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Ababneh HS, Frigault MJ, Ng AK, Patel CG. Radiation therapy as bridging and salvage strategy among patients with secondary central nervous system lymphoma undergoing CD19-targeted chimeric antigen receptor T-cell therapy. Hematol Oncol 2024; 42:e3243. [PMID: 38103211 DOI: 10.1002/hon.3243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Hazim S Ababneh
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew J Frigault
- Division of Hematology & Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrea K Ng
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Chirayu G Patel
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Ababneh HS, Ng AK, Abramson JS, Soumerai JD, Takvorian RW, Frigault MJ, Patel CG. Metabolic parameters predict survival and toxicity in chimeric antigen receptor T-cell therapy-treated relapsed/refractory large B-cell lymphoma. Hematol Oncol 2024; 42:e3231. [PMID: 37795759 DOI: 10.1002/hon.3231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 09/18/2023] [Accepted: 09/21/2023] [Indexed: 10/06/2023]
Abstract
CD19-targeted chimeric antigen receptor (CAR) T-cell therapy has revolutionized treatment for patients with relapsed/refractory large B-cell lymphoma (LBCL). However, data available concerning the impact of the prognostic value of quantitative 18F-fluorodeoxyglucose positron emission tomography-computed tomography (FDG PET/CT) parameters on the CAR T-related outcomes and toxicities are limited. Therefore, we aimed to evaluate the predictive value of pre- and post-CAR T metabolic parameters on survival and toxicities following CAR T-cell therapy. Fifty-nine patients with PET/CT scans done pre-and post-CAR T infusion were retrospectively identified and analyzed in a single institution database of LBCL patients treated with commercial CD19-targeted CAR T-cell therapy. The median follow-up was 10.7 months [interquartile range (IQR): 2.6-25.5 months]. The overall response (complete response-CR and partial response) and CR rates post-CAR T were 76% (n = 45) and 53% (n = 31), respectively. On univariate analysis, low pre-CAR T total lesion glycolysis (TLG) and metabolic tumor volume (MTV) predicted improved overall response post-CAR T (OR = 4.7, p = 0.01, OR = 9.5, p = 0.03, respectively) and CR post-CAR T (OR = 12.4, p = 0.0004, OR = 10.9, p = 0.0001, respectively). High TLG pre-CAR T was correlated with cytokine release syndrome (CRS, OR = 3.25, p = 0.04). High MTV pre-CAR T was correlated with developing immune effector cell neurotoxicity syndrome (ICANS) events (OR = 4.3, p = 0.01), and high SUV pre-CAR T was associated with grade 3-4 neurological events (OR = 12, p = 0.01). High MTV/TLG/SUVmax post-CAR T were significantly associated with inferior Overall survival (OS). On multivariate analysis, high TLG pre-CAR T (HR = 2.4, p = 0.03), age ≥60 (HR = 2.7, p = 0.03), and bulky disease (≥5 cm) at the time of apheresis (HR = 2.5, p = 0.02) were identified to be independent prognostic factors for inferior PFS. High MTV post-CAR T was identified as the most prognostic factor associated with inferior OS.
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Affiliation(s)
- Hazim S Ababneh
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrea K Ng
- Department of Radiation Oncology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeremy S Abramson
- Division of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jacob D Soumerai
- Division of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ronald W Takvorian
- Division of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew J Frigault
- Division of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Chirayu G Patel
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Ababneh HS, Yee AJ, Raje NS, Martin S, Frigault MJ, Ng AK, Patel CG. Radiation therapy as a bridging and salvage strategy in patients with relapsed or refractory multiple myeloma undergoing BCMA-targeted CAR T-cell therapy. Radiother Oncol 2023; 189:109933. [PMID: 37778534 DOI: 10.1016/j.radonc.2023.109933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 09/18/2023] [Accepted: 09/23/2023] [Indexed: 10/03/2023]
Abstract
Radiation therapy (RT) may play an important role prior to and following BCMA-targeted CAR T-cell therapy in multiple myeloma (MM). We report a series of 13 patients: 5 patients received bridging RT pre-CAR T, 4 patients received salvage RT post-CAR T failure, and 4 patients received both. There was no worsening of CAR-T- or RT-related toxicities. The RT in-field local control rate was 100%, with a median follow-up after each RT course of 7.3 months. RT as a bridging and salvage strategy is safe, feasible, and offers excellent local control in MM patients treated with CAR T-cell therapy.
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Affiliation(s)
- Hazim S Ababneh
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew J Yee
- Division of Hematology & Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Noopur S Raje
- Division of Hematology & Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sidney Martin
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Matthew J Frigault
- Division of Hematology & Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrea K Ng
- Department of Radiation Oncology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Chirayu G Patel
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Ababneh HS, Ng AK, Frigault MJ, Abramson JS, Johnson PC, Jacobson CA, Patel CG. Salvage radiotherapy in relapsed/refractory large B-cell lymphoma after failure of CAR T-cell therapy. Haematologica 2023; 108:2972-2981. [PMID: 37317884 PMCID: PMC10620597 DOI: 10.3324/haematol.2023.282804] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 06/05/2023] [Indexed: 06/16/2023] Open
Abstract
Despite the success of CD19-targeted chimeric antigen receptor (CAR T)-cell therapy in patients with relapsed/refractory large B-cell lymphoma (LBCL), there is a need for effective salvage strategies post-CAR T-cell therapy failure. We conducted a multi-institutional retrospective study of patients who relapsed following CAR T-cell therapy (axicabtagene ciloleucel [axi-cel] or tisagenlecleucel [tisa-cel]) and received salvage therapies (radiation therapy [RT] alone, systemic therapy alone, or combined modality therapy [CMT]). A total of 120 patients with post-CAR T relapsed LBCL received salvage therapies (RT alone, 25 patients; CMT, 15 patients; systemic therapy alone, 80 patients). The median follow-up from CAR T-cell infusion was 10.2 months (interquartile range, 5.2-20.9 months). Failure occurred in previously involved sites prior to CAR T-cell therapy in 78% of patients (n=93). A total of 93 sites were irradiated in 54 patients who received any salvage RT post-CAR T failure. The median dose/fractionation were 30 Gy (range, 4-50.4 Gy) and 10 fractions (range, 1-28 fractions). The 1-year local control rate for the 81 assessable sites was 84%. On univariate analysis, the median overall survival (OS) from the start date of RT was significantly higher among patients who received comprehensive RT versus focal RT (19.1 months vs. 3.0 months; P=<0.001). Twenty-three of 29 patients who received comprehensive RT had limited-stage disease. Among these, there was no difference in median OS among the patients who received RT alone versus those who received RT followed by additional therapies (log-rank P=0.2). On multivariate survival analysis, achieving PR or CR post-CAR T (hazard ratio =0.5; 95% confidence interval: 0.3-0.9; P=0.01) was independently associated with superior OS. Our findings suggest that RT can provide local control for LBCL relapsed post-CAR T-cell therapy, particularly in patients with limited-stage relapsed disease treated with comprehensive RT.
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Affiliation(s)
- Hazim S Ababneh
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Andrea K Ng
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston
| | - Matthew J Frigault
- Division of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jeremy S Abramson
- Division of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Patrick Connor Johnson
- Division of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Caron A Jacobson
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Chirayu G Patel
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston.
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Ballas LK, Jr AAG, He Z, Plastaras JP, Dandapani SV, Patel CG, Khan MK, Ng AK. Phase II Multi-Institutional Study of a Low-Dose (4 Gy) Palliative Response-Adapted Radiotherapy Regimen for Symptomatic Bone Metastases from Multiple Myeloma: Planned Interim Analysis of First 40 Patients. Int J Radiat Oncol Biol Phys 2023; 117:S107. [PMID: 37784282 DOI: 10.1016/j.ijrobp.2023.06.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Painful bone lesions are common in patients with multiple myeloma (MM). Radiotherapy (RT) is effective in providing pain relief from MM bone lesions in over 80% of patients. There is no consensus as to the most effective dose or fractionation for palliation. Shorter courses of therapy are not only more convenient for patients, but they also have less impact on timing of systemic therapies. There is precedent for using 4 Gy in the palliation of lymphomas, which have similar radiosensitivity to myeloma. The primary objective of this trial is to determine whether treatment with a total dose of 4 Gy to a painful myeloma bone lesion achieves patient-reported pain reduction comparable to historical controls at 4 weeks. MATERIALS/METHODS Patients with a known diagnosis of MM and a painful bone lesion that was not at the base of skull, in need of stabilization, or causing cord compression were treated with 4 Gy (2 Gy x 2 or 4 Gy x 1). Patients' pain was measured using the brief pain index (BPI) prior to treatment and at 2, 4, 8 weeks and 6 months following treatment. Pain response was determined by the international consensus on palliative radiotherapy and considered change in BPI and oral morphine equivalent dose (OMED). A planned interim analysis for futility was completed after 40 patients. Reirradiation with clinician choice regimens could be considered at ≥4 weeks following initial treatment for indeterminate pain response or pain progression. RESULTS Forty patients were treated at 6 institutions between 2019 and 2022. Median age was 65 years with 40% women and 88% with an ECOG of 0-1. A complete response (CR) was defined as a BPI score of 0 with no concomitant increase in OMED. A partial response (PR) was defined as BPI reduction in 2 or more without analgesic increase, or an OMED reduction of 25% or more without an increase in pain. An indeterminate response (IR) was any response that is not captured by a CR, PR or pain progression. A CR was achieved in 48%, a PR in 38% of patients, an IR in 13% with 1 patient who refused participation. Pain response was achieved in 86% of patients. Seven patients (18%) requested reirradiation at ≥4 weeks. Median BPI at baseline and 4 weeks after RT for patients with CR, PR, and IR were 3.75 and 0, 4.00 and 1, and 5.25 and 4.75, respectively. Median change of BPI between baseline and 4 weeks after RT for all responders (CR and PR) was -3.25. The median PTV volume (cc) for patients with CR, PR and IR were 81, 140 and 226, respectively. Based on these results, the futility threshold was not met, and the recommendation by the DSMC is to continue the trial. CONCLUSION In the first 40 patients who received 4 Gy palliation for painful bone lesions from multiple myeloma, there were 86% that had a pain response (48% CR, 38% PR). This low dose, response-adapted treatment, led to reirradiation in less than 20% of patients.
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Affiliation(s)
- L K Ballas
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - A A Garsa Jr
- University of Southern California Keck School of Medicine, Department of Radiation Oncology, Los Angeles, CA
| | - Z He
- Keck School of Medicine of University of Southern California, Los Angeles, CA
| | - J P Plastaras
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - S V Dandapani
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA
| | - C G Patel
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN
| | | | - A K Ng
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
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Divakaran S, Lopez DM, Parks SM, Hainer J, Ng AK, Blankstein R, Di Carli MF, Nohria A. Functional testing, coronary artery calcifications, and outcomes in Hodgkin lymphoma survivors treated with chest radiation. Cardiooncology 2023; 9:5. [PMID: 36670480 PMCID: PMC9854101 DOI: 10.1186/s40959-023-00157-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 01/09/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND Consensus guidelines recommend periodic screening for coronary artery disease (CAD) in Hodgkin lymphoma (HL) survivors treated with radiation therapy (RT) to the chest. However, the prognostic utility of screening strategies in this population remains unclear. We evaluated the association between functional testing, coronary artery calcifications (CAC), and guideline-based risk assessment and major adverse cardiovascular events (MACE) in HL survivors treated with RT. METHODS We retrospectively studied HL survivors treated with RT who underwent functional testing between 2003 and 2020 and chest computed tomography (CT) within 12 months of each other at our center. CAC was assessed semi-quantitatively from CT images. Cardiovascular risk was estimated using the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. Diagnostic test characteristics were calculated using major adverse cardiac events (MACE) during follow-up as the gold standard. RESULTS The study included 159 patients (median age at functional testing 48 years, median age at HL diagnosis 27 years, 62.9% female). Abnormal functional testing had the highest specificity (94.2% (95% CI 88.4%-97.6%)) and positive likelihood ratio (4.55 (95% CI 1.86-11.13)) while CAC had the highest sensitivity (63.2% (95% CI 46.0%-78.2%)) and lowest negative likelihood ratio (0.52 (95% CI 0.34-0.80)). Specificity for ACC/AHA risk assessment was also high (88.5% (95% CI 81.1%-93.7%)). Over 3.3 years of follow-up, abnormal functional testing (adjusted subdistribution hazard ratio (SHR) 5.10, 95% CI 2.41 - 10.78, p < 0.001) and CAC (adjusted SHR 3.58, 95% CI 1.35 - 9.47, p = 0.010) were both significantly associated with MACE. CONCLUSIONS In HL survivors treated with RT, both abnormal functional testing and ACC/AHA risk assessment had high specificity for subsequent MACE, but CAC had higher sensitivity. Further research is needed to inform CAD screening and primary prevention strategies in this population.
