; (Q.L.); (Y.L.); (S.T.); (J.J.)
- Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin 300072, China
| | - Yangfan Liang
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin 300072, China; (Q.L.); (Y.L.); (S.T.); (J.J.)
- Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin 300072, China
| | - Sijia Tian
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin 300072, China; (Q.L.); (Y.L.); (S.T.); (J.J.)
- Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin 300072, China
| | - Jie Jin
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin 300072, China; (Q.L.); (Y.L.); (S.T.); (J.J.)
- Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin 300072, China
| | - Yanmei Zhao
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin 300072, China; (Q.L.); (Y.L.); (S.T.); (J.J.)
- Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin 300072, China
| | - Haojun Fan
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin 300072, China; (Q.L.); (Y.L.); (S.T.); (J.J.)
- Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin 300072, China
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Arcelli A, Tarantino G, Cellini F, Buwenge M, Macchia G, Bertini F, Guido A, Deodato F, Cilla S, Scotti V, Rosetto ME, Djan I, Parisi S, Mattiucci GC, Fiore M, Bonomo P, Belgioia L, Niespolo RM, Gabriele P, Di Marco M, Simoni N, Ma J, Strigari L, Mazzarotto R, Morganti AG. Comparative Effectiveness of Chemotherapy Alone Versus Radiotherapy-Based Regimens in Locally Advanced Pancreatic Cancer: A Real-World Multicenter Analysis (PAULA-1). Curr Oncol 2023; 30:5690-5703. [PMID: 37366910 DOI: 10.3390/curroncol30060427] [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: 04/05/2023] [Revised: 05/30/2023] [Accepted: 06/04/2023] [Indexed: 06/28/2023] Open
Abstract
Different options for locally advanced pancreatic cancer (LAPC) are available based on international guidelines: chemotherapy (CHT), chemoradiation (CRT), and stereotactic body radiotherapy (SBRT). However, the role of radiotherapy is debated in LAPC. We retrospectively compared CHT, CRT, and SBRT ± CHT in a real-world setting in terms of overall survival (OS), local control (LC), and distant metastasis-free survival (DMFS). LAPC patients from a multicentric retrospective database were included (2005-2018). Survival curves were calculated using the Kaplan-Meier method. Multivariable Cox analysis was performed to identify predictors of LC, OS, and DMFS. Of the 419 patients included, 71.1% were treated with CRT, 15.5% with CHT, and 13.4% with SBRT. Multivariable analysis showed higher LC rates for CRT (HR: 0.56, 95%CI 0.34-0.92, p = 0.022) or SBRT (HR: 0.27, 95%CI 0.13-0.54, p < 0.001), compared to CHT. CRT (HR: 0.44, 95%CI 0.28-0.70, p < 0.001) and SBRT (HR: 0.40, 95%CI 0.22-0.74, p = 0.003) were predictors of prolonged OS with respect to CHT. No significant differences were recorded in terms of DMFS. In selected patients, the addition of radiotherapy to CHT is still an option to be considered. In patients referred for radiotherapy, CRT can be replaced by SBRT considering its duration, higher LC rate, and OS rate, which are at least comparable to that of CRT.
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Affiliation(s)
- Alessandra Arcelli
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Giuseppe Tarantino
- Dana Farber Cancer Institute, Harvard Medical School, Boston, MA 02215, USA
| | - Francesco Cellini
- Radioterapia Oncologica ed Ematologia, Dipartimento Universitario Diagnostica per Immagini, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Radioterapia Oncologica ed Ematologia, Dipartimento di Diagnostica per Immagini, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, 00168 Rome, Italy
| | - Milly Buwenge
- Radiation Oncology, Department of Medical and Surgical Sciences-DIMEC, University of Bologna, 40138 Bologna, Italy
| | - Gabriella Macchia
- Radiation Oncology Unit, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, 86100 Campobasso, Italy
| | - Federica Bertini
- Radiation Oncology Department, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, 33081 Aviano, Italy
| | - Alessandra Guido
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Francesco Deodato
- Radioterapia Oncologica ed Ematologia, Dipartimento Universitario Diagnostica per Immagini, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Radiation Oncology Unit, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, 86100 Campobasso, Italy
| | - Savino Cilla
- Medical Physics Unit, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, 86100 Campobasso, Italy
| | | | | | - Igor Djan
- Institute of Oncology Vojvodina, Sremska Kamenica, Medical Faculty, University of Novi Sad, 21204 Novi Sad, Serbia
| | - Salvatore Parisi
- Radiotherapy Unit, Ospedale Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy
| | - Gian Carlo Mattiucci
- Radioterapia Oncologica ed Ematologia, Dipartimento Universitario Diagnostica per Immagini, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Radiation Oncology, Mater Olbia Hospital, 07026 Olbia, Italy
| | - Michele Fiore
- Research Unit of Radiation Oncology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, 00128 Rome, Italy
- Operative Research Unit of Radiation Oncology, Fondazione Policlinico Campus Bio-Medico di Roma, 00128 Rome, Italy
| | - Pierluigi Bonomo
- Radiation Oncology, Azienda Ospedaliero Universitaria Careggi, 50134 Florence, Italy
| | - Liliana Belgioia
- Department of Radiotherapy, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy
- Health Science Departmente (DISSAL), University of Genoa, 16132 Genova, Italy
| | - Rita Marina Niespolo
- Radiation Oncology, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy
| | - Pietro Gabriele
- Department of Radiotherapy, Fondazione del Piemonte per l'Oncologia (FPO), IRCCS Candiolo, 10060 Candiolo, Italy
| | - Mariacristina Di Marco
- Oncology Unit, Department of Medical and Surgical Sciences-DIMEC, University of Bologna, S. Orsola-Malpighi Hospital, 40138 Bologna, Italy
| | - Nicola Simoni
- Radiotherapy Unit, Azienda Ospedaliera Universitaria, 43126 Parma, Italy
| | - Johnny Ma
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Radiation Oncology, Department of Medical and Surgical Sciences-DIMEC, University of Bologna, 40138 Bologna, Italy
| | - Lidia Strigari
- Department of Medical Physics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | | | - Alessio Giuseppe Morganti
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Radiation Oncology, Department of Medical and Surgical Sciences-DIMEC, University of Bologna, 40138 Bologna, Italy
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Liu X, Tao Y, Yang B, Pang T, Yu L, Li W, Feng S, Liu R, Li J, Liu Z, Qiu J. A novel X-Ray and γ-Ray combination strategy for potential dose escalation in patients with locally advanced pancreatic cancer. Med Phys 2023; 50:1855-1864. [PMID: 36458937 DOI: 10.1002/mp.16142] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 11/16/2022] [Accepted: 11/21/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Treatment of locally advanced pancreatic cancer (LAPC) has long been calling for advances in technology of radiotherapy. Patients who received radiotherapy still had high risks of local recurrence, while suffering from gastrointestinal side effects. Based on the inherent characteristics of the x-ray and γ-Ray radiation techniques, here we proposed and investigated an unexplored radiation therapy. PURPOSE To investigate the potential clinical benefit of a novel x-ray and γ-Ray combination radiation technique in patients with LAPC. METHODS Retrospective intensity-modulated radiotherapy (IMRT) treatment plans of 10 LAPC patients were randomly selected to compare with dual-modality plans. The prescribed dose to PGTV was 60.2 Gy. The PGTV dose was further escalated in dual-modality plan while maintaining clinically tolerable dose to organs at risk (OARs). Dosimetric comparisons were made and analyzed for three treatment plans (tomotherapy, standard dual-modality plan, escalated dual-modality plan) to assess the ability to increase dose to target volume while minimizing dose in adjacent OARs. Finally, radiobiological models were utilized for comparison. RESULTS All strategies resulted in dosimetrically acceptable plans. Dual-modality plans were present with similar conformity index (CI) and significantly lower gradient index (GI) compared with tomotherapy (3.64 ± 0.37 vs. 4.14 ± 0.61, p = 0.002; 3.64 ± 0.42 vs. 4.14 ± 0.61, p = 0.003). Dmean of PGTV (65.46 ± 3.13 vs. 61.56 ± 1.00, p = 0.009; 77.98 ± 5.86 vs. 61.56 ± 1.00, p < 0.001) and PCTV (55.04 ± 2.14 vs. 53.93 ± 1.67, p = 0.016; 58.24 ± 3.24 vs. 53.93 ± 1.67, p = 0.001) were significantly higher, while Dmean of the stomach was reduced in both dual-modality plans (17.98 ± 10.23 vs. 19.34 ± 9.75, p = 0.024; 17.62 ± 9.92 vs. 19.34 ± 9.75, p = 0.040). The lower V30Gy in the liver (4.83 ± 5.87 vs. 6.23 ± 6.68, p = 0.015; 4.90 ± 5.93 vs. 6.23 ± 6.68, p = 0.016) and lower V45Gy of the small intestine (3.35 ± 3.30 vs. 4.06 ± 3.87, p = 0.052) were found in dual-modality plans. Meanwhile, radiobiological models demonstrated higher probability of tumor control (29.27% ± 9.61% vs. 18.34% ± 4.70%, p < 0.001; 44.67% ± 18.16% vs. 18.34% ± 4.70%, p = 0.001) and lower probability of small intestine complication (2.16% ± 2.30% vs. 1.25% ± 2.72%, p = 0.048) in favor of dual-modality strategy. CONCLUSIONS A novel dual-modality strategy of x-ray and γ-Ray combination radiation appears reliable for target dose escalation and normal tissue dose reduction. This strategy might be beneficial for local tumor control and the protection of normal organs in patients with LAPC.
