1
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Klopp AH, Enserro D, Powell M, Randall M, Schink JC, Mannel RS, Holman L, Bender D, Kushnir CL, Backes F, Zweizig SL, Waggoner S, Bradley KA, Lawrence LD, Hanjani P, Darus CJ, Small W, Cardenes HR, Feddock JM, Miller DS. Radiation Therapy With or Without Cisplatin for Local Recurrences of Endometrial Cancer: Results From an NRG Oncology/GOG Prospective Randomized Multicenter Clinical Trial. J Clin Oncol 2024:JCO2301279. [PMID: 38662968 DOI: 10.1200/jco.23.01279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 11/30/2023] [Accepted: 02/20/2024] [Indexed: 04/28/2024] Open
Abstract
PURPOSE Pelvic recurrence is a frequent pattern of relapse for women with endometrial cancer. A randomized trial compared progression-free survival (PFS) after treatment with radiation therapy alone as compared with concurrent chemotherapy. MATERIALS AND METHODS Between February 2008 and August 2020, 165 patients were randomly assigned 1:1 to receive either radiation treatment alone or a combination of chemotherapy and radiation treatment. The primary objective of this study was to determine whether chemoradiation therapy was more effective than radiation therapy alone at improving PFS. RESULTS The majority of patients had low-grade (1 or 2) endometrioid histology (82%) and recurrences confined to the vagina (86%). External beam with either the three-dimensional or intensity modulated radiation treatment technique was followed by a boost delivered with brachytherapy or external beam. Patients randomly assigned to receive chemotherapy were treated with once weekly cisplatin (40 mg/m2). Rates of acute toxicity were higher in patients treated with chemoradiation as compared with radiation treatment alone. Median PFS was longer for patients treated with radiation therapy alone as compared with chemotherapy and radiation (median PFS was not reached for RT v 73 months for chemoradiation, hazard ratio of 1.25 (95% CI, 0.75 to 2.07). At 3 years, 73% of patients treated definitively with radiation and 62% of patients treated with chemoradiation were alive and free of disease progression. CONCLUSION Excellent outcomes can be achieved for women with localized recurrences of endometrial cancer when treated with radiation therapy. The addition of chemotherapy does not improve PFS for patients treated with definitive radiation therapy for recurrent endometrial cancer and increases acute toxicity. Patients with low-grade and vaginal recurrences who constituted the majority of those enrolled are best treated with radiation therapy alone.
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Affiliation(s)
- Ann H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Danielle Enserro
- Clinical Trials Development Division, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Matthew Powell
- Washington University School of Medicine, Obstetrics & Gynecology, St Louis, MO
| | - Marcus Randall
- University of Kentucky, Radiation Oncology, Lexington, KY
| | - Julian C Schink
- Cancer Treatment Centers of America, City of Hope, Gynecologic Oncology, Chicago, IL
| | | | - Laura Holman
- University of Oklahoma Health Sciences, Oklahoma City, OK
| | - David Bender
- University of Iowa Hospitals & Clinics, Iowa City, IA
| | | | - Floor Backes
- The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, OH
| | - Susan L Zweizig
- University of Massachusetts Memorial Health Care, Gynecologic Oncology, Worcester, MA
| | - Steven Waggoner
- Cleveland Clinic Foundation, Medical Oncology, Cleveland, OH
| | - Kristin A Bradley
- University of Wisconsin Hospital and Clinics, Radiation Oncology, Madison, WI
| | | | - Parviz Hanjani
- Abington Memorial Hospital, Gynecologic Oncology, Abington, PA
| | - Christopher J Darus
- Maine Medical Center, Gynecologic Oncology, Scarborough, ME
- Providence Gynecologic Oncology Program and Earle A Chiles Research Institute, Portland, OR
| | - William Small
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Cardinal Bernardin Cancer Center, Chicago, IL
| | - Higinia R Cardenes
- New York-Presbyterian Hospital, Weill Cornell Medicine, Clinical Radiation Oncology, New York, NY
| | | | - David S Miller
- University of Texas Southwestern Medical Center, Gynecologic Oncology, Dallas, TX
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2