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Affiliation(s)
- Sanjay Divakaran
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Boston, MA, USA
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Brigham & Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, USA
| | - Diana M Lopez
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Boston, MA, USA
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Brigham & Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, USA
| | - Sean M Parks
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Jon Hainer
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Andrea K Ng
- Harvard Medical School, Boston, MA, USA
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, MA, USA
| | - Ron Blankstein
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Boston, MA, USA
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Brigham & Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, USA
| | - Marcelo F Di Carli
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Boston, MA, USA
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Brigham & Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, USA
| | - Anju Nohria
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Brigham & Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
- Harvard Medical School, Boston, MA, USA.
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Jones G, Plastaras JP, Ng AK, Kelsey CR. The Evolving Role of Radiation Therapy in DLBCL: From Early-Stage to Refractory Disease. Oncology (Williston Park) 2022; 36:718-727. [PMID: 36548096 DOI: 10.46883/2022.25920980] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma. Historically, radiation therapy (RT) served as the primary treatment modality for patients with localized disease. While still an option for select patients who are not candidates for systemic therapy, RT is currently used most frequently as a consolidation treatment after chemoimmunotherapy. Consolidation RT is most commonly recommended after an abbreviated course of systemic therapy in patients who have bulky disease or multiple risk factors, or in the setting of a partial response. Consolidation RT is also appropriate in some patients with advanced DLBCL, including those presenting with bulky disease (≥7.5 cm). While many patients achieve sustained remissions after first-line therapy, up to 50% of patients with DLBCL will eventually relapse. The most common salvage options include second-line chemotherapy followed by high-dose chemotherapy and autologous stem cell transplantation (ASCT) and chimeric antigen receptor (CAR) T-cell therapy. RT can be used in both settings to optimize clinical outcomes. This includes consolidation RT in patients with localized presentations or bulky disease in the setting of ASCT and bridging RT in select patients undergoing CAR T-cell therapy. RT is also a valuable modality in any patient with symptomatic disease requiring palliation.
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Dabaja BS, Ng AK. Let us give our Hodgkin's lymphoma patients the radiation they need. Leuk Lymphoma 2022; 63:2763-2764. [PMID: 36107106 DOI: 10.1080/10428194.2022.2123237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
| | - Andrea K Ng
- Dana-Farber Brigham Cancer Center, Harvard Medical School, Boston, MA, USA
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Liu KX, Milligan MG, Schoenfeld JD, Tishler RB, Ng AK, Devlin PM, Fite E, Rabinowits G, Hanna GJ, Silk AW, Yoon CH, Thakuria M, Margalit DN. Characterization of clinical outcomes after shorter course hypofractionated and standard-course radiotherapy for stage I-III curatively-treated Merkel cell carcinoma. Radiother Oncol 2022; 173:32-40. [PMID: 35595174 DOI: 10.1016/j.radonc.2022.05.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 05/08/2022] [Accepted: 05/09/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Limited data exists regarding the efficacy of curative hypofractionated radiotherapy (hypo-RT) regimens compared to conventionally-fractionated radiotherapy (conv-RT) for Merkel cell carcinoma (MCC). METHODS A retrospective analysis of 241 patients diagnosed with non-metastatic MCC from 2005-2021 and who received RT at Dana-Farber/Brigham & Women's Cancer Center. The primary outcome was cumulative incidence of in-field locoregional relapse using Gray's test with competing risks of death and isolated out-of-field recurrence. Secondary outcomes included overall survival (OS) and MCC-specific survival using log-rank tests, and risk factors of recurrence using Cox-proportional hazards regression. RESULTS There were 50 (20.6%) and 193 (79.4%) courses of hypo-RT and conv-RT, respectively. The hypo-RT cohort was older (≥73 years at diagnosis: 78.0% vs. 41.5%, p<0.01), and received a lower equivalent total RT dose in 2 Gy per fraction (<50 Gy: 58.0% vs. 5.2%, p<0.01). Median follow-up was 65.1 months (range: 1.2-194.5) for conv-RT and 25.0 months (range: 1.6-131.3) for hypo-RT cohorts. Two-year cumulative incidence of in-field locoregional relapse was low in both groups (1.1% conv-RT vs. 4.1% hypo-RT, p=0.114). While two-year OS was lower for the hypo-RT group (62.6% vs. 84.4%, p=0.0008), two-year MCC-specific survival was similar (84.7 vs. 86.6%, p=0.743). On multivariable analysis, immunosuppression, clinical stage III disease, and lymphovascular invasion were associated with any-recurrence when controlling for sex, age, and hypo-RT. CONCLUSIONS AND RELEVANCE There was no difference in cumulative incidence of in-field locoregional relapse or MCC-specific survival between hypo-RT and conv-RT. Prospective studies are needed to confirm hypo-RT as an efficacious treatment option for MCC.
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Affiliation(s)
- Kevin X Liu
- Department of Radiation Oncology, Brigham & Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, United States
| | - Michael G Milligan
- Department of Radiation Oncology, Brigham & Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, United States
| | - Jonathan D Schoenfeld
- Department of Radiation Oncology, Brigham & Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, United States; Merkel Cell Carcinoma Center of Excellence, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts, United States
| | - Roy B Tishler
- Department of Radiation Oncology, Brigham & Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, United States; Merkel Cell Carcinoma Center of Excellence, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts, United States
| | - Andrea K Ng
- Department of Radiation Oncology, Brigham & Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, United States
| | - Phillip M Devlin
- Department of Radiation Oncology, Brigham & Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, United States
| | - Elliott Fite
- Department of Radiation Oncology, Brigham & Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, United States
| | - Guilherme Rabinowits
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, United States
| | - Glenn J Hanna
- Merkel Cell Carcinoma Center of Excellence, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts, United States; Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, United States
| | - Ann W Silk
- Merkel Cell Carcinoma Center of Excellence, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts, United States; Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, United States
| | - Charles H Yoon
- Merkel Cell Carcinoma Center of Excellence, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts, United States; Division of Surgical Oncology, Department of Surgery, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts, United States
| | - Manisha Thakuria
- Merkel Cell Carcinoma Center of Excellence, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts, United States; Department of Dermatology, Dana-Farber Cancer Institute, Boston, Massachusetts, United States
| | - Danielle N Margalit
- Department of Radiation Oncology, Brigham & Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, United States; Merkel Cell Carcinoma Center of Excellence, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts, United States.
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Shbib Dabaja B, Boyce-Fappiano D, Dong W, Damron E, Fang P, Gunther J, Rodriguez MA, Strati P, Steiner R, Nair R, Lee H, Abou Yehia Z, Shihadeh F, Pinnix C, Ng AK. Second Malignancies in Patients with Hodgkin’s Lymphoma: Half a Century of Experience. Clin Transl Radiat Oncol 2022; 35:64-69. [PMID: 35601797 PMCID: PMC9121058 DOI: 10.1016/j.ctro.2022.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 04/07/2022] [Accepted: 04/25/2022] [Indexed: 12/05/2022] Open
Abstract
Purpose Therapeutic improvements for Hodgkin’s Lymphoma (HL) has resulted in excellent survival outcomes. Thus, patients are increasing susceptible to developing secondary malignancy (SM) a feared iatrogenic complication. Materials & Methods We evaluated the SM risk in a cohort of patients with HL treated over a 50-year period. In total, 1653 patients were treated for HL from 1956 to 2009 at a tertiary-cancer-center. A cumulative incidence function was used to quantify SM risk and the Fine and Gray competing risk model was used to identify disease and treatment related correlates. Results Two-hundred-ninety patients (19%) developed SMs. Paradoxically, SM risk was higher in the modern era with 20-year cumulative incidence rates of 11.1%, 11.9%, 17% and 21.8%, for patients treated <1970, 1971–1986, 1986–1995 and 1996–2009, respectively. We hypothesized that the disproportionately high rate of early deaths in the early era may skew the assessment of SM risks, a much-delayed event. When the analysis was restricted to patients with early-stage favorable HL treated >1980, we found a reversal of the trend, especially on the risk of solid tumor, with a hazard ratio of 0.57 (p = 0.0651) in patients treated after 1996. Conclusion Our findings highlight the limitations of comparing the risk of a late event between groups with disparate rates of early deaths, despite the use of a competing risk model. When partially corrected for, patients treated in the more recent time period experienced a lower solid tumor risk.
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Affiliation(s)
- Bouthaina Shbib Dabaja
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Corresponding author at: Department of Radiation Oncology, Division of Radiation Oncology Incident Commander, University of Texas MD Anderson Cancer Center, Director of Research of the International Lymphoma Radiation Oncology Group (ILROG), 1515 Holcombe Blvd., Houston, TX 77030, USA.
| | - David Boyce-Fappiano
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wenli Dong
- Departments of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ethan Damron
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Penny Fang
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jill Gunther
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maria A. Rodriguez
- Departments of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paolo Strati
- Departments of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Raphael Steiner
- Departments of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ranjit Nair
- Departments of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hun Lee
- Departments of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zeinab Abou Yehia
- Department of Radiation Oncology, Rutgers Robertwood Johnson Medical Center, Houston, TX, USA
| | - Ferial Shihadeh
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Chelsea Pinnix
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrea K. Ng
- Department of Radiation Oncology, Dana-Farber/Brigham and Women’s Cancer Center, Harvard Medical School, Houston, TX, USA
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11
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Wallner PE, Gerdeman AM, Warg L, Fussell MB, Segal S, Gudenkauf K, Laszakovits D, Bunting M, Davis BJ, Ng AK, Suh JH, Yashar CM, Alektiar KM, Wagner BJ. The ABR 2021 Radiation Oncology Remote Examinations: Development, Administration, and Implications for the Future. J Am Coll Radiol 2022; 19:663-668. [PMID: 35341700 PMCID: PMC8947774 DOI: 10.1016/j.jacr.2022.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 02/14/2022] [Accepted: 02/15/2022] [Indexed: 11/20/2022]
Abstract
With the onset of the global coronavirus disease 2019 pandemic in early 2020, it became apparent that routine administration of the ABR Qualifying and Certifying Exams would be disrupted. Initial intent for postponement was later altered to a recognition that replacement of the existing delivery methodologies was essential. Herein, the authors describe the conceptualization, development, administration, and future implications of the new remote examination delivery platforms.