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Affiliation(s)
- Xia Liu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yinjie Tao
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Yang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tingtian Pang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lang Yu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenbo Li
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Siqi Feng
- Our United Corporation, Xi'an, Shaanxi, China
| | - Renqing Liu
- Our United Corporation, Xi'an, Shaanxi, China
| | - Jinsheng Li
- Our United Corporation, Xi'an, Shaanxi, China
| | - Zhikai Liu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jie Qiu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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8
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Rhee DJ, Beddar S, Jaoude JA, Sawakuchi G, Martin R, Perles L, Yu C, He Y, Court LE, Ludmir EB, Koong AC, Das P, Koay EJ, Taniguichi C, Niedzielski JS. Dose Escalation for Pancreas SBRT: Potential and Limitations of using Daily Online Adaptive Radiation Therapy and an Iterative Isotoxicity Automated Planning Approach. Adv Radiat Oncol 2023; 8:101164. [PMID: 36798731 PMCID: PMC9926193 DOI: 10.1016/j.adro.2022.101164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 12/23/2022] [Indexed: 02/05/2023] Open
Abstract
Purpose To determine the dosimetric limitations of daily online adaptive pancreas stereotactic body radiation treatment by using an automated dose escalation approach. Methods and Materials We collected 108 planning and daily computed tomography (CT) scans from 18 patients (18 patients × 6 CT scans) who received 5-fraction pancreas stereotactic body radiation treatment at MD Anderson Cancer Center. Dose metrics from the original non-dose-escalated clinical plan (non-DE), the dose-escalated plan created on the original planning CT (DE-ORI), and the dose-escalated plan created on daily adaptive radiation therapy CT (DE-ART) were analyzed. We developed a dose-escalation planning algorithm within the radiation treatment planning system to automate the dose-escalation planning process for efficiency and consistency. In this algorithm, the prescription dose of the dose-escalation plan was escalated before violating any organ-at-risk (OAR) dose constraint. Dose metrics for 3 targets (gross target volume [GTV], tumor vessel interface [TVI], and dose-escalated planning target volume [DE-PTV]) and 9 OARs (duodenum, large bowel, small bowel, stomach, spinal cord, kidneys, liver, and skin) for the 3 plans were compared. Furthermore, we evaluated the effectiveness of the online adaptive dose-escalation planning process by quantifying the effect of the interfractional dose distribution variations among the DE-ART plans. Results The median D95% dose to the GTV/TVI/DE-PTV was 33.1/36.2/32.4 Gy, 48.5/50.9/40.4 Gy, and 53.7/58.2/44.8 Gy for non-DE, DE-ORI, and DE-ART, respectively. Most OAR dose constraints were not violated for the non-DE and DE-ART plans, while OAR constraints were violated for the majority of the DE-ORI patients due to interfractional motion and lack of adaptation. The maximum difference per fraction in D95%, due to interfractional motion, was 2.5 ± 2.7 Gy, 3.0 ± 2.9 Gy, and 2.0 ± 1.8 Gy for the TVI, GTV, and DE-PTV, respectively. Conclusions Most patients require daily adaptation of the radiation planning process to maximally escalate delivered dose to the pancreatic tumor without exceeding OAR constraints. Using our automated approach, patients can receive higher target dose than standard of care without violating OAR constraints.
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Affiliation(s)
- Dong Joo Rhee
- Department of Radiation Physics, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sam Beddar
- Department of Radiation Physics, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph Abi Jaoude
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gabriel Sawakuchi
- Department of Radiation Physics, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rachael Martin
- Department of Radiation Physics, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Luis Perles
- Department of Radiation Physics, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cenji Yu
- Department of Radiation Physics, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- The University of Texas Graduate School of Biomedical Sciences at Houston, Houston, TX, USA
| | - Yulun He
- Department of Radiation Physics, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- The University of Texas Graduate School of Biomedical Sciences at Houston, Houston, TX, USA
| | - Laurence E. Court
- Department of Radiation Physics, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ethan B. Ludmir
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Albert C. Koong
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eugene J. Koay
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cullen Taniguichi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joshua S. Niedzielski
- Department of Radiation Physics, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Corresponding author: Joshua S. Niedzielski, PhD
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9
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Benkhaled S, Peters C, Jullian N, Arsenijevic T, Navez J, Van Gestel D, Moretti L, Van Laethem JL, Bouchart C. Combination, Modulation and Interplay of Modern Radiotherapy with the Tumor Microenvironment and Targeted Therapies in Pancreatic Cancer: Which Candidates to Boost Radiotherapy? Cancers (Basel) 2023; 15:cancers15030768. [PMID: 36765726 PMCID: PMC9913158 DOI: 10.3390/cancers15030768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/20/2023] [Accepted: 01/22/2023] [Indexed: 01/28/2023] Open
Abstract
Pancreatic ductal adenocarcinoma cancer (PDAC) is a highly diverse disease with low tumor immunogenicity. PDAC is also one of the deadliest solid tumor and will remain a common cause of cancer death in the future. Treatment options are limited, and tumors frequently develop resistance to current treatment modalities. Since PDAC patients do not respond well to immune checkpoint inhibitors (ICIs), novel methods for overcoming resistance are being explored. Compared to other solid tumors, the PDAC's tumor microenvironment (TME) is unique and complex and prevents systemic agents from effectively penetrating and killing tumor cells. Radiotherapy (RT) has the potential to modulate the TME (e.g., by exposing tumor-specific antigens, recruiting, and infiltrating immune cells) and, therefore, enhance the effectiveness of targeted systemic therapies. Interestingly, combining ICI with RT and/or chemotherapy has yielded promising preclinical results which were not successful when translated into clinical trials. In this context, current standards of care need to be challenged and transformed with modern treatment techniques and novel therapeutic combinations. One way to reconcile these findings is to abandon the concept that the TME is a well-compartmented population with spatial, temporal, physical, and chemical elements acting independently. This review will focus on the most interesting advancements of RT and describe the main components of the TME and their known modulation after RT in PDAC. Furthermore, we will provide a summary of current clinical data for combinations of RT/targeted therapy (tRT) and give an overview of the most promising future directions.