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Sitler CA, Tian C, Hamilton CA, Richardson MT, Chan JK, Kapp DS, Leath CA, Casablanca Y, Washington C, Chappell NP, Klopp AH, Shriver CD, Tarney CM, Bateman NW, Conrads TP, Maxwell GL, Phippen NT, Darcy KM. Immuno-Molecular Targeted Therapy Use and Survival Benefit in Patients with Stage IVB Cervical Carcinoma in Commission on Cancer ®-Accredited Facilities in the United States. Cancers (Basel) 2024; 16:1071. [PMID: 38473428 DOI: 10.3390/cancers16051071] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 02/27/2024] [Accepted: 03/03/2024] [Indexed: 03/14/2024] Open
Abstract
PURPOSE To investigate IMT use and survival in real-world stage IVB cervical cancer patients outside randomized clinical trials. METHODS Patients diagnosed with stage IVB cervical cancer during 2013-2019 in the National Cancer Database and treated with chemotherapy (CT) ± external beam radiation (EBRT) ± intracavitary brachytherapy (ICBT) ± IMT were studied. The adjusted hazard ratio (AHR) and 95% confidence interval (CI) for risk of death were estimated in patients treated with vs. without IMT after applying propensity score analysis to balance the clinical covariates. RESULTS There were 3164 evaluable patients, including 969 (31%) who were treated with IMT. The use of IMT increased from 11% in 2013 to 46% in 2019. Age, insurance, facility type, sites of distant metastasis, and type of first-line treatment were independently associated with using IMT. In propensity-score-balanced patients, the median survival was 18.6 vs. 13.1 months for with vs. without IMT (p < 0.001). The AHR was 0.72 (95% CI = 0.64-0.80) for adding IMT overall, 0.72 for IMT + CT, 0.66 for IMT + CT + EBRT, and 0.69 for IMT + CT + EBRT + ICBT. IMT-associated survival improvements were suggested in all subgroups by age, race/ethnicity, comorbidity score, facility type, tumor grade, tumor size, and site of metastasis. CONCLUSIONS IMT was associated with a consistent survival benefit in real-world patients with stage IVB cervical cancer.
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Affiliation(s)
- Collin A Sitler
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Chunqiao Tian
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., Bethesda, MD 20817, USA
| | - Chad A Hamilton
- Gynecologic Oncology Section, Women's Services and The Ochsner Cancer Institute, Ochsner Health, New Orleans, LA 70115, USA
| | - Michael T Richardson
- Department of Obstetrics and Gynecology, Los Angeles School of Medicine, University of California, Los Angeles, CA 90024, USA
| | - John K Chan
- Palo Alto Medical Foundation, California Pacific Medical Center, Sutter Health, San Francisco, CA 94010, USA
| | - Daniel S Kapp
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Charles A Leath
- Division of Gynecologic Oncology, University of Alabama at Birmingham, O'Neal Comprehensive Cancer Center, Birmingham, AL 35249, USA
| | - Yovanni Casablanca
- Gynecologic Oncology Division, Levine Cancer Institute, Atrium Health, Charlotte, NC 28204, USA
| | - Christina Washington
- Gynecologic Oncology Division, Stephenson Cancer Center, Oklahoma University Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Nicole P Chappell
- Gynecologic Oncology Division, GW Medical Faculty Associates, George Washington University, Washington, DC 20037, USA
| | - Ann H Klopp
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Craig D Shriver
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Christopher M Tarney
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Nicholas W Bateman
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., Bethesda, MD 20817, USA
| | - Thomas P Conrads
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Women's Health Integrated Research Center, Women's Service Line, Inova Health System, Falls Church, VA 22042, USA
| | - George Larry Maxwell
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Women's Health Integrated Research Center, Women's Service Line, Inova Health System, Falls Church, VA 22042, USA
| | - Neil T Phippen
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Kathleen M Darcy
- Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., Bethesda, MD 20817, USA