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Affiliation(s)
- Paul E Wallner
- Senior Vice President for Medical Affairs, GenesisCare USA, Fort Myers, Florida; and Associate Executive Director, Radiation Oncology, American Board of Radiology, Tucson, Arizona.
| | | | - Lydia Warg
- American Board of Radiology, Tucson, Arizona
| | | | - Scott Segal
- American Board of Radiology, Tucson, Arizona
| | | | - David Laszakovits
- Director, Communications and External Affarirs, American Board of Radiology, Tucson, Arizona
| | | | - Brian J Davis
- Professor, Radiation Oncology, Mayo Medical School, Rochester, Minnesota
| | - Andrea K Ng
- Professor, Radiation Oncology, Brigham and Women's Hospital, Boston, Massachusetts
| | - John H Suh
- Professor and Chair, Radiation Oncology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Catheryn M Yashar
- Professor, Radiation Oncology, University of California San Diego, San Diego, California
| | - Kaled M Alektiar
- Professor, Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Brent J Wagner
- Executive Director, American Board of Radiology, Tucson, Arizona
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12
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Lee SF, Vellayappan BA, Wong LC, Chiang CL, Chan SK, Wan EYF, Wong ICK, Lambert PC, Rachet B, Ng AK, Luque-Fernandez MA. Cardiovascular diseases among diffuse large B-cell lymphoma long-term survivors in Asia: a multistate model study. ESMO Open 2022; 7:100363. [PMID: 35026723 PMCID: PMC8760397 DOI: 10.1016/j.esmoop.2021.100363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 11/26/2021] [Accepted: 12/03/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND We modeled the clinical course of a cohort of diffuse large B-cell lymphoma (DLBCL) patients with no prior cardiovascular diseases (CVDs) using a multistate modeling framework. PATIENTS AND METHODS Data on 2600 patients with DLBCL diagnosed between 2000 and 2018 and had received chemotherapy with or without radiotherapy were obtained from a population-wide electronic health database of Hong Kong. We used the Markov illness-death model to quantify the impact of doxorubicin and various risk factors (therapeutic exposure, demographic, comorbidities, cardiovascular risk factors, and lifestyle factors which included smoking) on the clinical course of DLBCL (transitions into incident CVD, lymphoma death, and other causes of death). RESULTS A total of 613 (23.6%) and 230 (8.8%) of 2600 subjects died of lymphoma and developed incident CVD, respectively. Median follow-up was 7.0 years (interquartile range 3.8-10.8 years). Older ages [hazard ratio (HR) for >75 versus ≤60 years 1.88; 95% confidence interval (CI) 1.25-2.82 and HR for 61-75 versus ≤60 years 1.60; 95% CI 1.12-2.30], hypertension (HR 4.92; 95% CI 2.61-9.26), diabetes (HR 1.43; 95% CI 1.09-1.87), and baseline use of aspirin (HR 5.30; 95% CI 3.93-7.16) were associated with an increased risk of incident CVD. In a subgroup of anticipated higher-risk patients (aged 61-75 years, smoked, had diabetes, and received doxorubicin), we found that they remained on average 7.9 (95% CI 7.2-8.8) years in the DLBCL state and 0.1 (95% CI 0.0-0.4) years in the CVD state, if they could be followed up for 10 years. The brief time in the CVD state is consistent with the high chance of death in patients who developed CVD. Other causes of death have overtaken DLBCL-related death after about 5 years. CONCLUSIONS In this Asian population-based cohort, we found that incident CVDs can occur soon after DLBCL treatment and continued to occur throughout survivorship. Clinicians are advised to balance the risks and benefits of treatment choices to minimize the risk of CVD.
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Affiliation(s)
- S F Lee
- Department of Clinical Oncology, The University of Hong Kong, Hong Kong; Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong
| | - B A Vellayappan
- Department of Radiation Oncology, National University Cancer Institute, Singapore
| | - L C Wong
- Department of Radiation Oncology, National University Cancer Institute, Singapore
| | - C L Chiang
- Department of Clinical Oncology, The University of Hong Kong, Hong Kong; Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong
| | - S K Chan
- Department of Clinical Oncology, The University of Hong Kong, Hong Kong
| | - E Y-F Wan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong; Department of Family Medicine and Primary Care, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong; Laboratory of Data Discovery for Health (D24H), Hong Kong Science and Technology Park, Sha Tin, Hong Kong
| | - I C-K Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong; Laboratory of Data Discovery for Health (D24H), Hong Kong Science and Technology Park, Sha Tin, Hong Kong; Research Department of Policy and Practice, School of Pharmacy, University College London, London, UK
| | - P C Lambert
- Biostatistics Research Group, Department of Health Sciences, University of Leicester, Leicester, UK; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - B Rachet
- Department of Non-Communicable Disease Epidemiology, ICON Group, London School of Hygiene and Tropical Medicine, London, UK
| | - A K Ng
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
| | - M A Luque-Fernandez
- Department of Family Medicine and Primary Care, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong; Department of Non-Communicable Disease and Cancer Epidemiology, Instituto de Investigacion Biosanitaria de Granada (ibs.GRANADA), Andalusian School of Public Health, Granada, Spain.
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13
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Ng AK, Yashar CM, Davis BJ, Suh JH, Alektiar KM, Wallner PE. Implications of Medical Board Certification Practices on Family Planning and Professional Trajectory for Early Career Female Radiation Oncologists: In Response to Dover et al. Pract Radiat Oncol 2021; 12:103-105. [PMID: 34775126 DOI: 10.1016/j.prro.2021.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 10/28/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Andrea K Ng
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Catheryn M Yashar
- Department of Radiation Oncology, University of California San Diego, San Diego, California
| | - Brian J Davis
- Department of Radiation Oncology, Mayo Medical School, Rochester, Minnesota
| | - John H Suh
- Department of Radiation Oncology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Kaled M Alektiar
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Paul E Wallner
- GenesisCare USA, Fort Myers, Florida; The American Board of Radiology, Tucson, Arizona.
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14
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Bergom C, Bradley JA, Ng AK, Samson P, Robinson C, Lopez-Mattei J, Mitchell JD. Past, Present, and Future of Radiation-Induced Cardiotoxicity: Refinements in Targeting, Surveillance, and Risk Stratification. JACC CardioOncol 2021; 3:343-359. [PMID: 34604796 PMCID: PMC8463722 DOI: 10.1016/j.jaccao.2021.06.007] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 06/07/2021] [Accepted: 06/09/2021] [Indexed: 12/13/2022] Open
Abstract
Radiation therapy is an important component of cancer therapy for many malignancies. With improvements in cardiac-sparing techniques, radiation-induced cardiac dysfunction has decreased but remains a continued concern. In this review, we provide an overview of the evolution of radiotherapy techniques in thoracic cancers and associated reductions in cardiac risk. We also highlight data demonstrating that in some cases radiation doses to specific cardiac substructures correlate with cardiac toxicities and/or survival beyond mean heart dose alone. Advanced cardiac imaging, cardiovascular risk assessment, and potentially even biomarkers can help guide post-radiotherapy patient care. In addition, treatment of ventricular arrhythmias with the use of ablative radiotherapy may inform knowledge of radiation-induced cardiac dysfunction. Future efforts should explore further personalization of radiotherapy to minimize cardiac dysfunction by coupling knowledge derived from enhanced dosimetry to cardiac substructures, post-radiation regional dysfunction seen on advanced cardiac imaging, and more complete cardiac toxicity data.
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Key Words
- CAC, coronary artery calcium
- CAD, coronary artery disease
- CMRI, cardiac magnetic resonance imaging
- CT, computed tomography
- HL, Hodgkin lymphoma
- LAD, left anterior descending artery
- LV, left ventricular
- MHD, mean heart dose
- NSCLC, non–small cell lung cancer
- RICD, radiation-induced cardiovascular disease
- RT, radiation therapy
- SBRT, stereotactic body radiation therapy
- breast cancer
- cancer survivorship
- childhood cancer
- esophageal cancer
- imaging
- lung cancer
- lymphoma
- radiation physics
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Affiliation(s)
- Carmen Bergom
- Department of Radiation Oncology, Washington University, Saint Louis, Missouri, USA
- Cardio-Oncology Center of Excellence, Washington University, St. Louis, Missouri, USA
- Alvin J. Siteman Center, Washington University, St. Louis, Missouri, USA
| | - Julie A. Bradley
- Department of Radiation Oncology, University of Florida, Jacksonville, Florida, USA
| | - Andrea K. Ng
- Department of Radiation Oncology, Dana-Farber/Brigham and Women’s Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Pamela Samson
- Department of Radiation Oncology, Washington University, Saint Louis, Missouri, USA
- Alvin J. Siteman Center, Washington University, St. Louis, Missouri, USA
| | - Clifford Robinson
- Department of Radiation Oncology, Washington University, Saint Louis, Missouri, USA
- Alvin J. Siteman Center, Washington University, St. Louis, Missouri, USA
- Division of Cardiology, Department of Medicine, Washington University, St. Louis, Missouri, USA
| | - Juan Lopez-Mattei
- Departments of Cardiology and Thoracic Imaging, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Joshua D. Mitchell
- Cardio-Oncology Center of Excellence, Washington University, St. Louis, Missouri, USA
- Alvin J. Siteman Center, Washington University, St. Louis, Missouri, USA
- Division of Cardiology, Department of Medicine, Washington University, St. Louis, Missouri, USA
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15
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Rizwan R, Gauvreau K, Vinograd C, Yamada JM, Mangano C, Ng AK, Alexander ME, Chen MH. Vo 2peak in Adult Survivors of Hodgkin Lymphoma: Rate of Decline, Sex Differences, and Cardiovascular Events. JACC CardioOncol 2021; 3:263-273. [PMID: 34396333 PMCID: PMC8352271 DOI: 10.1016/j.jaccao.2021.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 04/18/2021] [Accepted: 04/21/2021] [Indexed: 01/08/2023]
Abstract
Background Adult survivors of Hodgkin lymphoma (HL) are at increased risk of cardiovascular (CV) events secondary to mediastinal radiation therapy (RT). Objectives In this group of patients, we assessed the association between cardiopulmonary exercise testing (CPET), as determined by percent-predicted peak Vo2 (ppVo2peak), and clinical outcomes, as well as the rate of ppVo2peak decline and sex differences. Methods All survivors of HL who were >10 years post chest RT and who underwent ≥1 CPET were enrolled from a single center. Traditional CV and treatment risk factors, along with CV events, were ascertained. Results A total of 64 patients (67% female; median age 51 years [range 26 to 70 years]) with a median follow-up time after RT of 23 years (range 11 to 41 years), and 141 CPET studies, were included. Median initial ppVo2peak was 91% (range 58% to 138%). ppVo2peak in survivors declined by 7.5 percentage points every 10-year period after RT, as compared with age- and sex-based norms (P = 0.001), even after adjusting for hypertension and history of anthracycline. Both male and female patients had a similar rate of ppVo2peak decline. However, women had a lower ppVo2peak at all times, and they developed abnormal ppVo2peak (≤85%) on average earlier than men (24.1 years vs 47.0 years after RT). Patients with abnormal ppVo2peak vs normal ppVo2peak (>85%), had an increased risk of CV events (59% vs 16%). Abnormal ppVo2peak was independently associated with the risk of CV events (adjusted HR: 6.37; 95% CI: 2.06-19.80; P = 0.001). Conclusions Percent-predicted Vo2peak in long-term survivors of HL who were treated with chest RT progressively declined as compared with population- and sex-based norms. Importantly, women developed abnormal ppVo2peak more than 2 decades earlier than male survivors. Abnormal ppVo2peak was associated with an increased risk of CV events in this group of patients.