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Affiliation(s)
- Sofian Benkhaled
- Department of Radiation Oncology, Hopital Universitaire de Bruxelles (H.U.B.), Institut Jules Bordet, Université Libre de Bruxelles (ULB), Rue Meylenmeersch 90, 1070 Brussels, Belgium
- Department of Radiation Oncology, UNIL-CHUV, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Cedric Peters
- Department of Radiation Oncology, AZ Turnhout, Rubensstraat 166, 2300 Turnhout, Belgium
| | - Nicolas Jullian
- Department of Radiation Oncology, Hopital Universitaire de Bruxelles (H.U.B.), Institut Jules Bordet, Université Libre de Bruxelles (ULB), Rue Meylenmeersch 90, 1070 Brussels, Belgium
| | - Tatjana Arsenijevic
- Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium
- Department of Gastroenterology, Hepatology and Digestive Oncology, Hopital Universitaire de Bruxelles H.U.B. CUB Hopital Erasme, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070 Brussels, Belgium
| | - Julie Navez
- Department of Hepato-Biliary-Pancreatic Surgery, Hopital Universitaire de Bruxelles H.U.B. CUB Hopital Erasme, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium
| | - Dirk Van Gestel
- Department of Radiation Oncology, Hopital Universitaire de Bruxelles (H.U.B.), Institut Jules Bordet, Université Libre de Bruxelles (ULB), Rue Meylenmeersch 90, 1070 Brussels, Belgium
| | - Luigi Moretti
- Department of Radiation Oncology, Hopital Universitaire de Bruxelles (H.U.B.), Institut Jules Bordet, Université Libre de Bruxelles (ULB), Rue Meylenmeersch 90, 1070 Brussels, Belgium
| | - Jean-Luc Van Laethem
- Department of Gastroenterology, Hepatology and Digestive Oncology, Hopital Universitaire de Bruxelles H.U.B. CUB Hopital Erasme, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070 Brussels, Belgium
| | - Christelle Bouchart
- Department of Radiation Oncology, Hopital Universitaire de Bruxelles (H.U.B.), Institut Jules Bordet, Université Libre de Bruxelles (ULB), Rue Meylenmeersch 90, 1070 Brussels, Belgium
- Correspondence: ; Tel.: +32-25-413-800
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10
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Zhou S, Szöllősi AG, Huang X, Chang-Chien YC, Hajdu A. A Novel Immune-Related Gene Prognostic Index (IRGPI) in Pancreatic Adenocarcinoma (PAAD) and Its Implications in the Tumor Microenvironment. Cancers (Basel) 2022; 14:cancers14225652. [PMID: 36428747 PMCID: PMC9688924 DOI: 10.3390/cancers14225652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 10/04/2022] [Accepted: 11/03/2022] [Indexed: 11/19/2022] Open
Abstract
PURPOSE Pancreatic adenocarcinoma (PAAD) is one of the most lethal malignancies, with less than 10% of patients surviving more than 5 years. Existing biomarkers for reliable survival rate prediction need to be enhanced. As a result, the objective of this study was to create a novel immune-related gene prognostic index (IRGPI) for estimating overall survival (OS) and to analyze the molecular subtypes based on this index. Materials and procedures: RNA sequencing and clinical data were retrieved from publicly available sources and analyzed using several R software packages. A unique IRGPI and optimum risk model were developed using a machine learning algorithm. The prediction capability of our model was then compared to that of previously proposed models. A correlation study was also conducted between the immunological tumor microenvironment, risk groups, and IRGPI genes. Furthermore, we classified PAAD into different molecular subtypes based on the expression of IRGPI genes and investigated their features in tumor immunology using the K-means clustering technique. RESULTS A 12-gene IRGPI (FYN, MET, LRSAM1, PSPN, ERAP2, S100A1, IL20RB, MAP3K14, SEMA6C, PRKCG, CXCL11, and GH1) was established, and verified along with a risk model. OS prediction by our model outperformed previous gene signatures. According to the findings of our correlation studies, different risk groups and IRGPI genes were found to be tightly related to tumor microenvironments, and PAAD could be further subdivided into immunologically distinct molecular subtypes based on the expression of IRGPI genes. CONCLUSION The current study constructed and verified a unique IRGPI. Furthermore, our findings revealed a connection between the IRGPI and the immunological microenvironment of tumors. PAAD was differentiated into several molecular subtypes that might react differently to immunotherapy. These findings could provide new insights for precision and translational medicine for more innovative immunotherapy strategies.
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Affiliation(s)
- Shujing Zhou
- Department Data Science and Visualization, Faculty of Informatics, University of Debrecen, 4028 Debrecen, Hungary
- Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Attila Gábor Szöllősi
- Department of Immunology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Xufeng Huang
- Department Data Science and Visualization, Faculty of Informatics, University of Debrecen, 4028 Debrecen, Hungary
- Faculty of Dentistry, University of Debrecen, 4032 Debrecen, Hungary
| | - Yi-Che Chang-Chien
- Department of Pathology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
- Correspondence: (Y.-C.C.-C.); (A.H.)
| | - András Hajdu
- Department Data Science and Visualization, Faculty of Informatics, University of Debrecen, 4028 Debrecen, Hungary
- Correspondence: (Y.-C.C.-C.); (A.H.)
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11
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Kaučić H, Kosmina D, Schwarz D, Mack A, Čehobašić A, Leipold V, Avdićević A, Mlinarić M, Lekić M, Schwarz K, Banović M. Stereotactic Body Radiotherapy for Locally Advanced Pancreatic Cancer Using Optical Surface Management System - AlignRT as an Optical Body Surface Motion Management in Deep Breath Hold Patients: Results from a Single-Arm Retrospective Study. Cancer Manag Res 2022; 14:2161-2172. [PMID: 35855763 PMCID: PMC9288179 DOI: 10.2147/cmar.s368662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 06/22/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose To assess the efficacy and safety of stereotactic body radiotherapy for patients with unresectable, locally advanced pancreatic cancer using Optical Surface Management System - AlignRT (OSMS-AlignRT) as an optical body surface motion management in deep breath hold. Patients and Methods Forty-five patients diagnosed with locally advanced pancreatic cancer were treated with stereotactic body radiotherapy in 3 or 5 fractions, and received varying BED10 (median 79.5 Gy) from April 2017 to December 2020. All patients were treated in deep breath hold with OSMS-AlignRT used as optical body surface motion management. Thirty-three patients received systemic treatment before and/or after stereotactic body radiotherapy, and twelve patients received no systemic treatment. In this retrospective, observational, single-arm study, primary endpoints were overall survival and freedom from local progression (ie, local control). Secondary endpoints were progression-free survival and toxicity. Actuarial survival analysis and univariate analysis were investigated. Results Data from forty-five patients were analyzed. Median follow-up was 15 months. One-year freedom from local progression and survival were 95.5% and 71.1%, respectively. Median progression-free survival was 14 months. Median overall survival from diagnosis for all patients was 17 months, and 19 months for patients alive at the time of analysis. No patient had >G2 toxicity. Conclusion Stereotactic body radiotherapy for locally advanced pancreatic cancer using OSMS-AlignRT as optical body surface motion management in deep breath hold patients is an effective and safe local treatment option, with no >G2 toxicity, and could be a promising therapeutic option with acceptable toxicity, either as a single treatment or in a multimodal regimen. OSMS-AlignRT provided accurate and reliable body surface motion management during stereotactic body radiotherapy.
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Affiliation(s)
- Hrvoje Kaučić
- Department of Radiosurgery and Radiotherapy, Special Hospital Radiochirurgia Zagreb, Sveta Nedelja, Croatia.,University Josip Juraj Strossmayer in Osijek - Medical Faculty Osijek, Osijek, Croatia
| | - Domagoj Kosmina
- Department of Medical Physics, Special Hospital Radiochirurgia Zagreb, Sveta Nedelja, Croatia
| | - Dragan Schwarz
- Department of Surgery, Special Hospital Radiochirurgia Zagreb, Sveta Nedelja, Croatia.,Department of Surgery, Medical Faculty of University in Rijeka, Rijeka, Croatia.,Department of Surgery, University Josip Juraj Strossmayer in Osijek - Faculty of Dental medicine and Health, Osijek, Croatia
| | - Andreas Mack
- Swiss NeuroRadiosurgery Center, Swiss Clinical NeuroScience Institute, Zürich, Switzerland
| | - Adlan Čehobašić
- University Josip Juraj Strossmayer in Osijek - Medical Faculty Osijek, Osijek, Croatia.,Department of Medical Physics, Special Hospital Radiochirurgia Zagreb, Sveta Nedelja, Croatia
| | - Vanda Leipold
- University Josip Juraj Strossmayer in Osijek - Medical Faculty Osijek, Osijek, Croatia.,Department of Medical Physics, Special Hospital Radiochirurgia Zagreb, Sveta Nedelja, Croatia
| | - Asmir Avdićević
- Department of Radiosurgery and Radiotherapy, Special Hospital Radiochirurgia Zagreb, Sveta Nedelja, Croatia
| | - Mihaela Mlinarić
- Department of Medical Physics, Special Hospital Radiochirurgia Zagreb, Sveta Nedelja, Croatia
| | - Matea Lekić
- Department of Radiosurgery and Radiotherapy, Special Hospital Radiochirurgia Zagreb, Sveta Nedelja, Croatia
| | - Karla Schwarz
- University of Zagreb, Medical Faculty, Zagreb, Croatia
| | - Marija Banović
- Department of Endocrinology, Polyclinic Leptir, Zagreb, Croatia
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12
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Kaučić H, Kosmina D, Schwarz D, Mack A, Šobat H, Čehobašić A, Leipold V, Andrašek I, Avdičević A, Mlinarić M. Stereotactic Ablative Radiotherapy Using CALYPSO ® Extracranial Tracking for Intrafractional Tumor Motion Management-A New Potential Local Treatment for Unresectable Locally Advanced Pancreatic Cancer? Results from a Retrospective Study. Cancers (Basel) 2022; 14:cancers14112688. [PMID: 35681668 PMCID: PMC9179494 DOI: 10.3390/cancers14112688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/24/2022] [Accepted: 05/27/2022] [Indexed: 11/16/2022] Open
Abstract
(1) Background: The aim of this study was to evaluate the efficacy and safety of SABR for LAPC using Calypso® Extracranial Tracking for intrafractional, fiducial-based motion management, to present this motion management technique, as there are yet no published data on usage of Calypso® during SABR for LAPC, and to report on our clinical outcomes. (2) Methods: Fifty-four patients were treated with SABR in one, three, or five fractions, receiving median BED10 = 112.5 Gy. Thirty-eight patients received systemic treatment. End points were OS, FFLP, PFS, and toxicity. Actuarial survival analysis and univariate analysis were investigated. (3) Results: Median follow-up was 20 months. Median OS was 24 months. One-year FFLP and one-year OS were 100% and 90.7%, respectively. Median PFS was 18 months, and one-year PFS was 72.2%. Twenty-five patients (46.3%) were alive at the time of analysis, and both median FU and OS for this subgroup were 26 months. No acute/late toxicity > G2 was reported. (4) Conclusions: SABR for LAPC using Calypso® presented as an effective and safe treatment and could be a promising local therapeutic option with very acceptable toxicity, either as a single treatment or in a multimodality regimen. Dose escalation to the tumor combined with systemic treatment could yield better clinical outcomes.