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Manzar GS, Alam MBE, Lynn EJ, Karpinets TV, Harris T, Lo D, Yoshida-Court K, Napravnik TC, Sammouri J, Lin D, Andring LM, Bronk J, Wu X, Sims TT, Mathew G, Schmeler KM, Eifel PJ, Jhingran A, Lin LL, Joyner MM, Zhang J, Futreal A, Klopp AH, Colbert LE. Exploratory analysis of the cervix tumoral HPV antigen-specific T-cell repertoire during chemoradiation and after brachytherapy. Brachytherapy 2024; 23:123-135. [PMID: 38129211 DOI: 10.1016/j.brachy.2023.10.007] [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: 05/26/2023] [Revised: 10/17/2023] [Accepted: 10/24/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Chemoradiation (CRT) may modulate the immune milieu as an in-situ vaccine. Rapid dose delivery of brachytherapy has unclear impact on T-cell repertoires. HPV-associated cancers express viral oncoproteins E6/E7, which enable tracking antigen/tumor-specific immunity during CRT. METHODS Thirteen cervical cancer patients on a multi-institutional prospective protocol from 1/2020-1/2023 underwent standard-of-care CRT with pulsed-dose-rate brachytherapy boost (2 fractions). Cervix swabs at various timepoints underwent multiplex DNA deep sequencing of the TCR-β/CDR3 region with immunoSEQ. Separately, HPV-responsive T-cell clones were also expanded ex vivo. Statistical analysis was via Mann-Whitney-U. RESULTS TCR productive clonality, templates, frequency, or rearrangements increased post-brachytherapy in 8 patients. Seven patients had E6/E7-responsive evolution over CRT with increased productive templates (ranges: 1.2-50.2 fold-increase from baseline), frequency (1.2-1.7), rearrangements (1.2-40.2), and clonality (1.2-15.4). Five patients had HPV-responsive clonal expansion post-brachytherapy, without changes in HPV non-responsive clones. Epitope mapping revealed VDJ rearrangements targeting cervical cancer-associated antigens in 5 patients. The only two patients with disease recurrence lacked response in all metrics. A lack of global TCR remodeling correlated with worse recurrence-free survival, p = 0.04. CONCLUSION CRT and brachytherapy alters the cervical cancer microenvironment to facilitate the expansion of specific T-cell populations, which may contribute to treatment efficacy.
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Affiliation(s)
- Gohar S Manzar
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Molly B El Alam
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Erica J Lynn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Tatiana V Karpinets
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Timothy Harris
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - David Lo
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kyoko Yoshida-Court
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Julie Sammouri
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Daniel Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lauren M Andring
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Julianna Bronk
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Xiaogang Wu
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Travis T Sims
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Geena Mathew
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kathleen M Schmeler
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Patricia J Eifel
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Anuja Jhingran
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lilie L Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Melissa M Joyner
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jianhua Zhang
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Andrew Futreal
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ann H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lauren E Colbert
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
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4
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Brower JV, Bregar AJ, Klopp AH. Path to Precision: Refining Radiation Therapy Guidelines for Early Stage Endometrial Cancer Through Incorporation of Primary Tumor Size, Lower Uterine Segment Invasion, and Molecular Markers. Pract Radiat Oncol 2024; 14:154-160. [PMID: 38048989 DOI: 10.1016/j.prro.2023.11.009] [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] [Received: 09/27/2023] [Revised: 11/16/2023] [Accepted: 11/16/2023] [Indexed: 12/06/2023]
Affiliation(s)
- Jeffrey V Brower
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; Radiation Oncology Associates-New England, Manchester, New Hampshire.