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Affiliation(s)
- Raheel Rizwan
- Department of Pediatrics, Division of Genetics and Genomics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Cheryl Vinograd
- Department of Pediatrics, New York University Grossman School of Medicine, New York, New York, USA
| | - Jessica M Yamada
- Department of Pediatrics, Division of Genetics and Genomics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Christina Mangano
- Department of Pediatrics, Division of Genetics and Genomics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Andrea K Ng
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark E Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Ming Hui Chen
- Department of Pediatrics, Division of Genetics and Genomics, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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16
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Mulder RL, Hudson MM, Bhatia S, Landier W, Levitt G, Constine LS, Wallace WH, van Leeuwen FE, Ronckers CM, Henderson TO, Moskowitz CS, Friedman DN, Ng AK, Jenkinson HC, Demoor-Goldschmidt C, Skinner R, Kremer LC, Oeffinger KC. Updated Breast Cancer Surveillance Recommendations for Female Survivors of Childhood, Adolescent, and Young Adult Cancer From the International Guideline Harmonization Group. J Clin Oncol 2020; 38:4194-4207. [PMID: 33078972 PMCID: PMC7723685 DOI: 10.1200/jco.20.00562] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2020] [Indexed: 01/02/2023] Open
Abstract
PURPOSE As new evidence is available, the International Late Effects of Childhood Cancer Guideline Harmonization Group has updated breast cancer surveillance recommendations for female survivors of childhood, adolescent, and young adult cancer. METHODS We used evidence-based methods to apply new knowledge in refining the international harmonized recommendations developed in 2013. The guideline panel updated the systematic literature review, developed evidence summaries, appraised the evidence, and updated recommendations on the basis of evidence, clinical judgement, and consideration of benefits versus the harms of the surveillance interventions while attaining flexibility in implementation across different health care systems. The GRADE Evidence-to-Decision framework was used to translate evidence to recommendations. A survivor information form was developed to counsel survivors about the potential harms and benefits of surveillance. RESULTS The literature update identified new study findings related to the effects of prescribed moderate-dose chest radiation (10 to 19 Gy), radiation dose-volume, anthracyclines and alkylating agents in non-chest irradiated survivors, and the effects of ovarian function on breast cancer risk. Moreover, new data from prospective investigations were available regarding the performance metrics of mammography and magnetic resonance imaging among survivors of Hodgkin lymphoma. Modified recommendations include the performance of mammography and breast magnetic resonance imaging for survivors treated with 10 Gy or greater chest radiation (strong recommendation) and upper abdominal radiation exposing breast tissue at a young age (moderate recommendation) at least annually up to age 60 years. As a result of inconsistent evidence, no recommendation could be formulated for routine breast cancer surveillance for survivors treated with any type of anthracyclines in the absence of chest radiation. CONCLUSION The newly identified evidence prompted significant change to the recommendations formulated in 2013 related to moderate-dose chest radiation and anthracycline exposure as well as breast cancer surveillance modality.
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Affiliation(s)
- Renée L. Mulder
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Melissa M. Hudson
- Departments of Epidemiology and Cancer Control, and Oncology, St Jude Children’s Research Hospital, Memphis, TN
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship and Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Wendy Landier
- Institute for Cancer Outcomes and Survivorship and Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Gill Levitt
- Department of Oncology/Haematology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Louis S. Constine
- Departments of Radiation Oncology and Pediatrics, University of Rochester Medical Center, Rochester, NY
| | - W. Hamish Wallace
- Department of Paediatric Oncology, Royal Hospital for Sick Children, Edinburgh, United Kingdom
| | - Flora E. van Leeuwen
- Department of Epidemiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Cécile M. Ronckers
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Institute for Biostatistics and Registry Research, Medical University Brandenburg, Theodor Fontane, Neuruppin, Germany
| | - Tara O. Henderson
- Department of Pediatrics, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Chaya S. Moskowitz
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Danielle N. Friedman
- Departments of Pediatrics and Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Helen C. Jenkinson
- Department of Paediatric Oncology, Birmingham Children’s Hospital, NHS Foundation Trust, Birmingham, United Kingdom
| | - Charlotte Demoor-Goldschmidt
- Centre for Research in Epidemiology and Population Health, Cancer and Radiation team, University of Paris-Sud, Villejuif, France
- Department of Pediatric and Adolescent Hematology/Oncology, CHU Angers, Angers, France
| | - Roderick Skinner
- Department of Paediatric and Adolescent Haematology/Oncology, Great North Children’s Hospital and Newcastle University Centre for Cancer, Newcastle upon Tyne, United Kingdom
| | - Leontien C.M. Kremer
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Department of Pediatric Oncology, Emma Children’s Hospital, Amsterdam University Medical Center, University of Amsterdam, the Netherlands
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17
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Wallner PE, Segal S, Laszakovits DJ, Michalski JM, Ng AK. The American Board of Radiology Online Longitudinal Assessment Part 3 Maintenance of Certification Instrument: Rationale and Summary of 6-Month Experience. Pract Radiat Oncol 2020; 10:386-388. [PMID: 32771625 DOI: 10.1016/j.prro.2020.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 07/24/2020] [Accepted: 07/28/2020] [Indexed: 10/23/2022]
Affiliation(s)
| | - Scott Segal
- The American Board of Radiology, Tucson, Arizona
| | | | - Jeff M Michalski
- Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Andrea K Ng
- Dana-Farber/Brigham and Women's Hospital, Boston, Massachusetts
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18
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Dabaja BS, Ng AK, Terezakis SA, Plastaras JP, Yunes M, Wilson LD, Yang J, Gunther JR, Specht L, Yahalom J. ILROG Lymphoma Mini-Atlas Part II, Hodgkin Lymphoma. Int J Radiat Oncol Biol Phys 2020; 108:977-978. [PMID: 32768256 DOI: 10.1016/j.ijrobp.2020.05.063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 05/10/2020] [Accepted: 05/14/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Bouthaina Shbib Dabaja
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - Andrea K Ng
- Department of Radiation Oncology, Brigham & Women's Hospital, Boston, Massachusetts
| | - Stephanie A Terezakis
- Department of Radiation Oncology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - John P Plastaras
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Micheal Yunes
- Department of Radiation Oncology, Department of Radiology, UMMS-Baystate, Springfield, Massachusetts
| | - Lynn D Wilson
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - Joanna Yang
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
| | - Jillian R Gunther
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lena Specht
- Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Joachim Yahalom
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York City, New York
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19
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Wirth A, Mikhaeel NG, Aleman BM, Pinnix CC, Constine LS, Ricardi U, Illidge TM, Eich HT, Hoppe BS, Dabaja B, Ng AK, Kirova Y, Berthelsen AK, Dieckmann K, Yahalom J, Specht L. Involved Site Radiation Therapy in Adult Lymphomas: An Overview of International Lymphoma Radiation Oncology Group Guidelines. Int J Radiat Oncol Biol Phys 2020; 107:909-933. [DOI: 10.1016/j.ijrobp.2020.03.019] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 03/11/2020] [Indexed: 12/15/2022]
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20
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Patel CG, Ng AK. Involved-Site Radiation Therapy for Early-Stage NLPHL. Int J Radiat Oncol Biol Phys 2020; 107:21-22. [DOI: 10.1016/j.ijrobp.2019.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 08/31/2019] [Accepted: 09/13/2019] [Indexed: 11/28/2022]
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21
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Kim DW, Lee G, Lee H, Mahal AR, Lam MB, Ng AK. Response to hyperfractionated accelerated radiotherapy in chemotherapy-refractory non-Hodgkin lymphoma. Leuk Lymphoma 2020; 61:1428-1434. [PMID: 32102580 DOI: 10.1080/10428194.2020.1719096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Patients with chemotherapy-refractory non-Hodgkin lymphoma (NHL) have a poor prognosis with a median overall survival (OS) of only 10 months. To investigate the role of radiotherapy (RT) in such patients, we conducted a retrospective review of 17 patients with biopsy-proven refractory NHL who received hyperfractionated accelerated RT between 2000 and 2017. Forty-seven percent had stages I and II and 53% had stages III and IV disease. Majority (59%) had diffuse large B-cell lymphoma. One-year local control rate was 82%. Fifty-nine percent proceeded to hematopoietic stem cell transplantation (HSCT). At a median follow-up time of 8.8 months (range: 13 days to 17.4 years), 10 were alive with five in remission. Six patients were long-term survivors with a median OS of 8.1 years. Hyperfractionated accelerated RT in chemotherapy-refractory NHL provides durable local disease control in the majority of cases. Combined with HSCT, the RT regimen may also provide long-term disease remission in a subset of patients.
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Affiliation(s)
- Daniel W Kim
- Department of Radiation Oncology, Brigham and Women's/Dana-Farber Cancer Center, Boston, MA, USA
| | - Grace Lee
- Harvard Medical School, Boston, MA, USA
| | - Hwan Lee
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Miranda B Lam
- Department of Radiation Oncology, Brigham and Women's/Dana-Farber Cancer Center, Boston, MA, USA
| | - Andrea K Ng
- Department of Radiation Oncology, Brigham and Women's/Dana-Farber Cancer Center, Boston, MA, USA
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22
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Dabaja BS, Ng AK, Terezakis SA, Plastaras JP, Yunes M, Wilson LD, Specht L, Yahalom J. Making Every Single Gray Count: Involved Site Radiation Therapy Delineation Guidelines for Hematological Malignancies. Int J Radiat Oncol Biol Phys 2020; 106:279-281. [DOI: 10.1016/j.ijrobp.2019.10.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 08/07/2019] [Accepted: 10/18/2019] [Indexed: 12/31/2022]
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Abstract
Radiation therapy plays a critical role in the management of a wide range of hematologic malignancies. The optimal radiation dose and target volume, and safe and effective ways of integrating radiation with systemic agents, vary depending on the histologic subtypes, stage at presentation, patient performance status, response to systemic therapy if given, treatment intent, and patient preferences. Limiting doses to surrounding organs without sacrificing disease control is of paramount importance. Reducing radiation doses and treatment volume in selected cases, and the use of advanced radiotherapy technology, can improve the therapeutic ratio of patients receiving radiation therapy for hematologic malignancies.
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Affiliation(s)
- Yolanda D Tseng
- Department of Radiation Oncology, Seattle Cancer Care Alliance Proton Therapy Center, University of Washington School of Medicine, 1570 North 115th Street, Seattle, WA 98133, USA
| | - Andrea K Ng
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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Wallner PE, Kachnic LA, Alektiar KM, Davis BJ, Hardenbergh PH, Ng AK. The American Board of Radiology Initial Certification in Radiation Oncology: Moving Forward Through Collaboration. Int J Radiat Oncol Biol Phys 2019; 104:21-23. [PMID: 30967226 DOI: 10.1016/j.ijrobp.2019.01.090] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 01/21/2019] [Accepted: 01/25/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Paul E Wallner
- 21st Century Oncology, Inc, Ft. Myers, Florida; The American Board of Radiology, Tucson, Arizona.
| | | | | | | | | | - Andrea K Ng
- Brigham & Women's Hospital, Boston, Massachusetts
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25
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Binkley MS, Brady JL, Hajj C, Chelius M, Chau K, Balogh A, Levis M, Filippi AR, Jones M, Ahmed S, MacManus M, Wirth A, Oguchi M, Vistisen AK, Andraos TY, Ng AK, Aleman BMP, Choi SH, Kirova YM, Hardy S, Reinartz G, Eich HT, Bratman SV, Constine LS, Suh CO, Dabaja B, El-Galaly TC, Hodgson DC, Ricardi U, Yahalom J, Mikhaeel NG, Hoppe RT. Salvage Treatment and Survival for Relapsed Follicular Lymphoma Following Primary Radiation Therapy: A Collaborative Study on Behalf of ILROG. Int J Radiat Oncol Biol Phys 2019; 104:522-529. [PMID: 30858143 DOI: 10.1016/j.ijrobp.2019.03.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 02/18/2019] [Accepted: 03/02/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE We previously reported that ∼30% of patients with localized follicular lymphoma (FL) staged by 18F-fluorodeoxyglucose positron emission tomography-computed tomography receiving primary radiation therapy (RT) will relapse within 5 years. We sought to report outcomes for those who relapsed. METHODS AND MATERIALS We conducted a multicenter, retrospective study of patients aged ≥18 years who received RT ≥ 24 Gy for stage I to II, grade 1 to 3A FL, staged with 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography-computed tomography. Observation was defined as >6 months without treatment from relapse. Overall survival (OS) and freedom from progression (FFP) were estimated with Kaplan-Meier analysis and univariable and multivariable analyses with Cox regression. RESULTS Of 512 patients with median follow-up of 52 months, 149 (29.1%) developed recurrent lymphoma at a median of 23 months (range, 1-143) after primary RT. Median follow-up was 33 months after relapse. Three-year OS was 91.4% after recurrence. OS was significantly worse for those with relapse ≤12 months from date of diagnosis versus all others-88.7% versus 97.6%, respectively (P = .01)-and remained significantly worse on multivariable analyses (follicular lymphoma international prognostic index-adjusted hazard ratio, 3.61; P = .009). Histology at relapse included 93 indolent (grade 1-3A), 3 FL grade 3B/not otherwise specified, and 18 diffuse large B-cell lymphoma; 35 patients did not undergo biopsy. Of those with follow-up ≥3 months who underwent biopsy (n = 74) or had presumed (n = 23) indolent recurrence, 58 patients (59.8%) were observed, 19 (19.6%) had systemic therapy, 16 (16.5%) had RT, and 4 (4.1%) had systemic therapy + RT. For patients with indolent recurrences that were observed, 3-year FFP or freedom from treatment was 56.6% (median, 48 months). For all patients with biopsied/presumed indolent recurrence receiving salvage treatment (n = 59, including 20 initially observed) 3-year FFP was 73.9%. CONCLUSIONS Prognosis for patients with relapsed FL after primary radiation therapy is excellent, supporting the role of primary radiation in the management of early stage disease. Patients with localized FL treated with primary RT who experience early relapse (<12 months) have inferior survival compared with those with longer disease-free interval.