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Affiliation(s)
- Hrvoje Kaučić
- Specijalna bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia; (D.K.); (D.S.); (H.Š.); (A.Č.); (V.L.); (I.A.); (A.A.); (M.M.)
- Sveučilište Josipa Jurja Strossmayera u Osijeku—Medicinski Fakultet Osijek, Josipa Huttlera 4, 31000 Osijek, Croatia
- Correspondence: ; Tel.: +385-91-5622-191
| | - Domagoj Kosmina
- Specijalna bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia; (D.K.); (D.S.); (H.Š.); (A.Č.); (V.L.); (I.A.); (A.A.); (M.M.)
| | - Dragan Schwarz
- Specijalna bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia; (D.K.); (D.S.); (H.Š.); (A.Č.); (V.L.); (I.A.); (A.A.); (M.M.)
- Medicinski Fakultet Sveučilišta u Rijeci, Braće Branchetta 20/1, 51000 Rijeka, Croatia
- Sveučilište Josipa Jurja Strossmayera u Osijeku—Fakultet za Dentalnu Medicinu i Zdravstvo Osijek, Crkvena Ulica 21, 31000 Osijek, Croatia
| | - Andreas Mack
- Swiss NeuroRadiosurgery Center, Bürglistrasse 29, 8002 Zürich, Switzerland;
| | - Hrvoje Šobat
- Specijalna bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia; (D.K.); (D.S.); (H.Š.); (A.Č.); (V.L.); (I.A.); (A.A.); (M.M.)
| | - Adlan Čehobašić
- Specijalna bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia; (D.K.); (D.S.); (H.Š.); (A.Č.); (V.L.); (I.A.); (A.A.); (M.M.)
- Sveučilište Josipa Jurja Strossmayera u Osijeku—Medicinski Fakultet Osijek, Josipa Huttlera 4, 31000 Osijek, Croatia
| | - Vanda Leipold
- Specijalna bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia; (D.K.); (D.S.); (H.Š.); (A.Č.); (V.L.); (I.A.); (A.A.); (M.M.)
- Sveučilište Josipa Jurja Strossmayera u Osijeku—Medicinski Fakultet Osijek, Josipa Huttlera 4, 31000 Osijek, Croatia
| | - Iva Andrašek
- Specijalna bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia; (D.K.); (D.S.); (H.Š.); (A.Č.); (V.L.); (I.A.); (A.A.); (M.M.)
| | - Asmir Avdičević
- Specijalna bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia; (D.K.); (D.S.); (H.Š.); (A.Č.); (V.L.); (I.A.); (A.A.); (M.M.)
| | - Mihaela Mlinarić
- Specijalna bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia; (D.K.); (D.S.); (H.Š.); (A.Č.); (V.L.); (I.A.); (A.A.); (M.M.)
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13
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Simoni N, Rossi G, Cellini F, Vitolo V, Orlandi E, Valentini V, Mazzarotto R, Sverzellati N, D'Abbiero N. Ablative Radiotherapy (ART) for Locally Advanced Pancreatic Cancer (LAPC): Toward a New Paradigm? Life (Basel) 2022; 12:life12040465. [PMID: 35454956 PMCID: PMC9025325 DOI: 10.3390/life12040465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 03/17/2022] [Indexed: 11/16/2022] Open
Abstract
Locally advanced pancreatic cancer (LAPC) represents a major urgency in oncology. Due to the massive involvement of the peripancreatic vessels, a curative-intent surgery is generally precluded. Historically, LAPC has been an indication for palliative systemic therapy. In recent years, with the introduction of intensive multi-agent chemotherapy regimens and aggressive surgical approaches, the survival of LAPC patients has significantly improved. In this complex and rapidly evolving scenario, the role of radiotherapy is still debated. The use of standard-dose conventional fractionated radiotherapy in LAPC has led to unsatisfactory oncological outcomes. However, technological advances in radiation therapy over recent years have definitively changed this paradigm. The use of ablative doses of radiotherapy, in association with image-guidance, respiratory organ-motion management, and adaptive protocols, has led to unprecedented results in terms of local control and survival. In this overview, principles, clinical applications, and current pitfalls of ablative radiotherapy (ART) as an emerging treatment option for LAPC are discussed.
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Affiliation(s)
- Nicola Simoni
- Radiotherapy Unit, Azienda Ospedaliera Universitaria, 43126 Parma, Italy
| | - Gabriella Rossi
- Department of Radiation Oncology, Azienda Ospedaliero Universitaria Integrata, 37126 Verona, Italy
| | - Francesco Cellini
- Radioterapia Oncologica ed Ematologia, Dipartimento Universitario Diagnostica per Immagini, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
- Radioterapia Oncologica ed Ematologia, Dipartimento di Diagnostica per Immagini, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, 00168 Roma, Italy
| | - Viviana Vitolo
- Radiation Oncology Clinical Department, National Center for Oncological Hadrontherapy (CNAO), 27100 Pavia, Italy
| | - Ester Orlandi
- Radiation Oncology Clinical Department, National Center for Oncological Hadrontherapy (CNAO), 27100 Pavia, Italy
| | - Vincenzo Valentini
- Radioterapia Oncologica ed Ematologia, Dipartimento Universitario Diagnostica per Immagini, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
- Radioterapia Oncologica ed Ematologia, Dipartimento di Diagnostica per Immagini, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, 00168 Roma, Italy
| | - Renzo Mazzarotto
- Department of Radiation Oncology, Azienda Ospedaliero Universitaria Integrata, 37126 Verona, Italy
| | - Nicola Sverzellati
- Division of Radiology, Azienda Ospedaliera Universitaria, 43126 Parma, Italy
| | - Nunziata D'Abbiero
- Radiotherapy Unit, Azienda Ospedaliera Universitaria, 43126 Parma, Italy
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14
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Piper M, Van Court B, Mueller A, Watanabe S, Bickett T, Bhatia S, Darragh LB, Mayeda M, Nguyen D, Gadwa J, Knitz M, Corbo S, Morgan R, Lee JJ, Dent A, Goodman K, Messersmith W, Schulick R, Del Chiaro M, Zhu Y, Kedl RM, Lenz L, Karam SD. Targeting Treg-Expressed STAT3 Enhances NK-Mediated Surveillance of Metastasis and Improves Therapeutic Response in Pancreatic Adenocarcinoma. Clin Cancer Res 2022; 28:1013-1026. [PMID: 34862244 PMCID: PMC8898296 DOI: 10.1158/1078-0432.ccr-21-2767] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 10/01/2021] [Accepted: 11/29/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE Metastasis remains a major hurdle in treating aggressive malignancies such as pancreatic ductal adenocarcinoma (PDAC). Improving response to treatment, therefore, requires a more detailed characterization of the cellular populations involved in controlling metastatic burden. EXPERIMENTAL DESIGN PDAC patient tissue samples were subjected to RNA sequencing analysis to identify changes in immune infiltration following radiotherapy. Genetically engineered mouse strains in combination with orthotopic tumor models of PDAC were used to characterize disease progression. Flow cytometry was used to analyze tumor infiltrating, circulating, and nodal immune populations. RESULTS We demonstrate that although radiotherapy increases the infiltration and activation of dendritic cells (DC), it also increases the infiltration of regulatory T cells (Treg) while failing to recruit natural killer (NK) and CD8 T cells in PDAC patient tissue samples. In murine orthotopic tumor models, we show that genetic and pharmacologic depletion of Tregs and NK cells enhances and attenuates response to radiotherapy, respectively. We further demonstrate that targeted inhibition of STAT3 on Tregs results in improved control of local and distant disease progression and enhanced NK-mediated immunosurveillance of metastasis. Moreover, combination treatment of STAT3 antisense oligonucleotide (ASO) and radiotherapy invigorated systemic immune activation and conferred a survival advantage in orthotopic and metastatic tumor models. Finally, we show the response to STAT3 ASO + radiotherapy treatment is dependent on NK and DC subsets. CONCLUSIONS Our results suggest targeting Treg-mediated immunosuppression is a critical step in mediating a response to treatment, and identifying NK cells as not only a prognostic marker of improved survival, but also as an effector population that functions to combat metastasis.