| | - Amy J Bregar
- Division of Gynecologic Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ann H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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5
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Sammouri J, Venkatesan AM, Lin LL, Jhingran A, Klopp AH, Joyner MM, Eifel PJ, Colbert LE. Management and long-term clinical outcomes of patients with stage IVA cervical cancer with bladder involvement. Gynecol Oncol 2024; 180:24-34. [PMID: 38041900 DOI: 10.1016/j.ygyno.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 11/07/2023] [Accepted: 11/10/2023] [Indexed: 12/04/2023]
Abstract
OBJECTIVE To describe the long-term outcomes of patients with stage IVA cervical cancer, a rare and deadly disease for which long-term toxicity data are scarce, to guide clinician counseling and survivorship support. METHODS In a retrospective review of a prospectively maintained database, we identified 76 patients with stage IVA cervical cancer with biopsy- or MRI-proven bladder mucosal involvement who received definitive radiotherapy (external beam radiotherapy [EBRT] alone or EBRT plus brachytherapy) with or without chemotherapy at our institution between 2000 and 2020. We used Kaplan-Meier modeling to estimate recurrence-free survival (RFS) and overall survival (OS) and used proportional hazard modeling to identify clinical variables associated with recurrence or survival. We performed actuarial competing risk modeling for severe late toxicity (grades 3 to 5, occurring >6 months of follow-up) and vesicovaginal fistulae (VVF), censoring for pelvic recurrence and death, and made comparisons between potential predictors using Gray's test and binary logistic regression. RESULTS The median follow-up time was 76 months (interquartile range 58-91). The median OS duration was 35 months (range, 18-not reached), and the 2- and 5-year OS rates were 53.6% and 40.9%, respectively. OS and RFS did not differ significantly between patients who received EBRT alone (N = 18) or EBRT plus brachytherapy (N = 49). Current smoking was a strong predictor of severe late toxicity, whose incidence was 14% at 2 years and 17% at 10 years. The VVF incidence was 24% at 2 years and 32% at 10 years. CONCLUSION Patients with stage IVA cervical cancer, even those who receive EBRT alone, can have long-term survival. These patients should be followed closely for late radiation-related toxicity.
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Affiliation(s)
- Julie Sammouri
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Aradhana M Venkatesan
- Department of Abdominal Imaging, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lilie L Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anuja Jhingran
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ann H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Melissa M Joyner
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Patricia J Eifel
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lauren E Colbert
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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6
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Yoder AK, Lakomy DS, Wu J, Andring LM, Corrigan KL, Fellman B, Jhingran A, Klopp AH, Colbert LE, Soliman PT, Frumovitz MM, Peterson SK, Lin LL. Comparing long-term sexual dysfunction across different uterine cancer treatment modalities. Brachytherapy 2024; 23:1-9. [PMID: 37914588 DOI: 10.1016/j.brachy.2023.09.008] [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: 04/25/2023] [Revised: 07/14/2023] [Accepted: 09/17/2023] [Indexed: 11/03/2023]
Abstract
INTRODUCTION The objective of this study was to assess differences in long-term sexual and menopausal side effects after uterine cancer treatment among treatment modalities. METHODS AND MATERIALS This is a cross-sectional study that examined women treated for uterine cancer from 2006-2018. Eligible women included those who underwent a hysterectomy/bilateral salpino-oophorectemy alone (HS), with brachytherapy (BT), or with external beam radiation therapy (EBRT). A noncancer cohort of women who underwent a hysterectomy/BSO for benign indications were also identified (non-CA). To compare outcomes, we utilized a shortened form of the female sexual function index (FSFI) and the menopause survey, which consists of 3 subscales: hot flashes, vaginal symptoms, and urinary symptoms. Demographic, comorbidity, and other treatment variables were collected. Survey totals were compared across cohorts using ANOVA tests and logistic regression. RESULTS A total of 284 women completed the Menopause Survey (Non-CA 64, HS 60, BT 69, EBRT 91); 116 women reported sexual activity in the last 4 weeks and completed the FSFI (NC 32, HS 21, BT 31, EBRT 32). The mean FSFI score for the entire cohort was 11.4 (SD 4.16), which indicates poor sexual function. There was no significant difference between any cohort in the overall FSFI score (p = 0.708) or in any of the FSFI subscales (all p > 0.05). On univariate analysis, BT was associated with fewer menopausal hot flashes and vaginal symptoms compared to the non-CA cohort (p < 0.05), which did not persist on multivariable analysis. CONCLUSION There was no significant difference in sexual dysfunction or menopausal symptoms in those treated for uterine cancer with or without adjuvant radiation. Most patients reported poor sexual function.