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Affiliation(s)
- Michael S Binkley
- Stanford Cancer Institute and Stanford University School of Medicine, Stanford, CA.
| | - Jessica L Brady
- Guy's Cancer Centre, Guy's and St Thomas' NHS Hospital, London, United Kingdom
| | - Carla Hajj
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Karen Chau
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alex Balogh
- Tom Baker Cancer Center, Calgary, AB, Canada
| | - Mario Levis
- Department of Oncology, University of Turin, Torino, Italy
| | | | - Michael Jones
- Princess Margaret Cancer Center, Toronto, ON, Canada
| | - Sameera Ahmed
- Princess Margaret Cancer Center, Toronto, ON, Canada
| | - Michael MacManus
- Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Trans-Tasman Radiation Oncology Group, Waratah, NSW, Australia
| | - Andrew Wirth
- Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | | | | | | | - Andrea K Ng
- Dana Farber and Harvard University School of Medicine, Boston, MA
| | - Berthe M P Aleman
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Seo Hee Choi
- Yonsei Cancer Center, Yonsei University Health System, Seoul, South Korea
| | | | | | - Gabriele Reinartz
- Department of Radiation Oncology, Munster University, Munster, Germany
| | - Hans T Eich
- Department of Radiation Oncology, Munster University, Munster, Germany
| | - Scott V Bratman
- Stanford Cancer Institute and Stanford University School of Medicine, Stanford, CA
| | | | - Chang-Ok Suh
- Yonsei Cancer Center, Yonsei University Health System, Seoul, South Korea
| | | | | | | | | | | | - N George Mikhaeel
- Guy's Cancer Centre, Guy's and St Thomas' NHS Hospital, London, United Kingdom
| | - Richard T Hoppe
- Stanford Cancer Institute and Stanford University School of Medicine, Stanford, CA
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26
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Ng AK, Yahalom J, Goda JS, Constine LS, Pinnix CC, Kelsey CR, Hoppe B, Oguchi M, Suh CO, Wirth A, Qi S, Davies A, Moskowitz CH, Laskar S, Li Y, Mauch PM, Specht L, Illidge T. Role of Radiation Therapy in Patients With Relapsed/Refractory Diffuse Large B-Cell Lymphoma: Guidelines from the International Lymphoma Radiation Oncology Group. Int J Radiat Oncol Biol Phys 2019; 100:652-669. [PMID: 29413279 DOI: 10.1016/j.ijrobp.2017.12.005] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 11/16/2017] [Accepted: 12/03/2017] [Indexed: 01/15/2023]
Abstract
Approximately 30% to 40% of patients with diffuse large B-cell lymphoma (DLBCL) will have either primary refractory disease or relapse after chemotherapy. In transplant-eligible patients, those with disease sensitive to salvage chemotherapy will significantly benefit from high-dose therapy with autologous stem cell transplantation. The rationale for considering radiation therapy (RT) for selected patients with relapsed/refractory DLBCL as a part of the salvage program is based on data regarding the patterns of relapse and retrospective series showing improved local control and clinical outcomes for patients who received peritransplant RT. In transplant-ineligible patients, RT can provide effective palliation and, in selected cases, be administered with curative intent if the relapsed/refractory disease is localized. We have reviewed the indications for RT in the setting of relapsed/refractory DLBCL and provided recommendations regarding the optimal timing of RT, dose fractionation scheme, and treatment volume in the context of specific case scenarios.
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Affiliation(s)
- Andrea K Ng
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts.
| | - Joachim Yahalom
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jayant S Goda
- Department of Radiation Oncology, Tata Memorial Center, Navi, Mumbai, India
| | - Louis S Constine
- Departments of Radiation Oncology and Pediatrics, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - Chelsea C Pinnix
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Chris R Kelsey
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Bradford Hoppe
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - Masahiko Oguchi
- Department of Radiation Oncology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Chang-Ok Suh
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Andrew Wirth
- Division of Radiation Oncology, Peter MacCallum Cancer Institute, Melbourne, Victoria, Australia
| | - Shunan Qi
- Department of Radiation Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Andrew Davies
- Cancer Research UK Centre, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Craig H Moskowitz
- Lymphoma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Siddhartha Laskar
- Department of Radiation Oncology, Tata Memorial Center, Navi, Mumbai, India
| | - Yexiong Li
- Department of Radiation Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Peter M Mauch
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts
| | - Lena Specht
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Timothy Illidge
- Institute of Cancer Sciences, University of Manchester, Manchester Academic Health Sciences Centre, The Christie National Health Service Foundation Trust, Manchester, United Kingdom
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27
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Tseng YD, Ng AK, Wirth A. New tools of the trade: parsing out the role of radiotherapy for early-stage diffuse large B-cell lymphoma. Leuk Lymphoma 2018; 60:861-863. [PMID: 30481090 DOI: 10.1080/10428194.2018.1531397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Yolanda D Tseng
- a Department of Radiation Oncology , University of Washington , Seattle , WA , USA
| | - Andrea K Ng
- b Department of Radiation Oncology , Dana-Farber/Brigham and Women's Cancer Center , Boston , MA , USA
| | - Andrew Wirth
- c Division of Radiation Oncology , Peter MacCallum Cancer Centre , Parkville , Victoria
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28
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Affiliation(s)
- Flora E van Leeuwen
- Department of Epidemiology, Division of Psychosocial Research & Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Andrea K Ng
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, MA, USA.,Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
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29
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Tsang RW, Campbell BA, Goda JS, Kelsey CR, Kirova YM, Parikh RR, Ng AK, Ricardi U, Suh CO, Mauch PM, Specht L, Yahalom J. Radiation Therapy for Solitary Plasmacytoma and Multiple Myeloma: Guidelines From the International Lymphoma Radiation Oncology Group. Int J Radiat Oncol Biol Phys 2018; 101:794-808. [PMID: 29976492 DOI: 10.1016/j.ijrobp.2018.05.009] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 04/16/2018] [Accepted: 05/02/2018] [Indexed: 12/15/2022]
Abstract
PURPOSE To develop guidelines for the work-up and radiation therapy (RT) management of patients with plasma cell neoplasms. METHODS AND MATERIALS A literature review was conducted covering staging, work-up, and RT management of plasma cell neoplasms. Guidelines were developed through consensus by an international panel of radiation oncologists with expertise in these diseases, from the International Lymphoma Radiation Oncology Group. RT volume definitions are based on the International Commission on Radiation Units and Measurements. RESULTS Plasma cell neoplasms account for approximately one-fifth of mature B-cell neoplasms in the United States. The majority (∼95%) are diagnosed as multiple myeloma, in which there has been tremendous progress in systemic therapy approaches with novel drugs over the last 2 decades, resulting in improvements in disease control and survival. In contrast, a small proportion of patients with plasma cell neoplasms present with a localized plasmacytoma in the bone, or in extramedullary (extraosseous) soft tissues, and definitive RT is the standard treatment. RT provides long-term local control in the solitary bone plasmacytomas and is potentially curative in the extramedullary cases. This guideline reviews the diagnostic work-up, principles, and indications for RT, target volume definition, treatment planning, and follow-up procedures for solitary plasmacytoma. Specifically, detailed recommendations for RT volumes and dose/fractionation are provided, illustrated with specific case scenarios. The role of palliative RT in multiple myeloma is also discussed. CONCLUSIONS The International Lymphoma Radiation Oncology Group presents a standardized approach to the use and implementation of definitive RT in solitary plasmacytomas. The modern principles outlining the supportive role of palliative RT in multiple myeloma in an era of novel systemic therapies are also discussed.
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Affiliation(s)
- Richard W Tsang
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada.
| | - Belinda A Campbell
- Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Jayant S Goda
- Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India
| | - Chris R Kelsey
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Youlia M Kirova
- Department of Radiation Therapy, Institut Curie, Paris, France
| | - Rahul R Parikh
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Andrea K Ng
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, Massachusetts
| | - Umberto Ricardi
- Radiation Oncology Unit, Department of Oncology, University of Torino, Torino, Italy
| | - Chang-Ok Suh
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, South Korea
| | - Peter M Mauch
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, Massachusetts
| | - Lena Specht
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Joachim Yahalom
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
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30
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Dabaja BS, Zelenetz AD, Ng AK, Tsang RW, Qi S, Allen PK, Hodgson D, Ricardi U, Hoppe RT, Advani R, Mauch PM, Constine LS, Specht L, Li Y, Terezakis SA, Wirth A, Reinartz G, Eich HT, Aleman BMP, Barr P, Yahalom J. Early-stage mantle cell lymphoma: a retrospective analysis from the International Lymphoma Radiation Oncology Group (ILROG). Ann Oncol 2018; 28:2185-2190. [PMID: 28911068 DOI: 10.1093/annonc/mdx334] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Mantle cell lymphoma (MCL) rarely presents as early-stage disease, but clinical observations suggest that patients who present with early-stage disease may have better outcomes than those with advanced-stage disease. Patients and methods In this 13-institution study, we examined outcomes among 179 patients with early-stage (stage I or II) MCL in an attempt to identify prognostic factors that influence treatment selection and outcome. Variables examined included clinical characteristics, treatment modality, response to therapy, sites of failure, and survival. Results Patients were predominantly male (78%) with head and neck being the most common presenting sites (75%). Most failures occurred outside the original disease site (79%). Although the administration of radiation therapy, either alone or with chemotherapy, reduced the risk of local failure, it did not translate into an improved freedom from progression or overall survival (OS). The treatment outcomes were independent of treatment modality. The 10-year OS for patients treated with chemotherapy alone, chemo-radiation therapy and radiation therapy alone were 69%, 62%, and 74% (P = 0.79), and the 10-year freedom from progression were 46%, 43%, and 31% (P = 0.64), respectively. Conclusion Given the excellent OS rates regardless of initial therapy in patients with early-stage MCL, de-intensified therapy to limit treatment-related toxicity is a reasonable approach.