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Affiliation(s)
- Miles Piper
- Department of Radiation Oncology, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Benjamin Van Court
- Department of Radiation Oncology, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Adam Mueller
- Department of Radiation Oncology, University of Colorado, Anschutz Medical Campus, Aurora, CO
- Department of Radiation Oncology, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Shuichi Watanabe
- Department of Radiation Oncology, University of Colorado, Anschutz Medical Campus, Aurora, CO
- Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Thomas Bickett
- Department of Radiation Oncology, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Shilpa Bhatia
- Department of Radiation Oncology, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Laurel B Darragh
- Department of Radiation Oncology, University of Colorado, Anschutz Medical Campus, Aurora, CO
- Department of Microbiology and Immunology, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Max Mayeda
- Department of Radiation Oncology, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Diemmy Nguyen
- Department of Radiation Oncology, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Jacob Gadwa
- Department of Radiation Oncology, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Michael Knitz
- Department of Radiation Oncology, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Sophia Corbo
- Department of Radiation Oncology, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Rustain Morgan
- Department of Radiology, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Jung-Jae Lee
- Department of Chemistry, University of Colorado Denver, Denver, CO 80204, USA
| | - Alexander Dent
- Department of Microbiology and Immunology, Indiana University School of Medicine, Indianapolis, IN
| | - Karyn Goodman
- Department of Radiation Oncology, University of Colorado, Anschutz Medical Campus, Aurora, CO
- Department of Radiation Oncology, Mount Sinai Hospital, New York, NY
| | - Wells Messersmith
- Department of Medical Oncology, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Rich Schulick
- Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO
- Department of Microbiology and Immunology, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Marco Del Chiaro
- Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Yuwen Zhu
- Department of Microbiology and Immunology, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Ross M. Kedl
- Department of Microbiology and Immunology, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Laurel Lenz
- Department of Microbiology and Immunology, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Sana D Karam
- Department of Radiation Oncology, University of Colorado, Anschutz Medical Campus, Aurora, CO
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15
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An Evaluation of Total Internal Motions of Locally Advanced Pancreatic Cancer during SABR Using Calypso ® Extracranial Tracking, and Its Possible Clinical Impact on Motion Management. Curr Oncol 2021; 28:4597-4610. [PMID: 34898575 PMCID: PMC8628737 DOI: 10.3390/curroncol28060389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 11/06/2021] [Indexed: 12/31/2022] Open
Abstract
(1) Background: the aims of this study were to determine the total extent of pancreatic cancer’s internal motions, using Calypso® extracranial tracking, and to indicate possible clinical advantages of continuous intrafractional fiducial-based tumor motion tracking during SABR. (2) Methods: thirty-four patients were treated with SABR for LAPC using Calypso® for motion management. Planning MSCTs in FB and DBH, and 4D-CTs were performed. Using data from Calypso® and 4D-CTs, the movements of the lesions in the CC, AP and LR directions, as well as the volumes of the 4D-CT-based ITV and the volumes of the Calypso®-based ITV were compared. (3) Results: significantly larger medians of tumor excursions were found with Calypso® than with 4D-CT: CC: 29 mm (p < 0.001); AP: 14 mm (p < 0.001) and LR: 11 mm (p < 0.039). The median volume of the Calypso®-based ITV was significantly larger than that of the 4D-CT based ITV (p < 0.001). (4) Conclusion: beside known respiratory-induced internal motions, pancreatic cancer seems to have significant additional motions which should be considered during respiratory motion management. Only direct and continuous intrafractional fiducial-based motion tracking seems to provide complete coverage of the target lesion with the prescribed isodose, which could allow for safe tumor dose escalation.
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Dai X, Lei Y, Wynne J, Janopaul-Naylor J, Wang T, Roper J, Curran WJ, Liu T, Patel P, Yang X. Synthetic CT-aided multiorgan segmentation for CBCT-guided adaptive pancreatic radiotherapy. Med Phys 2021; 48:7063-7073. [PMID: 34609745 PMCID: PMC8595847 DOI: 10.1002/mp.15264] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 09/15/2021] [Accepted: 09/17/2021] [Indexed: 12/19/2022] Open
Abstract
PURPOSE The delineation of organs at risk (OARs) is fundamental to cone-beam CT (CBCT)-based adaptive radiotherapy treatment planning, but is time consuming, labor intensive, and subject to interoperator variability. We investigated a deep learning-based rapid multiorgan delineation method for use in CBCT-guided adaptive pancreatic radiotherapy. METHODS To improve the accuracy of OAR delineation, two innovative solutions have been proposed in this study. First, instead of directly segmenting organs on CBCT images, a pretrained cycle-consistent generative adversarial network (cycleGAN) was applied to generating synthetic CT images given CBCT images. Second, an advanced deep learning model called mask-scoring regional convolutional neural network (MS R-CNN) was applied on those synthetic CT to detect the positions and shapes of multiple organs simultaneously for final segmentation. The OAR contours delineated by the proposed method were validated and compared with expert-drawn contours for geometric agreement using the Dice similarity coefficient (DSC), 95th percentile Hausdorff distance (HD95), mean surface distance (MSD), and residual mean square distance (RMS). RESULTS Across eight abdominal OARs including duodenum, large bowel, small bowel, left and right kidneys, liver, spinal cord, and stomach, the geometric comparisons between automated and expert contours are as follows: 0.92 (0.89-0.97) mean DSC, 2.90 mm (1.63-4.19 mm) mean HD95, 0.89 mm (0.61-1.36 mm) mean MSD, and 1.43 mm (0.90-2.10 mm) mean RMS. Compared to the competing methods, our proposed method had significant improvements (p < 0.05) in all the metrics for all the eight organs. Once the model was trained, the contours of eight OARs can be obtained on the order of seconds. CONCLUSIONS We demonstrated the feasibility of a synthetic CT-aided deep learning framework for automated delineation of multiple OARs on CBCT. The proposed method could be implemented in the setting of pancreatic adaptive radiotherapy to rapidly contour OARs with high accuracy.