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Affiliation(s)
- Alison K Yoder
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - David S Lakomy
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Juliana Wu
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; The University of Texas School of Public Health, Houston, TX
| | - Lauren M Andring
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kelsey L Corrigan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Bryan Fellman
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Anuja Jhingran
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ann H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lauren E Colbert
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Pamela T Soliman
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Michael M Frumovitz
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Susan K Peterson
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lilie L Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
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7
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Colbert LE, El Alam MB, Wang R, Karpinets T, Lo D, Lynn EJ, Harris TA, Elnaggar JH, Yoshida-Court K, Tomasic K, Bronk JK, Sammouri J, Yanamandra AV, Olvera AV, Carlin LG, Sims T, Delgado Medrano AY, Napravnik TC, O'Hara M, Lin D, Abana CO, Li HX, Eifel PJ, Jhingran A, Joyner M, Lin L, Ramondetta LM, Futreal AM, Schmeler KM, Mathew G, Dorta-Estremera S, Zhang J, Wu X, Ajami NJ, Wong M, Taniguchi C, Petrosino JF, Sastry KJ, Okhuysen PC, Martinez SA, Tan L, Mahmud I, Lorenzi PL, Wargo JA, Klopp AH. Tumor-resident Lactobacillus iners confer chemoradiation resistance through lactate-induced metabolic rewiring. Cancer Cell 2023; 41:1945-1962.e11. [PMID: 37863066 PMCID: PMC10841640 DOI: 10.1016/j.ccell.2023.09.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 07/01/2023] [Accepted: 09/25/2023] [Indexed: 10/22/2023]
Abstract
Tumor microbiota can produce active metabolites that affect cancer and immune cell signaling, metabolism, and proliferation. Here, we explore tumor and gut microbiome features that affect chemoradiation response in patients with cervical cancer using a combined approach of deep microbiome sequencing, targeted bacterial culture, and in vitro assays. We identify that an obligate L-lactate-producing lactic acid bacterium found in tumors, Lactobacillus iners, is associated with decreased survival in patients, induces chemotherapy and radiation resistance in cervical cancer cells, and leads to metabolic rewiring, or alterations in multiple metabolic pathways, in tumors. Genomically similar L-lactate-producing lactic acid bacteria commensal to other body sites are also significantly associated with survival in colorectal, lung, head and neck, and skin cancers. Our findings demonstrate that lactic acid bacteria in the tumor microenvironment can alter tumor metabolism and lactate signaling pathways, causing therapeutic resistance. Lactic acid bacteria could be promising therapeutic targets across cancer types.
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Affiliation(s)
- Lauren E Colbert
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
| | - Molly B El Alam
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Rui Wang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Tatiana Karpinets
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - David Lo
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Erica J Lynn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Timothy A Harris
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Jacob H Elnaggar
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; LSU School of Medicine, Louisiana State University, Baton Rouge, LA 70803, USA
| | - Kyoko Yoshida-Court
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Katarina Tomasic
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Julianna K Bronk
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Julie Sammouri
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Ananta V Yanamandra
- Department of Translational and Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Adilene V Olvera
- Departments of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Lily G Carlin
- Departments of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Travis Sims
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Andrea Y Delgado Medrano
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Tatiana Cisneros Napravnik
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Madison O'Hara
- Department of Thoracic Head and Neck Medical Oncology at The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Daniel Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Chike O Abana
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Hannah X Li
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Patricia J Eifel
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Anuja Jhingran
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Melissa Joyner
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Lilie Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Lois M Ramondetta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Andrew M Futreal