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Affiliation(s)
- B S Dabaja
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - A D Zelenetz
- Memorial Sloan-Kettering Cancer Center, New York
| | - A K Ng
- Department of Radiation Oncology, Brigham & Women's Hospital, Boston, USA
| | - R W Tsang
- Department of Radiation Oncology, Princess Margaret Hospital, Toronto, Canada
| | - S Qi
- Memorial Sloan-Kettering Cancer Center, New York
| | - P K Allen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - D Hodgson
- Department of Radiation Oncology, Princess Margaret Hospital, Toronto, Canada
| | - U Ricardi
- Department of Oncology, University of Turin, Turin, Italy
| | | | | | - P M Mauch
- Department of Radiation Oncology, Brigham & Women's Hospital, Boston, USA
| | - L S Constine
- University of Rochester Medical Center, Rochester, USA
| | - L Specht
- Department of Oncology and Hematology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Y Li
- Department of Radiation Oncology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - S A Terezakis
- Department of Radiation Oncology, Johns Hopkins School of Medicine, Baltimore, USA
| | - A Wirth
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, East Melbourne, Australia
| | - G Reinartz
- Department of Radiation Oncology, University of Muenster, Muenster, Germany
| | - H T Eich
- Department of Radiation Oncology, University of Muenster, Muenster, Germany
| | - B M P Aleman
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - P Barr
- University of Rochester Medical Center, Rochester, USA
| | - J Yahalom
- Memorial Sloan-Kettering Cancer Center, New York
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31
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Constine LS, Yahalom J, Ng AK, Hodgson DC, Wirth A, Milgrom SA, Mikhaeel NG, Eich HT, Illidge T, Ricardi U, Dieckmann K, Moskowitz CH, Advani R, Mauch PM, Specht L, Hoppe RT. The Role of Radiation Therapy in Patients With Relapsed or Refractory Hodgkin Lymphoma: Guidelines From the International Lymphoma Radiation Oncology Group. Int J Radiat Oncol Biol Phys 2018; 100:1100-1118. [PMID: 29722655 DOI: 10.1016/j.ijrobp.2018.01.011] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 12/18/2017] [Accepted: 01/02/2018] [Indexed: 02/02/2023]
Abstract
Relapsed and refractory Hodgkin lymphoma (HL) challenges clinicians to devise treatment strategies that are effective and safe. This problem is particularly prominent in an era when de-escalation trials are designed to minimize therapeutic toxicities in both early- and advanced-stage disease. Radiation therapy is the single most effective treatment modality for HL, and its integration into salvage regimens, or its independent use in select patients, must be understood to maximize our success in treating these patients. The complexity of treating relapsed or refractory HL derives from the spectrum of primary treatment approaches currently in use that creates heterogeneity in both treatment exposure and the potential toxicities of salvage therapy. Patients can have relapsed or refractory disease after limited or aggressive primary therapy (with or without radiation therapy), at early or delayed time points, with limited or extensive disease volumes, and with varying degrees of residual morbidity from primary therapy. Their response to salvage systemic therapy can be partial or complete, and the use of consolidative stem cell transplantation is variably applied. New biologics and immunotherapeutic approaches have broadened but also complicated salvage treatment approaches. Through all of this, radiation therapy remains an integral component of treatment for many patients, but it must be used effectively and judiciously. The purpose of this review is to describe the different treatment scenarios and provide guidance for radiation dose, volume, and timing in patients with relapsed or refractory HL.
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Affiliation(s)
- Louis S Constine
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York; Department of Pediatrics, University of Rochester Medical Center, Rochester, New York.
| | - Joachim Yahalom
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrea K Ng
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - David C Hodgson
- Department of Radiation Oncology, University of Toronto and Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
| | - Andrew Wirth
- Division of Radiation Oncology, Peter MacCallum Cancer Institute, East Melbourne, Australia
| | - Sarah A Milgrom
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - N George Mikhaeel
- Department of Clinical Oncology, Guy's Cancer Centre and King's College London University, London, UK
| | - Hans Theodor Eich
- Department of Radiation Oncology, University of Münster, Münster, Germany
| | - Tim Illidge
- Division of Cancer Sciences, University of Manchester, Manchester Academic Health Sciences Centre, The Christie National Health Service Foundation Trust, Manchester, UK
| | - Umberto Ricardi
- Radiation Oncology Unit, Department of Oncology, University of Torino, Torino, Italy
| | - Karin Dieckmann
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Craig H Moskowitz
- Division of Hematologic Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ranjana Advani
- Department of Medicine, Division of Medical Oncology, Stanford University, Stanford, California
| | - Peter M Mauch
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, Massachusetts; Died September 8, 2017
| | - Lena Specht
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Richard T Hoppe
- Department of Radiation Oncology, Stanford University, Stanford, California
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32
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Patel CG, Michaelson E, Chen YH, Silver B, Marcus KJ, Stevenson MA, Mauch PM, Ng AK. Reduced Mortality Risk in the Recent Era in Early-Stage Hodgkin Lymphoma Patients Treated With Radiation Therapy With or Without Chemotherapy. Int J Radiat Oncol Biol Phys 2017; 100:498-506. [PMID: 29153331 DOI: 10.1016/j.ijrobp.2017.09.048] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 08/31/2017] [Accepted: 09/22/2017] [Indexed: 12/30/2022]
Abstract
PURPOSE To determine the effect of treatment changes over time on all-cause mortality risk in patients with early-stage Hodgkin lymphoma (HL) after radiation therapy. The long-term survivorship of those with HL necessitates quantification of the late risk of mortality from HL and other causes. METHODS AND MATERIALS An institutional review board-approved retrospective study was conducted using a multi-institutional database of 1541 stage I and II HL patients treated from 1968 to 2007 with radiation therapy alone or combined-modality treatment. The analytic methods included cumulative incidence function, Kaplan-Meier estimates and log-rank tests for overall survival (OS) differences, and Cox proportional hazards modeling. RESULTS The median age at diagnosis was 27 years. At a median follow-up of 15.2 years (35% of patients with >20 years of follow-up), 395 patients had died of all causes, including 85 HL, 168 second malignancy (25 hematologic and 143 nonhematologic), 70 cardiovascular, and 21 pulmonary deaths. The cumulative incidence of non-HL mortality had surpassed HL mortality at 8.3 years. For patients treated from 1968 to 1982, 1983 to 1992, and 1993 to 2007, the 15-year OS rates were 78%, 85%, and 88%, respectively (P=.0016). On Cox proportional hazards analysis, age, B symptoms, and number of disease sites were significantly associated with all-cause mortality in the first decade of follow-up, with a trend toward significance for radiation field extent. CONCLUSIONS The all-cause mortality risk was significantly lower for patients treated in the most recent era during the first decade of follow-up, likely due to improved HL therapy resulting in a higher cure rate and lower treatment-related toxicity from smaller radiation fields. Current efforts toward radiation treatment reduction might further reduce the long-term mortality risk for these patients.
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Affiliation(s)
- Chirayu G Patel
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Evan Michaelson
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Yu-Hui Chen
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Barbara Silver
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Karen J Marcus
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Mary Ann Stevenson
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Peter M Mauch
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Andrea K Ng
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts.
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Kamran SC, Jacene HA, Chen YH, Mauch PM, Ng AK. Clinical outcome of patients with early stage favorable Hodgkin lymphoma treated with ABVD × two cycles followed by FDG-PET/CT restaging and 20 Gy of involved-site radiotherapy. Leuk Lymphoma 2017; 59:1384-1390. [PMID: 28937297 DOI: 10.1080/10428194.2017.1376745] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Our purpose was to assess outcome of patients with early-stage, favorable (per GHSG criteria) Hodgkin Lymphoma (HL) staged with FDG-PET/CT and treated with two cycles of adriamycin, bleomycin, vincristine, and dacarbazine (ABVD) followed by PET/CT assessment and involved-site radiotherapy (ISRT) to 20 Gy. Records of 23 patients who met eligibility criteria, treated between 2008 and 2016, were reviewed. PET response after two cycles of ABVD was independently assessed by a nuclear medicine physician. After two cycles of ABVD, 91.3% of patients had a Deauville score of 1-2; 1 patient had a score of 3. Median follow-up was 45.3 months. As of this analysis, all patients are alive without disease. One patient had an out-of-field relapse, yielding a 4-year relapse-free survival rate of 92.9% (95%CI [59.1, 99.0]). Our results showed that with careful patient selection by initial disease characteristics and FDG-PET response to chemotherapy, the use of a more restricted treatment volume of ISRT to 20 Gy following ABVD × 2 is associated with excellent outcomes.
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Affiliation(s)
- Sophia C Kamran
- a Harvard Radiation Oncology Program , Dana-Farber Cancer Institute/Brigham and Women's Hospital , Boston , MA , USA
| | - Heather A Jacene
- b Department of Radiology , Dana-Farber Cancer Institute/Brigham and Women's Hospital , Boston , MA , USA
| | - Yu-Hui Chen
- c Department of Biostatistics and Computational Biology , Dana-Farber Cancer Institute/Brigham and Women's Hospital , Boston , MA , USA
| | - Peter M Mauch
- d Department of Radiation Oncology , Dana-Farber Cancer Institute/Brigham and Women's Hospital , Boston , MA , USA
| | - Andrea K Ng
- d Department of Radiation Oncology , Dana-Farber Cancer Institute/Brigham and Women's Hospital , Boston , MA , USA
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van Leeuwen FE, Ng AK. Long-term risk of second malignancy and cardiovascular disease after Hodgkin lymphoma treatment. Hematology Am Soc Hematol Educ Program 2016; 2016:323-330. [PMID: 27913498 PMCID: PMC6142518 DOI: 10.1182/asheducation-2016.1.323] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Long-term survivors of Hodgkin lymphoma (HL) experience several late adverse effects of treatment, with second malignant neoplasms (SMNs) and cardiovascular diseases (CVDs) being the leading causes of death in these patients. Other late effects have also been identified, such as pulmonary dysfunction, endocrinopathies (thyroid dysfunction, infertility), neck muscle atrophy, and persistent fatigue. HL survivors have two- to fourfold increased risks to develop SMNs and CVD compared with the general population. With respect to SMNs, radiotherapy is associated with 1.5- to 15-fold increased risk of solid malignancies. The relative risk (RR) of solid tumors increases steadily with increasing follow-up time from 5 to 15 years since radiotherapy, and remains elevated for at least 40 years. The RR of solid SMNs increases strongly with younger age at first treatment. Risks of lung, breast, and gastrointestinal (GI) cancers increase with higher radiation dose. Alkylating agent chemotherapy, especially procarbazine, does not only increase risk of leukemia but also of solid malignancies, in particular, cancers of the lung and GI tract. In contrast, gonadotoxic chemotherapy decreases the risk of radiation-associated breast cancer, through induction of premature menopause. Smoking appears to multiply the radiation- and chemotherapy-associated risks of lung cancer. Both radiotherapy and chemotherapy for HL may cause cardiovascular toxicity. Radiotherapy increases the risk of coronary heart disease, valvular heart disease, congestive heart failure (HF), and pericarditis, whereas anthracycline-containing chemotherapy increases the risks of HF and valvular heart disease. Cardiovascular toxicity following radiotherapy is usually observed from 5 to at least 35 years after therapy, whereas anthracycline-related toxicity is already observed during treatment, up to at least 25 years. The joint effects of anthracyclines, radiotherapy, and conventional cardiovascular risk factors (eg, hypertension, smoking, and physical inactivity) appear to be additive rather than multiplicative. HL survivors need lifelong risk-based screening for selected SMNs and CVDs. Furthermore, preventive strategies should include lifestyle and drug-based interventions to minimize exposure to conventional risk factors for cancer and CVD.
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Affiliation(s)
- Flora E. van Leeuwen
- Division of Psychosocial Research and Epidemiology, Department of Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands; and
| | - Andrea K. Ng
- Department of Radiation Oncology, Brigham and Women’s Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
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Abstract
Long-term survivors of Hodgkin lymphoma (HL) are at risk for a range of late effects, with second malignant neoplasm and cardiovascular diseases being the leading causes of death in these patients. The excess risks remain significantly elevated decades after treatment, and are clearly associated with extent of treatment exposures. Other late effects have also been identified, such as pulmonary dysfunction, endocrinopathies, muscle atrophy, and persistent fatigue. Systemic documentation of late effects and recognition of treatment- and patient-related risk factors are important, as they inform optimal surveillance and risk-reduction strategies, as well as guide therapeutic modifications in newly diagnosed patients to minimize treatment-related complications. As HL therapy evolves over time, with adoption of novel agents and contemporary treatment techniques, late effect risks and follow-up recommendations need to be continuously updated.