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Affiliation(s)
- Xianjin Dai
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Yang Lei
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Jacob Wynne
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - James Janopaul-Naylor
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Tonghe Wang
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Justin Roper
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Walter J Curran
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Tian Liu
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Pretesh Patel
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Xiaofeng Yang
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
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Liu P, Gao XS, Wang Z, Li X, Xi C, Jia C, Xie M, Lyu F, Ding X. Investigate the Dosimetric and Potential Clinical Benefits Utilizing Stereotactic Body Radiation Therapy With Simultaneous Integrated Boost Technique for Locally Advanced Pancreatic Cancer: A Comparison Between Photon and Proton Beam Therapy. Front Oncol 2021; 11:747532. [PMID: 34631584 PMCID: PMC8493097 DOI: 10.3389/fonc.2021.747532] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 08/30/2021] [Indexed: 12/24/2022] Open
Abstract
Purpose To investigate the potential clinical benefits of using stereotactic body radiation therapy (SBRT) with simultaneous integrated boost (SIB) technique for locally advanced pancreatic cancer (LAPC) among different treatment modalities and planning strategies, including photon and proton. Method A total of 19 patients were retrospectively selected in this study: 13 cases with the tumor located in the head of the pancreas and 6 cases with the tumor in the body of the pancreas. SBRT-SIB plans were generated using volumetric modulated arc therapy (VMAT), two-field Intensity Modulated Proton Therapy (IMPT), and three-field IMPT. The IMPT used the robust optimization parameters of ± 3.5% range and 5-mm setup uncertainties. Root-mean-square deviation dose (RMSD) volume histograms were used to evaluate the target coverage robustness quantitatively. Dosimetric metrics based on the dose-volume histogram (DVH), homogeneity index (HI), and normal tissue complication probability (NTCP) were analyzed to evaluate the potential clinical benefits among different planning groups. Results With a similar CTV and SIB coverage, two-field IMPT provided a lower maximum dose for the stomach (median: 18.6GyE, p<0.05) and duodenum (median: 32.62GyE, p<0.05) when the target was located in the head of the pancreas compared to VMAT and three-field IMPT. The risks of gastric bleed (3.42%) and grade ≥ 3 GI toxicity (4.55%) were also decreased. However, for the target in the body of the pancreas, VMAT showed a lower maximum dose for the stomach (median 30.93GyE, p<0.05) and toxicity of gastric bleed (median: 8.67%, p<0.05) compared to two-field IMPT and three-field IMPT, while other maximum doses and NTCPs were similar. The RMSD volume histogram (RVH) analysis shows that three-field IMPT provided better robustness for targets but not for OARs. Instead, three-field IMPT increased the Dmean of organs such as the stomach, duodenum, and intestine. Conclusion The results indicated that the tumor locations could play a critical role in determining clinical benefits among different treatment modalities. Two-field IMPT could be a better option for LAPC patients whose tumors are located in the head of the pancreas. It provides lower severe toxicity for the stomach and duodenum. Nevertheless, VMAT is preferred for the body with better protection for the possibility of gastric bleed.
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Affiliation(s)
- Peilin Liu
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Xian-Shu Gao
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Zishen Wang
- Department of Radiation Oncology, Hebei Yizhou Tumor Hospital, Zhuozhou, China
| | - Xiaomei Li
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Cao Xi
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Chenghao Jia
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Mu Xie
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Feng Lyu
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Xuanfeng Ding
- Department of Radiation Oncology, Beaumont Health, Proton Beam Therapy Center, Royal Oak, MI, United States
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Yang L, Bai Y, Li Q, Chen J, Liu F, Weng X, Xu F. Analysis of the Curative Effect of Neoadjuvant Therapy on Pancreatic Cancer. Front Oncol 2021; 11:695645. [PMID: 34485131 PMCID: PMC8416459 DOI: 10.3389/fonc.2021.695645] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 07/30/2021] [Indexed: 12/24/2022] Open
Abstract
The prevalence of pancreatic cancer is sharply increasing recently, which significantly increases the economic burden of the population. At present, the primary treatment of resectable pancreatic cancer is surgical resection, followed by chemotherapy with or without radiation. However, the recurrence rates remain high even after R0 resection. This treatment strategy does not distinguish undetected metastatic disease, and it is prone to postoperative complications. Neoadjuvant therapies, including neoadjuvant chemotherapy and radiotherapy, is being increasingly utilized in borderline resectable as well as resectable pancreatic cancer. This review summarized and discussed clinical trials of neoadjuvant therapy for pancreatic cancer, comparing resection rates, outcome measures, and adverse reactions between neoadjuvant chemotherapy and neoadjuvant chemoradiotherapy.
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Affiliation(s)
- Liqiong Yang
- Laboratory of Molecular Pharmacology, Department of Pharmacology, School of Pharmacy, Southwest Medical University, Luzhou, China
| | - Yun Bai
- Department of Public Health, Chengdu Medical College, Chengdu, China
| | - Qing Li
- Department of Anesthesiology, Gulinxian People's Hospital of Sichuan Province, Luzhou, China
| | - Jie Chen
- Department of Digestive Surgery, School of Chinese Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong.,Department of Orthopedics, Shanghai Institute of Traumatology and Orthopaedics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Fangfang Liu
- Department of Art, Art College, Southwest Minzu University, Chengdu, China
| | - Xiechuan Weng
- Department of Neuroscience, Beijing Institute of Basic Medical Sciences, Beijing, China
| | - Fan Xu
- Department of Public Health, Chengdu Medical College, Chengdu, China
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Arcelli A, Bertini F, Strolin S, Macchia G, Deodato F, Cilla S, Parisi S, Sainato A, Fiore M, Gabriele P, Genovesi D, Cellini F, Guido A, Cammelli S, Buwenge M, Loi E, Bisello S, Renzulli M, Golfieri R, Morganti AG, Strigari L. Definition of Local Recurrence Site in Resected Pancreatic Adenocarcinoma: A Multicenter Study (DOLORES-1). Cancers (Basel) 2021; 13:cancers13123051. [PMID: 34207481 PMCID: PMC8234595 DOI: 10.3390/cancers13123051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/09/2021] [Accepted: 06/15/2021] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Pancreatic cancer remains a disease with a dismal outlook for patients, with high relapse rates after surgery and adjuvant treatments. Thanks to the high conformality achievable with advanced radiotherapy techniques, a more robust definition of clinical target volume (CTV) margins is mandatory. Moreover, a precise CTV definition may affect local control, minimizing radiation-related toxicity and allowing dose escalation. Contrary to two recent studies, RTOG contouring guidelines are not based on a pattern of failure analysis. We provided a local failure risk map in resected pancreatic cancer, validating the results of previous studies. Moreover, according to a new probabilistic approach, we provided new CTV contouring guidelines for the postoperative radiotherapy of pancreatic cancer, modeling targets’ margins on a combination of our validated local failure map (30% of local failures) and RTOG guidelines (70% of local failures). Abstract The study aimed to generate a local failure (LF) risk map in resected pancreatic cancer (PC) and validate the results of previous studies, proposing new guidelines for PC postoperative radiotherapy clinical target volume (CTV) delineation. Follow-up computer tomography (CT) of resected PC was retrospectively reviewed by two radiologists identifying LFs and plotting them on a representative patient CT scan. The percentages of LF points randomly extracted based on CTV following the RTOG guidelines and based on the LF database were 70% and 30%, respectively. According to the Kernel density estimation, an LF 3D distribution map was generated and compared with the results of previous studies using a Dice index. Among the 64 resected patients, 59.4% underwent adjuvant treatment. LFs closer to the root of the celiac axis (CA) or the superior mesenteric artery (SMA) were reported in 32.8% and 67.2% cases, respectively. The mean (± standard deviation) distances of LF points to CA and SMA were 21.5 ± 17.9 mm and 21.6 ± 12.1 mm, respectively. The Dice values comparing our iso-level risk maps corresponding to 80% and 90% of the LF probabilistic density and the CTVs-80 and CTVs-90 of previous publications were 0.45–0.53 and 0.58–0.60, respectively. According to the Kernel density approach, a validated LF map was proposed, modeling a new adjuvant CTV based on a PC pattern of failure.
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Affiliation(s)
- Alessandra Arcelli
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (F.B.); (A.G.); (S.C.); (M.B.); (S.B.); (A.G.M.)
- Department of Experimental, Diagnostic and Specialty Medicine–DIMES, Alma Mater Studiorum, Bologna University, 40138 Bologna, Italy;
- Correspondence: or ; Tel.: +39-051-214-35-64
| | - Federica Bertini
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (F.B.); (A.G.); (S.C.); (M.B.); (S.B.); (A.G.M.)
- Department of Experimental, Diagnostic and Specialty Medicine–DIMES, Alma Mater Studiorum, Bologna University, 40138 Bologna, Italy;
| | - Silvia Strolin
- Medical Physics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (S.S.); (E.L.); (L.S.)
| | - Gabriella Macchia
- Radiation Oncology Unit, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, 86100 Campobasso, Italy; (G.M.); (F.D.)
| | - Francesco Deodato
- Radiation Oncology Unit, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, 86100 Campobasso, Italy; (G.M.); (F.D.)