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Kathleen M Schmeler
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Geena Mathew
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | | | - Jianhua Zhang
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Xiaogang Wu
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Nadim J Ajami
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; Platform for Innovative Microbiome and Translational Research, Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Matthew Wong
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; Platform for Innovative Microbiome and Translational Research, Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Cullen Taniguchi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Joseph F Petrosino
- Department of Molecular Virology and Microbiology, The Alkek Center for Metagenomics and Microbiome Research, Baylor College of Medicine, Houston, TX 77030, USA
| | - K Jagannadha Sastry
- Department of Thoracic Head and Neck Medical Oncology at The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Pablo C Okhuysen
- Departments of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Sara A Martinez
- Metabolomics Core Facility, Department of Bioinformatics and Computational Biology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Lin Tan
- Metabolomics Core Facility, Department of Bioinformatics and Computational Biology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Iqbal Mahmud
- Metabolomics Core Facility, Department of Bioinformatics and Computational Biology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Philip L Lorenzi
- Metabolomics Core Facility, Department of Bioinformatics and Computational Biology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Jennifer A Wargo
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; LSU School of Medicine, Louisiana State University, Baton Rouge, LA 70803, USA; Platform for Innovative Microbiome and Translational Research, Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Ann H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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8
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Jacobsen MC, Rigaud B, Simiele SJ, Rauch GM, Ning MS, Vedam S, Klopp AH, Stafford RJ, Brock KK, Venkatesan AM. Feasibility of quantitative diffusion-weighted imaging during intra-procedural MRI-guided brachytherapy of locally advanced cervical and vaginal cancers. Brachytherapy 2023; 22:736-745. [PMID: 37612174 DOI: 10.1016/j.brachy.2023.06.007] [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: 01/11/2023] [Revised: 05/30/2023] [Accepted: 06/15/2023] [Indexed: 08/25/2023]
Abstract
PURPOSE To determine the feasibility of quantitative apparent diffusion coefficient (ADC) acquisition during magnetic resonance imaging-guided brachytherapy (MRgBT) using reduced field-of-view (rFOV) diffusion-weighted imaging (DWI). METHODS AND MATERIALS T2-weighted (T2w) MR and full-FOV single-shot echo planar (ssEPI) DWI were acquired in 7 patients with cervical or vaginal malignancy at baseline and prior to brachytherapy, while rFOV-DWI was acquired during MRgBT following brachytherapy applicator placement. The gross target volume (GTV) was contoured on the T2w images and registered to the ADC map. Voxels at the GTV's maximum Maurer distance comprised a central sub-volume (GTVcenter). Contour ADC mean and standard deviation were compared between timepoints using repeated measures ANOVA. RESULTS ssEPI-DWI mean ADC increased between baseline and prebrachytherapy from 1.03 ± 0.18 10-3 mm2/s to 1.34 ± 0.28 10-3 mm2/s for the GTV (p = 0.06) and from 0.84 ± 0.13 10-3 mm2/s to 1.26 ± 0.25 10-3 mm2/s at the level of the GTVcenter (p = 0.03), consistent with early treatment response. rFOV-DWI during MRgBT demonstrated mean ADC values of 1.28 ± 0.14 10-3 mm2/s and 1.28 ± 0.19 10-3 mm2/s for the GTV and GTVcenter, respectively (p = 0.02 and p = 0.03 relative to baseline). No significant differences were observed between ssEPI-DWI and rFOV-DWI ADC measurements. CONCLUSIONS Quantitative ADC measurement in the setting of MRI guided brachytherapy implant placement for cervical and vaginal cancers is feasible using rFOV-DWI, with comparable mean ADC comparable to prebrachytherapy ssEPI-DWI, and may enable MRI-guided radiotherapy targeting of low ADC, radiation resistant sub-volumes of tumor.
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Affiliation(s)
- Megan C Jacobsen
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Bastien Rigaud
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Samantha J Simiele
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Gaiane M Rauch
- Department of Abdominal Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Matthew S Ning
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sastry Vedam
- University of Maryland, Department of Radiation Oncology, Baltimore, MD
| | - Ann H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - R Jason Stafford
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kristy K Brock
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX; Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Aradhana M Venkatesan
- Department of Abdominal Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX.