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Affiliation(s)
- Andrea K Ng
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Flora E van Leeuwen
- Department of Epidemiology, Division of Psychosocial Research & Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands.
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Ng AK, Dabaja BS, Hoppe RT, Illidge T, Yahalom J. Re-Examining the Role of Radiation Therapy for Diffuse Large B-Cell Lymphoma in the Modern Era. J Clin Oncol 2016; 34:1443-7. [DOI: 10.1200/jco.2015.64.9418] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Andrea K. Ng
- Brigham and Women’s Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | | | | | - Timothy Illidge
- University of Manchester, Manchester Academic Health Sciences Centre, The Christie National Health Service Foundation Trust, Manchester, United Kingdom
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Adams MJ, Ng AK, Mauch P, Lipsitz SR, Winters P, Lipshultz SE. Corrigendum to “Peak oxygen consumption in Hodgkin's lymphoma survivors treated with mediastinal radiotherapy as a predictor of quality of life 5 years later” [Prog. Pediatr. Cardiol. 39/2PA (2015) 93–98]. Progress in Pediatric Cardiology 2016. [DOI: 10.1016/j.ppedcard.2016.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Affiliation(s)
| | - Andrea K. Ng
- Dana-Farber Cancer Institute and Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
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Adams MJ, Ng AK, Mauch P, Lipsitz SR, Winters P, Lipshultz SE. Peak oxygen consumption in Hodgkin's lymphoma survivors treated with mediastinal radiotherapy as a predictor of quality of life 5years later. Progress in Pediatric Cardiology 2015. [DOI: 10.1016/j.ppedcard.2015.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Chandra RA, Wilhite TJ, Balboni TA, Spektor A, Ng AK, Hodi FS, Schoenfeld JD. Abstract A20: A systematic evaluation of abscopal responses following radiation therapy in patients with metastatic melanoma treated with ipilimumab. Cancer Immunol Res 2015. [DOI: 10.1158/2326-6074.tumimm14-a20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Purpose/Objective(s): Prior case reports and preclinical studies have suggested that combined radiotherapy and immunotherapy may generate tumor responses outside the radiation treatment field (the “abscopal effect”). However, the frequency of this phenomenon and the radiation parameters associated with its occurrence are relatively unexplored. We aimed to systemically evaluate out-of-field responses following radiotherapy in a large cohort of patients with metastatic melanoma who had been also been treated with the CTLA-4 inhibitor ipilimumab.
Materials/Methods: We retrospectively reviewed records from 91 consecutive patients with metastatic melanoma who were treated with ipilimumab and radiation therapy at our institution. These 91 patients received a total of 208 courses of palliative radiation treatment between October 2007 and June 2014. Overall survival was calculated from the date patients were diagnosed with metastatic melanoma using the Kaplan-Meier method. We reviewed radiographic imaging before and after each course of radiotherapy, and the largest “index” lesion outside the radiation treatment field was identified. The difference in the largest diameters of the index lesions were calculated comparing the pre- and post- radiation treatment imaging studies as well as two consecutive imaging studies performed immediately prior to radiotherapy. A favorable response was defined as any decrease in the size of the index lesion. We compared the number of favorable responses before and after radiation therapy using McNemar's test. We also calculated the difference in response on the two imaging studies prior to radiation as compared to before and after radiation therapy by calculating the difference between the percent changes in index lesion diameter (“delta-delta”), and analyzed the significance of these differences using the binomial test. Finally, we used Pearson's chi-squared test to assess associations between radiation treatment parameters and changes in response rate.
Results: Patient median survival was 19 months (IQR: 11-48 months, median follow up 17 months), with 5-year survival of 22%. There were 116 radiotherapy courses identified with available data from at least two consecutive imaging studies prior to initiation of radiation as well as a single post-radiation study. Index lesions shrank in 10 instances prior to radiation therapy (9%) as compared with 29 instances (25%) after radiation therapy; in 22 of these 29 instances (76%) the index lesion had been increasing in size prior to radiotherapy (p<0.001). Radiotherapy was also associated with an improved rate of index lesion response (delta-delta) in 65% of cases (p=0.004). A radiation fraction size ≤3 Gy was associated with an improved rate of index lesion response as compared with hypofractionated treatment including stereotactic radiosurgery and stereotactic body radiotherapy (78% favorable as compared with 52%, p=0.016).
Conclusions: Our systematic review of metastatic melanoma patients treated with the combination of radiotherapy and ipilimumab suggests that a subset of patients may have more favorable out-of-field responses following treatment with radiation. Interestingly, we found that smaller radiation fraction sizes (≤3 Gy/fraction) were associated with a more favorable change in response. If confirmed, these results may have important ramifications for the design of future trials that seek to combine radiation and immunotherapy to maximize the likelihood of achieving an abscopal effect.
Citation Format: Ravi A. Chandra, Tyler J. Wilhite, Tracy A. Balboni, Alexander Spektor, Andrea K. Ng, Frank Stephen Hodi, Jr., Jonathan D. Schoenfeld. A systematic evaluation of abscopal responses following radiation therapy in patients with metastatic melanoma treated with ipilimumab. [abstract]. In: Proceedings of the AACR Special Conference: Tumor Immunology and Immunotherapy: A New Chapter; December 1-4, 2014; Orlando, FL. Philadelphia (PA): AACR; Cancer Immunol Res 2015;3(10 Suppl):Abstract nr A20.
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Affiliation(s)
| | | | - Tracy A. Balboni
- 3Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA,
| | - Alexander Spektor
- 3Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA,
| | - Andrea K. Ng
- 3Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA,
| | - Frank Stephen Hodi
- 4Medical Oncology and Center for Immuno-Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Jonathan D. Schoenfeld
- 3Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA,
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Chandra RA, Wilhite TJ, Balboni TA, Alexander BM, Spektor A, Ott PA, Ng AK, Hodi FS, Schoenfeld JD. A systematic evaluation of abscopal responses following radiotherapy in patients with metastatic melanoma treated with ipilimumab. Oncoimmunology 2015; 4:e1046028. [PMID: 26451318 DOI: 10.1080/2162402x.2015.1046028] [Citation(s) in RCA: 151] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 04/21/2015] [Accepted: 04/23/2015] [Indexed: 01/12/2023] Open
Abstract
Case reports and preclinical data suggest radiotherapy and immunotherapy may synergize to generate "abscopal" responses outside the radiation field. This phenomenon remains relatively unexplored, prompting our systematic evaluation of metastatic melanoma patients treated with the CTLA-4 inhibitor ipilimumab and palliative radiation therapy. We evaluated 47 consecutive metastatic melanoma patients treated with ipilimumab and 65 courses of radiation. Responses of index lesions outside the radiation field were compared before and after radiotherapy, and parameters associated with favorable response were assessed. Median survival was 28 months, with an estimated 20% 5-y survival. Index lesions shrank in 7 instances prior to radiation therapy (11%), compared with 16 instances (25%) after radiation therapy; in 11 of the latter instances (69%), the index lesion had been increasing in size prior to radiotherapy (P = 0.03). In 68% of cases, radiotherapy was associated with an improved rate of index lesion response (P = 0.006). Radiation fraction size ≤ 3 Gy was the only parameter identified associated with favorable index lesion response (P = 0.014). Our systematic review of melanoma patients treated with radiotherapy and ipilimumab suggests that a subset of patients may have more favorable out-of-field responses following treatment with radiation. Interestingly, we found that multiple fraction radiation regimens were associated with a more favorable response. These results are encouraging regarding potential synergies between radiation and immunotherapy, but suggest that attention and even prospective testing of radiation parameters critical to producing abscopal effects in human patients would be of value.
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Affiliation(s)
| | | | - Tracy A Balboni
- Department of Radiation Oncology; Brigham and Women's Hospital/Dana-Farber Cancer Institute ; Boston, MA USA
| | - Brian M Alexander
- Department of Radiation Oncology; Brigham and Women's Hospital/Dana-Farber Cancer Institute ; Boston, MA USA
| | - Alexander Spektor
- Department of Radiation Oncology; Brigham and Women's Hospital/Dana-Farber Cancer Institute ; Boston, MA USA
| | - Patrick A Ott
- Medical Oncology and Center for Immuno-Oncology; Dana-Farber Cancer Institute ; Boston, MA USA
| | - Andrea K Ng
- Department of Radiation Oncology; Brigham and Women's Hospital/Dana-Farber Cancer Institute ; Boston, MA USA
| | - F Stephen Hodi
- Medical Oncology and Center for Immuno-Oncology; Dana-Farber Cancer Institute ; Boston, MA USA
| | - Jonathan D Schoenfeld
- Department of Radiation Oncology; Brigham and Women's Hospital/Dana-Farber Cancer Institute ; Boston, MA USA
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Ng PY, Sin WC, Ng AK, Chan WM. Cardiac abnormalities in patients with septic shock detected by speckle tracking echocardiography. Crit Care 2015. [PMCID: PMC4471191 DOI: 10.1186/cc14215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Abstract
Long-term survivors of Hodgkin lymphoma (HL) are at an increased risk for a range of late complications, with subsequent malignant neoplasm and cardiovascular disease representing the 2 leading causes of death in these patients. Raising awareness, close follow-up, and adoption of selected early-detection and risk-reduction strategies may help to reduce the adverse impact of these late effects on patients. This chapter reviews known long-term complications of HL therapy, risk factors, and the timing of their occurrence. Where available, data on the efficacy of screening for selected late effects of HL are presented. Current evidence-based and consensus-based recommendations on follow-up of long-term HL survivors are also reviewed. As HL therapy evolves over time, late effects and implications on follow-up of patients treated in the contemporary era should be considered and opportunities for future research should be explored.
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Affiliation(s)
- Andrea K Ng
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, MA
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Wattson DA, Hunink MGM, DiPiro PJ, Das P, Hodgson DC, Mauch PM, Ng AK. Low-dose chest computed tomography for lung cancer screening among Hodgkin lymphoma survivors: a cost-effectiveness analysis. Int J Radiat Oncol Biol Phys 2014; 90:344-53. [PMID: 25104066 DOI: 10.1016/j.ijrobp.2014.06.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Revised: 05/29/2014] [Accepted: 06/03/2014] [Indexed: 01/02/2023]
Abstract
PURPOSE Hodgkin lymphoma (HL) survivors face an increased risk of treatment-related lung cancer. Screening with low-dose computed tomography (LDCT) may allow detection of early stage, resectable cancers. We developed a Markov decision-analytic and cost-effectiveness model to estimate the merits of annual LDCT screening among HL survivors. METHODS AND MATERIALS Population databases and HL-specific literature informed key model parameters, including lung cancer rates and stage distribution, cause-specific survival estimates, and utilities. Relative risks accounted for radiation therapy (RT) technique, smoking status (>10 pack-years or current smokers vs not), age at HL diagnosis, time from HL treatment, and excess radiation from LDCTs. LDCT assumptions, including expected stage-shift, false-positive rates, and likely additional workup were derived from the National Lung Screening Trial and preliminary results from an internal phase 2 protocol that performed annual LDCTs in 53 HL survivors. We assumed a 3% discount rate and a willingness-to-pay (WTP) threshold of $50,000 per quality-adjusted life year (QALY). RESULTS Annual LDCT screening was cost effective for all smokers. A male smoker treated with mantle RT at age 25 achieved maximum QALYs by initiating screening 12 years post-HL, with a life expectancy benefit of 2.1 months and an incremental cost of $34,841/QALY. Among nonsmokers, annual screening produced a QALY benefit in some cases, but the incremental cost was not below the WTP threshold for any patient subsets. As age at HL diagnosis increased, earlier initiation of screening improved outcomes. Sensitivity analyses revealed that the model was most sensitive to the lung cancer incidence and mortality rates and expected stage-shift from screening. CONCLUSIONS HL survivors are an important high-risk population that may benefit from screening, especially those treated in the past with large radiation fields including mantle or involved-field RT. Screening may be cost effective for all smokers but possibly not for nonsmokers despite a small life expectancy benefit.