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, 00168 Roma, Italy;
| | - Savino Cilla
- Medical Physics Unit, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, 86100 Campobasso, Italy;
| | - Salvatore Parisi
- Unit of Radiation Therapy, IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy;
| | - Aldo Sainato
- Radiation Oncology, Pisa University Hospital, 56126 Pisa, Italy;
| | - Michele Fiore
- Radiation Oncology, Campus Bio-Medico University, 00128 Rome, Italy;
| | - Pietro Gabriele
- Radiation Therapy, Candiolo Cancer Institute–FPO, IRCCS Candiolo, 10060 Candiolo, Italy;
| | - Domenico Genovesi
- Department of Radiation Oncology, SS. Annunziata Hospital, G. D’Annunzio University of Chieti, 66100 Chieti, Italy;
| | - Francesco Cellini
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, 00168 Roma, Italy;
- Fondazione Policlinico Universitario A. Gemelli, IRCCS, UOC di Radioterapia, Dipartimento di Scienze Radiologiche, Radioterapiche ed Ematologiche, 00168 Roma, Italy
| | - Alessandra Guido
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (F.B.); (A.G.); (S.C.); (M.B.); (S.B.); (A.G.M.)
| | - Silvia Cammelli
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (F.B.); (A.G.); (S.C.); (M.B.); (S.B.); (A.G.M.)
- Department of Experimental, Diagnostic and Specialty Medicine–DIMES, Alma Mater Studiorum, Bologna University, 40138 Bologna, Italy;
| | - Milly Buwenge
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (F.B.); (A.G.); (S.C.); (M.B.); (S.B.); (A.G.M.)
- Department of Experimental, Diagnostic and Specialty Medicine–DIMES, Alma Mater Studiorum, Bologna University, 40138 Bologna, Italy;
| | - Emiliano Loi
- Medical Physics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (S.S.); (E.L.); (L.S.)
| | - Silvia Bisello
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (F.B.); (A.G.); (S.C.); (M.B.); (S.B.); (A.G.M.)
- Department of Experimental, Diagnostic and Specialty Medicine–DIMES, Alma Mater Studiorum, Bologna University, 40138 Bologna, Italy;
| | - Matteo Renzulli
- Radiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Rita Golfieri
- Department of Experimental, Diagnostic and Specialty Medicine–DIMES, Alma Mater Studiorum, Bologna University, 40138 Bologna, Italy;
- Radiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Alessio G. Morganti
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (F.B.); (A.G.); (S.C.); (M.B.); (S.B.); (A.G.M.)
- Department of Experimental, Diagnostic and Specialty Medicine–DIMES, Alma Mater Studiorum, Bologna University, 40138 Bologna, Italy;
| | - Lidia Strigari
- Medical Physics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (S.S.); (E.L.); (L.S.)
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Zeeshan MS, Ramzan Z. Current controversies and advances in the management of pancreatic adenocarcinoma. World J Gastrointest Oncol 2021; 13:472-494. [PMID: 34163568 PMCID: PMC8204360 DOI: 10.4251/wjgo.v13.i6.472] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/22/2021] [Accepted: 05/25/2021] [Indexed: 02/06/2023] Open
Abstract
Pancreatic adenocarcinoma is a lethal disease with a mortality rate that has not significantly improved over decades. This is likely due to several challenges unique to pancreatic cancer. Most patients with pancreatic cancer are diagnosed at a late stage of disease due to the lack of specific symptoms prompting an early investigation. A small subset of patients who are diagnosed at an early stage have a better chance at survival with curative surgical resection, but most patients still succumb to the disease in a few years. The dismal overall prognosis is due to suspected micro-metastasis at an early stage. Due to this reason, there is a recent interest in treating all patients with pancreatic cancers with systemic therapy upfront (including the ones that are surgically resectable). This approach is still not the standard of care due to the lack of robust prospective data available. Recent advancements in treatment regimens of chemotherapy, radiation and immunotherapy have improved the overall short-term survival but the long-term survival still remains poor. Novel approaches in diagnosis and treatment have shown promise in clinical studies but long-term clinical data is lacking. The following manuscript presents an overview of the epidemiology, diagnosis, staging, recent advances, novel approaches and controversies in the management of pancreatic adenocarcinoma.
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Affiliation(s)
- Muhammad Shehroz Zeeshan
- Gastrointestinal Section, Department of Medicine, Texas Health Harris Methodist Hospital, Fort Worth, TX 76104, United States
| | - Zeeshan Ramzan
- Gastrointestinal Section, Department of Medicine, Texas Health Harris Methodist Hospital, Fort Worth, TX 76104, United States
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21
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McCarthy PM, Rendo MJ, Uy MD, Adams AM, O’Shea AE, Nelson DW, Fenderson JL, Cebe KM, Krell RW, Clifton GT, Peoples GE, Vreeland TJ. Near Complete Pathologic Response to PD-1 Inhibitor and Radiotherapy in a Patient with Locally Advanced Pancreatic Ductal Adenocarcinoma. Onco Targets Ther 2021; 14:3537-3544. [PMID: 34103944 PMCID: PMC8179799 DOI: 10.2147/ott.s311661] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 05/05/2021] [Indexed: 01/11/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) remains deadly despite advances in systemic therapies and surgical techniques. While there is increasing utilization of immune therapies across diverse cancer types, PDAC remains generally resistant to these treatments. We report a case of locally advanced PDAC treated with preoperative radiation and anti-PD-1 immunotherapy guided by preoperative PD-L1 tumor analysis. After 4 months of preoperative therapy, the patient was submitted to resection, demonstrating a near-complete pathologic response on final tumor analysis. We will discuss the relevant literature and current state of immunotherapeutics for PDAC.
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Affiliation(s)
| | - Matthew J Rendo
- Department of Hematology and Oncology, Brooke Army Medical Center, San Antonio, TX, USA
| | - Matthew D Uy
- Department of Pathology, Brooke Army Medical Center, San Antonio, TX, USA
| | - Alexandra M Adams
- Department of Surgery, Brooke Army Medical Center, San Antonio, TX, USA
| | - Anne E O’Shea
- Department of Surgery, Brooke Army Medical Center, San Antonio, TX, USA
| | | | - Joshua L Fenderson
- Department of Hematology and Oncology, Brooke Army Medical Center, San Antonio, TX, USA
| | - Katherine M Cebe
- Department of Pathology, Brooke Army Medical Center, San Antonio, TX, USA
| | - Robert W Krell
- Department of Surgery, Brooke Army Medical Center, San Antonio, TX, USA
| | - Guy T Clifton
- Department of Surgery, Brooke Army Medical Center, San Antonio, TX, USA
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Gaya A, Camilleri P, Nash A, Hughes D, Good J. Implementation of Stereotactic MRI-Guided Adaptive Radiotherapy (SMART) for Hepatobiliary and Pancreatic Cancers in the United Kingdom - Fifty in Five. Cureus 2021; 13:e15075. [PMID: 34150409 PMCID: PMC8208498 DOI: 10.7759/cureus.15075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
The first MRIdian® MR linear accelerator (MR-Linac; ViewRay, Oakwood Village, Ohio) in the United Kingdom went live in December 2019 following a record installation time. Stereotactic MRI-guided Adaptive Radiotherapy (SMART) has since been implemented and has advantages of excellent soft tissue definition of both target and organs at risk (OARs), real-time target and OAR visualisation on cine-MRI, daily recontouring of target and critical OARs with live online plan adaptation/re-optimisation, and automatic respiratory-gated treatment delivery. We present a multi-disciplinary narrative and technical description of how this innovative technique was implemented for hepatobiliary (HPB) cancers. In particular, we explain how a collaborative approach and desire to push the boundaries and improve outcomes enabled 50 patients to be treated in the first five months, many with technically challenging tumours not always deliverable on other platforms. Physics, dosimetry, radiographer, and clinician perspectives on implementing SMART are presented. MRIdian® single fraction lung stereotactic ablative radiotherapy (SABR) will shortly be implemented along with innovative research in conjunction with our academic partners.