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9
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Andring LM, Corrigan KL, Rooney M, Bailard N, Domingo M, Fellman B, Varkey J, Foster-Mills T, Kazantsev T, Lin L, Jhingran A, Colbert L, Eifel P, Klopp AH, Joyner M. Patient Reported Outcomes for Women Undergoing Definitive Chemoradiation for Gynecologic Cancer: A Prospective Clinical Trial. Pract Radiat Oncol 2023; 13:e538-e546. [PMID: 37597615 DOI: 10.1016/j.prro.2023.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 04/18/2023] [Revised: 07/11/2023] [Accepted: 07/21/2023] [Indexed: 08/21/2023]
Abstract
PURPOSE Patients with gynecologic malignancies have high psychosocial and symptom burden. We report data from a prospective trial evaluating patient-reported outcome (PRO) metrics in women undergoing definitive chemoradiation with brachytherapy (BT). METHODS AND MATERIALS A single-institution prospective trial evaluating outcomes of gynecologic cancer patients undergoing BT. Questionnaires to assess PROs at baseline, post-BT, and 60-day follow-up were collected, using European Organization for Research and Treatment of Cancer-Quality of Life Question-Core 30 and European Organization for Research and Treatment of Cancer-Quality of Life Question-Cervical Cancer Module validated metrics. Higher scores for functional scales/global health and lower scores for symptom items are favorable. European Organization for Research and Treatment of Cancer-Quality of Life Question-Core 30 mean scores were compared with a reference population. When comparing the study population between time points, medians, interquartile range, and nonparametric testing were used. RESULTS Thirty-three patients were enrolled, and 29 (88%) completed baseline PRO metrics. Mean global health score was worse than the reference population of women with any cancer diagnosis at baseline (41 vs 59, P < .001) and decreased further at follow-up (42 vs 33, P = .005). Compared with the cervical cancer reference, our patients had significantly worse social function (62 vs 83, P = .03), financial toxicity (49 vs 10, P < .001), fatigue (49 vs 34, P = .04), nausea/vomiting (26 vs 9, P = .001), and appetite loss (36 vs 16, P = .004).The majority of patients described depression (53%), feeling less attractive (64%), life interference (66%), and/or worry (69%). At baseline, higher global health scores were associated with improved physical functioning (R20.58, P < .001), social functioning (R20.56, P < .001), and body image (R20.40, P < .001); lower scores with more symptom burden (R20.71, P < .001), financial toxicity (R20.50, P < .001), and/or sexual worry (R20.25, P = .001). CONCLUSIONS Patients with cervical cancer have significant symptom burden and psychosocial toxicity, contributing to decreased quality of life. These data highlight the need for improved support throughout treatment for this high-risk population.
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Affiliation(s)
| | | | | | | | | | - Bryan Fellman
- Department of Statistical Analysis The University of Texas, MD Anderson Cancer Center, Houston, Texas
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10
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Lin D, Wu X, Karpinets T, Alam MBE, Sammouri J, Lynn EJ, Harris T, Lo DK, Wang R, Ajami NJ, Zhang J, Klopp AH, Colbert L. Changes in the Abundances of Cervical and Rectal Mycobiota during Chemoradiotherapy in Cervical Cancer. Int J Radiat Oncol Biol Phys 2023; 117:e527. [PMID: 37785637 DOI: 10.1016/j.ijrobp.2023.06.1804] [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) Globally, cervical cancer is the fourth most frequent cancer in women. The local and gut microbiomes of cervical cancer patients primarily consist of bacteria, viruses, and fungi. Bacterial composition has been previously associated with response to chemoradiotherapy (CRT) and patient outcome. Recently, our group has demonstrated that the HPV virome dynamically shifts during treatment and was associated with treatment response. Although connections between fungi and cervicovaginal health have been established, little is known about the fungal microbiome during treatment of cervical cancer. In this study, we sought to explore changes in fungal distribution throughout CRT for a cohort of cervical cancer patients. MATERIALS/METHODS This study includes 57 patients diagnosed with cervical cancer at a single institution with samples collected throughout CRT timepoints: baseline, week 1, week 3, and week 5. 170 swab specimens were included in this analysis: 138 cervical swabs from 56 patients and 32 rectal swabs from 9 patients. Whole genome sequencing data was obtained from the swabs using the Illumina HiSeqX platform (2 × 150bp). Fungal reads were log transformed to reduce variability and skewness and normalized to the total library size resulting in log normalized fungal reads per million (RPM). Bacterial reads were normalized with the same methodology. Timepoint analysis was performed using Wilcoxon signed rank tests or Friedman tests (with Dunn's multiple comparisons test) when comparing two or more time points, respectively. RESULTS All swab samples contained reads mapped to fungi. Of the 3.70 × 109 total reads across all sequenced samples, 19.2% did not map specifically to the human genome: 91.8% of these non-human reads could not be mapped to an individual microbial genome. Of the remaining 8.2% of non-human reads that mapped to a specific microbial genome (1.6% of total), 97.4% were classified as bacterial (1.5% of total), 0.71% as virus (0.011% of total), and 0.44% as fungal (0.0069% of total). Comparison of fungal RPM in the cervical and rectal microbiome revealed a significant decrease during treatment from baseline to week 5 (cervical, P = 0.0002; rectal, P = 0.0273). Distribution of bacterial reads exhibited similar trends as decreases were observed between baseline and week 5 for both cervical (P = 0.0116) and rectal (P = 0.0195) samples. Fungi to bacteria distribution ratios in the rectal microbiome revealed significant differences when comparing across all timepoints (P = 0.0041), baseline vs. week 1 (P = 0.0028), baseline vs. week 3 (P = 0.0389), and baseline vs. week 5 (P = 0.0113) with all three later timepoints higher relative to baseline. CONCLUSION The distributions of cervical and gut fungal reads and their relationship to the bacteriome shift during CRT. Further investigation into characterizing fungi and their relationship with other microbiota will be valuable to understanding its potential associations with cervical cancer and treatment response.