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Affiliation(s)
| | - M G Myriam Hunink
- Departments of Radiology and Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands and Center for Health Decision Science, Harvard School of Public Health, Boston, Massachusetts
| | - Pamela J DiPiro
- Department of Imaging, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Prajnan Das
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David C Hodgson
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Peter M Mauch
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Andrea K Ng
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts
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Jang JW, Brown JG, Mauch PM, Ng AK. Four-dimensional versus 3-dimensional computed tomographic planning for gastric mucosa associated lymphoid tissue lymphoma. Pract Radiat Oncol 2014; 3:124-9. [PMID: 24674315 DOI: 10.1016/j.prro.2012.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Revised: 05/08/2012] [Accepted: 05/10/2012] [Indexed: 12/28/2022]
Abstract
PURPOSE This study compares dosimetric parameters of 4-dimensional (4D) and 3-dimensional (3D) computed tomographic (CT) planning for gastric mucosa-associated lymphoid tissue (MALT) lymphoma in an attempt to identify any potential benefit of 4DCT planning. METHODS AND MATERIALS We identified 18 patients who received definitive 4DCT radiation planning from September 2006 to September 2011 for gastric MALT lymphoma at our institution. In addition to the kidneys and liver, we contoured an internal target volume (ITV) and static clinical target volume (sCTV) for each patient based on the 4D and 3D images, respectively, to develop 3D conformal radiation plans. Using the static and motion plans, we measured the volume of ITV covered by at least 95% of the prescribed dose (V95), the minimum dose received by 95% of the ITV (D95), and the volume of organs receiving at least 20 Gy or 30 Gy (V20 or V30). RESULTS Volumes of the ITV, motion liver, left kidney, and right kidney were significantly larger than their static counterparts. The static plan significantly lowered the ITV V95 and D95 compared with the motion plan. However, this undercoverage was significantly associated with the superior-inferior (SI) respiratory excursions. A V95 of >98% was observed in 92% of patients with SI excursions <15 mm versus 33% of patients with SI excursions >15 mm (P = .02). When compared with the motion plan, the static plan also significantly lowered the liver V30 and left kidney V20. CONCLUSIONS The 3DCT planning can result in undercoverage of the ITV and altered estimation of doses to normal structures. However, in patients with limited respiratory excursions (<15 mm), 4D and 3D images generated similar ITV coverage.
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Affiliation(s)
- Joanne W Jang
- Harvard Radiation Oncology Program, Boston, Massachusetts.
| | - Johann G Brown
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Peter M Mauch
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Andrea K Ng
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston, Massachusetts
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Chen MH, Blackington LH, Zhou J, Chu TF, Gauvreau K, Marcus KJ, Fisher DC, Diller LR, Ng AK. Blood pressure is associated with occult cardiovascular disease in prospectively studied Hodgkin lymphoma survivors after chest radiation. Leuk Lymphoma 2014; 55:2477-83. [DOI: 10.3109/10428194.2013.879716] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Ming Hui Chen
- Department of Cardiology, Boston Children's Hospital,
Boston, MA, USA
- Department of Medicine, Brigham & Women's Hospital, Boston, MA, USA
- Harvard Medical School,
Boston, MA, USA
| | | | - Jing Zhou
- Department of Cardiology, Boston Children's Hospital,
Boston, MA, USA
| | - Tammy F. Chu
- Department of Cardiology, Boston Children's Hospital,
Boston, MA, USA
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital,
Boston, MA, USA
- Harvard Medical School,
Boston, MA, USA
| | - Karen J. Marcus
- Harvard Medical School,
Boston, MA, USA
- Department of Pediatric Oncology, Dana Farber Cancer Institute,
Boston, MA, USA
| | - David C. Fisher
- Harvard Medical School,
Boston, MA, USA
- Department of Hematology/Oncology, Dana Farber Cancer Institute,
Boston, MA, USA
| | - Lisa R. Diller
- Harvard Medical School,
Boston, MA, USA
- Department of Pediatric Oncology, Dana Farber Cancer Institute,
Boston, MA, USA
| | - Andrea K. Ng
- Harvard Medical School,
Boston, MA, USA
- Department of Radiation Oncology, Brigham & Women's Hospital, Boston, MA, USA
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Travis LB, Ng AK, Allan JM, Pui CH, Kennedy AR, Xu XG, Purdy JA, Applegate K, Yahalom J, Constine LS, Gilbert ES, Boice JD. Second malignant neoplasms and cardiovascular disease following radiotherapy. Health Phys 2014; 106:229-246. [PMID: 24378498 DOI: 10.1097/hp.0000000000000013] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Second malignant neoplasms (SMNs) and cardiovascular disease (CVD) are among the most serious and life-threatening late adverse effects experienced by the growing number of cancer survivors worldwide and are due in part to radiotherapy. The National Council on Radiation Protection and Measurements (NCRP) convened an expert scientific committee to critically and comprehensively review associations between radiotherapy and SMNs and CVD, taking into account radiobiology; genomics; treatment (i.e., radiotherapy with or without chemotherapy and other therapies); type of radiation; and quantitative considerations (i.e., dose-response relationships). Major conclusions of the NCRP include: (1) the relevance of older technologies for current risk assessment when organ-specific absorbed dose and the appropriate relative biological effectiveness are taken into account and (2) the identification of critical research needs with regard to newer radiation modalities, dose-response relationships, and genetic susceptibility. Recommendation for research priorities and infrastructural requirements include (1) long-term large-scale follow-up of extant cancer survivors and prospectively treated patients to characterize risks of SMNs and CVD in terms of radiation dose and type; (2) biological sample collection to integrate epidemiological studies with molecular and genetic evaluations; (3) investigation of interactions between radiotherapy and other potential confounding factors, such as age, sex, race, tobacco and alcohol use, dietary intake, energy balance, and other cofactors, as well as genetic susceptibility; (4) focusing on adolescent and young adult cancer survivors, given the sparse research in this population; and (5) construction of comprehensive risk prediction models for SMNs and CVD to permit the development of follow-up guidelines and prevention and intervention strategies.
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Affiliation(s)
- Lois B Travis
- *Rubin Center for Cancer Survivorship and Department of Radiation Oncology, James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY; †Department of Radiation Oncology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and the Dana-Farber Cancer Institute, Boston, MA; ‡Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK; §Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN; and the University of Tennessee Health Science Center, Memphis, TN; **Department of Radiation Oncology, University of Pennsylvania School of Medicine, Philadelphia, PA; ††Nuclear Engineering and Engineering Physics Program, Rensselaer Polytechnic Institute, Troy, NY; ‡‡Department of Radiation Oncology, University of California at Davis, Davis, CA; §§Department of Radiology, Emory University, Atlanta, GA; ***Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY; †††Division ofCancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD; ‡‡‡National Council on Radiation Protection and Measurements, Bethesda, MD, and the Department of Medicine, Vanderbilt University, Nashville, TN
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Russo AL, Chen YH, Martin NE, Vinjamoori A, Luthy SK, Freedman A, Michaelson EM, Silver B, Mauch PM, Ng AK. Low-Dose Involved-Field Radiation in the Treatment of Non-Hodgkin Lymphoma: Predictors of Response and Treatment Failure. Int J Radiat Oncol Biol Phys 2013; 86:121-7. [DOI: 10.1016/j.ijrobp.2012.12.024] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Revised: 12/06/2012] [Accepted: 12/31/2012] [Indexed: 11/29/2022]
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Beard CJ, Travis LB, Chen MH, Arvold ND, Nguyen PL, Martin NE, Kuban DA, Ng AK, Hoffman KE. Outcomes in stage I testicular seminoma: a population-based study of 9193 patients. Cancer 2013; 119:2771-7. [PMID: 23633409 DOI: 10.1002/cncr.28086] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 02/21/2013] [Accepted: 02/25/2013] [Indexed: 11/10/2022]
Abstract
BACKGROUND Few studies have quantified temporal patterns of cause-specific mortality in contemporary cohorts of men with early-stage seminoma. Given that several management strategies can be applied in these patients, each resulting in excellent long-term survival, it is important to evaluate associated long-term sequelae. In particular, data describing long-term risks of cardiovascular disease (CVD) are conflicting. METHODS We identified 9193 men diagnosed with stage I seminoma (ages 15-70 years) in the population-based SEER registries (1973-2001). We calculated survival estimates, standardized mortality ratios (SMRs), and adjusted hazard rates (AHRs). RESULTS During 121,037 person-years of follow-up (median, 12.3 years), 915 deaths (SMR, 1.23; 95% CI, 1.16-1.32) were reported, with significant excesses for suicide (n = 39; SMR, 1.45; 95% CI, 1.06-1.98), infection (n = 58; SMR, 2.32; 95% CI, 1.80-3.00), and second malignant neoplasms (SMNs; n = 291; SMR, 1.81; 95% CI, 1.61-2.03), but not CVD (n = 201; SMR, 0.91; 95% CI, 0.80-1.05). After radiotherapy (78% patients), CVD deaths were not increased (n = 158; SMR, 0.89; 95% CI, 0.76-1.04), in contrast to SMN deaths (n = 246; SMR, 1.89; 95% CI, 1.67-2.14). SMN mortality was higher among patients administered radiotherapy than among those not given radiotherapy (AHR, 1.36; 95% CI, 0.99-1.88; P = .059), with a cumulative 15-year risk of 2.64% (95% CI, 2.19-3.16). Suicide, although rare, accounted for 1 in 230 deaths. CONCLUSIONS Modern radiotherapy as applied in this large population-based study is not associated with excess CVD mortality. Although increased all-cause mortality exists, cumulative SMN risk is considerably smaller than reported in historical series, but additional follow-up will be required to characterize long-term trends. The increased risk of suicide, previously unreported in men with stage I seminoma, requires confirmation.
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Affiliation(s)
- Clair J Beard
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA 02115, USA.
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Ng AK, Garber JE, Diller LR, Birdwell RL, Feng Y, Neuberg DS, Silver B, Fisher DC, Marcus KJ, Mauch PM. Prospective study of the efficacy of breast magnetic resonance imaging and mammographic screening in survivors of Hodgkin lymphoma. J Clin Oncol 2013; 31:2282-8. [PMID: 23610104 DOI: 10.1200/jco.2012.46.5732] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
PURPOSE Current guidelines recommend breast magnetic resonance imaging (MRI) as an adjunct to mammography for breast cancer screening in female cancer survivors treated with chest irradiation at a young age, beginning 8 to 10 years after treatment. Prospective data evaluating its efficacy in female cancer survivors are lacking. This study sought to compare the sensitivity and specificity of breast MRI with those of mammography in women who received chest irradiation for Hodgkin lymphoma (HL). PATIENTS AND METHODS We enrolled 148 women treated with chest irradiation for HL at age ≤ 35 years who were > 8 years beyond treatment. Yearly breast MRI and mammogram were performed over a 3-year period. Sensitivity and specificity of the two screening modalities were compared. RESULTS With the screening, 63 biopsies were performed in 45 women; 18 (29%) showed a malignancy. All but one of the screen-detected malignancies were preinvasive or subcentimeter node-negative breast cancers. After excluding first-screen MRI and mammogram, mammogram sensitivity was 68% as compared with 67% for MRI (P = 1.0). Sensitivity increased to 94% using both screening modalities. The specificities of mammogram alone, MRI alone, and both were 93%, 94%, and 90%, respectively. CONCLUSION In contrast to women with genetic or familial risk, in HL survivors breast MRI was not more sensitive than mammogram for breast cancer detection. However, the two screening modalities complement each other in the detection of early cases of disease. Early diagnosis is particularly important in these patients, given the breast cancer treatment challenges in patients who have received prior cancer therapy.
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Affiliation(s)
- Andrea K Ng
- Brigham and Women's Hospital, Boston, MA, USA.
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