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Affiliation(s)
- Andrew Gaya
- Clinical Oncologist, GenesisCare, London, GBR
| | - Philip Camilleri
- Radiotherapy, Oxford University Hospitals NHS Foundation Trust, Oxford, GBR
| | - Adam Nash
- Radiotherapy, GenesisCare, Oxford, GBR
| | | | - James Good
- Radiotherapy, Queen Elizabeth Hospital, Birmingham, GBR
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23
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Rossi G, Simoni N, Paiella S, Rossi R, Venezia M, Micera R, Malleo G, Salvia R, Giuliani T, Di Gioia A, Auriemma A, Milella M, Guariglia S, Cavedon C, Bassi C, Mazzarotto R. Risk Adapted Ablative Radiotherapy After Intensive Chemotherapy for Locally Advanced Pancreatic Cancer. Front Oncol 2021; 11:662205. [PMID: 33959509 PMCID: PMC8093383 DOI: 10.3389/fonc.2021.662205] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/16/2021] [Indexed: 01/05/2023] Open
Abstract
Background and Objective To assess the efficacy of a Risk-Adapted Ablative Radiotherapy (RAdAR) approach, after intensive induction chemotherapy, in patients with locally advanced pancreatic cancer (LAPC). Material and Methods Patients with LAPC who received RAdAR following induction chemotherapy from January 2017 to December 2019 were included in this observational study. The RAdAR approach consisted of an anatomy- and simultaneous integrated boost (SIB)-based dose prescription strategy. RAdAR was delivered with stereotactic ablative radiation therapy (SAbR), administering 30 Gy in 5 fractions to the tumor volume (PTVt) and 50 Gy SIB (BED10 100 Gy) to the vascular involvement, or with (hypo-)fractionated ablative radiotherapy (HART) prescribing 50.4 Gy in 28 fractions to the PTVt, with a vascular SIB of 78.4 Gy (BED10 100 Gy). Primary end points were freedom from local progression (FFLP), overall survival (OS), and progression-free survival (PFS). Results Sixty-four LAPC patients were included. Induction chemotherapy consisted of gemcitabine/nab-paclitaxel in 60.9% and FOLFIRINOX in 39.1% of cases. SAbR was used in 52 (81.2%) patients, and HART in 12 (18.8%). After RAdAR, surgery was performed in 17 (26.6%) patients. Median follow-up was 16.1 months. Overall local control (LC) rate was 78.1%, with no difference between resected and non-resected patients (2-year FFLP 75.3% vs 56.4%; p = 0.112). Median OS and PFS were 29.7 months and 8.7 months, respectively, for the entire cohort. Resected patients had a better median OS (not reached versus 26.1 months; p = 0.0001) and PFS (19 versus 5.6 months; p < 0.0001) compared to non-resected patients. In non-resected patients, no significant difference was found between SAbR and HART for median FFLP (28.1 versus 18.5 months; p = 0.614), OS (27.4 versus 25.3 months; p = 0.624), and PFS (5.7 versus 4.3 months; p = 0.486). One patient (1.6%) experienced acute grade 4 gastro-intestinal bleeding. No other acute or late grade ≥ 3 toxicities were observed. Conclusions The RAdAR approach, following intensive induction chemotherapy, is an effective radiation treatment strategy for selected LAPC patients, representing a promising therapeutic option in a multimodality treatment regimen.
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Affiliation(s)
- Gabriella Rossi
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Nicola Simoni
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Salvatore Paiella
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Rossi
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Martina Venezia
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Renato Micera
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Tommaso Giuliani
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Anthony Di Gioia
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Alessandra Auriemma
- Department of Oncology, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Michele Milella
- Department of Oncology, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Stefania Guariglia
- Department of Medical Physics, University of Verona Hospital Trust, Verona, Italy
| | - Carlo Cavedon
- Department of Medical Physics, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Renzo Mazzarotto
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona, Italy
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24
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Cusumano D, Boldrini L, Yadav P, Casà C, Lee SL, Romano A, Piras A, Chiloiro G, Placidi L, Catucci F, Votta C, Mattiucci GC, Indovina L, Gambacorta MA, Bassetti M, Valentini V. Delta Radiomics Analysis for Local Control Prediction in Pancreatic Cancer Patients Treated Using Magnetic Resonance Guided Radiotherapy. Diagnostics (Basel) 2021; 11:diagnostics11010072. [PMID: 33466307 PMCID: PMC7824764 DOI: 10.3390/diagnostics11010072] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 12/31/2020] [Accepted: 12/31/2020] [Indexed: 02/07/2023] Open
Abstract
The aim of this study is to investigate the role of Delta Radiomics analysis in the prediction of one-year local control (1yLC) in patients affected by locally advanced pancreatic cancer (LAPC) and treated using Magnetic Resonance guided Radiotherapy (MRgRT). A total of 35 patients from two institutions were enrolled: A 0.35 Tesla T2*/T1 MR image was acquired for each case during simulation and on each treatment fraction. Physical dose was converted in biologically effective dose (BED) to compensate for different radiotherapy schemes. Delta Radiomics analysis was performed considering the gross tumour volume (GTV) delineated on MR images acquired at BED of 20, 40, and 60 Gy. The performance of the delta features in predicting 1yLC was investigated in terms of Wilcoxon Mann-Whitney test and area under receiver operating characteristic (ROC) curve (AUC). The most significant feature in predicting 1yLC was the variation of cluster shade calculated at BED = 40 Gy, with a p-value of 0.005 and an AUC of 0.78 (0.61-0.94). Delta Radiomics analysis on low-field MR images might play a promising role in 1yLC prediction for LAPC patients: further studies including an external validation dataset and a larger cohort of patients are recommended to confirm the validity of this preliminary experience.
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Affiliation(s)
- Davide Cusumano
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (D.C.); (L.B.); (A.R.); (A.P.); (G.C.); (L.P.); (F.C.); (C.V.); (G.C.M.); (L.I.); (M.A.G.); (V.V.)
| | - Luca Boldrini
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (D.C.); (L.B.); (A.R.); (A.P.); (G.C.); (L.P.); (F.C.); (C.V.); (G.C.M.); (L.I.); (M.A.G.); (V.V.)
| | - Poonam Yadav
- Department of Human Oncology, School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Ave, Madison, WI 53792, USA; (P.Y.); (M.B.)
| | - Calogero Casà
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (D.C.); (L.B.); (A.R.); (A.P.); (G.C.); (L.P.); (F.C.); (C.V.); (G.C.M.); (L.I.); (M.A.G.); (V.V.)
- Correspondence: ; Tel.: +39-06-3015-5226
| | - Sangjune Laurence Lee
- Department of Oncology, University of Calgary, 1331 29 Street NW, Calgary, AB T2N 1N4, Canada;
| | - Angela Romano
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (D.C.); (L.B.); (A.R.); (A.P.); (G.C.); (L.P.); (F.C.); (C.V.); (G.C.M.); (L.I.); (M.A.G.); (V.V.)
| | - Antonio Piras
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (D.C.); (L.B.); (A.R.); (A.P.); (G.C.); (L.P.); (F.C.); (C.V.); (G.C.M.); (L.I.); (M.A.G.); (V.V.)
| | - Giuditta Chiloiro
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (D.C.); (L.B.); (A.R.); (A.P.); (G.C.); (L.P.); (F.C.); (C.V.); (G.C.M.); (L.I.); (M.A.G.); (V.V.)
| | - Lorenzo Placidi
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (D.C.); (L.B.); (A.R.); (A.P.); (G.C.); (L.P.); (F.C.); (C.V.); (G.C.M.); (L.I.); (M.A.G.); (V.V.)
| | - Francesco Catucci
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (D.C.); (L.B.); (A.R.); (A.P.); (G.C.); (L.P.); (F.C.); (C.V.); (G.C.M.); (L.I.); (M.A.G.); (V.V.)
| | - Claudio Votta
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (D.C.); (L.B.); (A.R.); (A.P.); (G.C.); (L.P.); (F.C.); (C.V.); (G.C.M.); (L.I.); (M.A.G.); (V.V.)
| | - Gian Carlo Mattiucci
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (D.C.); (L.B.); (A.R.); (A.P.); (G.C.); (L.P.); (F.C.); (C.V.); (G.C.M.); (L.I.); (M.A.G.); (V.V.)
| | - Luca Indovina
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (D.C.); (L.B.); (A.R.); (A.P.); (G.C.); (L.P.); (F.C.); (C.V.); (G.C.M.); (L.I.); (M.A.G.); (V.V.)
| | - Maria Antonietta Gambacorta
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (D.C.); (L.B.); (A.R.); (A.P.); (G.C.); (L.P.); (F.C.); (C.V.); (G.C.M.); (L.I.); (M.A.G.); (V.V.)
| | - Michael Bassetti
- Department of Human Oncology, School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Ave, Madison, WI 53792, USA; (P.Y.); (M.B.)
| | - Vincenzo Valentini
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, 00168 Rome, Italy; (D.C.); (L.B.); (A.R.); (A.P.); (G.C.); (L.P.); (F.C.); (C.V.); (G.C.M.); (L.I.); (M.A.G.); (V.V.)
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