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Affiliation(s)
- D Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - X Wu
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - T Karpinets
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - M B El Alam
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - J Sammouri
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - E J Lynn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - T Harris
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - D K Lo
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - R Wang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - N J Ajami
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - J Zhang
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - A H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - L Colbert
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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11
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Seo A, Xiao W, Gjyshi O, Court K, Napravnik TC, Venkatesan A, Lynn EJ, Sammouri J, Colbert L, Jhingran A, Joyner MM, Lin LL, Gillison M, Klopp AH. HPV Circulating Cell-Free DNA Kinetics in Cervical Cancer Patients Undergoing Definitive Chemoradiation. Int J Radiat Oncol Biol Phys 2023; 117:S8-S9. [PMID: 37784579 DOI: 10.1016/j.ijrobp.2023.06.218] [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) The human papilloma virus (HPV) is a significant cause of cervical cancer and viral DNA can be detected in the blood of patients with cervical cancer (cfHPV-DNA). We hypothesized that detecting HPV cfDNA before, during and after chemoradiation (CRT) could provide insights into disease extent, clinical staging, and treatment response. MATERIALS/METHODS Forty-seven patients with cervical cancer were enrolled on this study between 2017 and 2022, either as part of a standard-of-care (SOC) treatment banking protocol (33 patients) or as part of a clinical trial combining a therapeutic HPV vaccine (PDS0101; Immunocerv, 14 patients). Longitudinal plasma samples were collected from each patient as baseline, during week 1, 3 or 5 of CRT. cfHPV-DNA was quantified using droplet digital PCR targeting the HPV E6/E7 oncogenes of 13 high-risk types based on analysis of cervical tumor genotype (AmpFire). Clinical covariates, including FIGO stage, primary tumor size, and treatment response were studied using appropriate statistical tests. RESULTS All 47 patients had detectable HPV cfDNA during CRT with 38 out of 47 having HPV type 16 detected. The median cfDNA at baseline was 24.5 copies/mL, with a range of 0 to 157,638 copies/mL. Of the 35 patients with at least three measurements, 20 (57%) had peak cfDNA counts at week 3, and 30 out of 35 showed a decline in cfDNA counts at week 5 compared to week 3. The proportion of patients who cleared cfDNA (<16 copies/mL) increased with each week of CRT, reaching 75% at week 5. Baseline cfDNA counts were associated with para-aortic nodal involvement (p<0.0001) but not with FIGO stage or gross tumor volume. A greater proportion of patients treated with therapeutic HPV-directed vaccine had clearance of cfDNA counts as compared to those treated with SOC (at week 3, 38% vs 5%, P = 0.02 and week 5, 79% vs 22%, P = 0.0054) CONCLUSION: HPV cfDNA levels change dynamically throughout definitive CRT and peak during the first 3 weeks for the majority of patients. Treatment with a therapeutic HPV vaccine was associated with a more rapid decline in cfHPV DNA. Further analysis of cfDNA kinetics could provide valuable information on the relationship between cfDNA levels, treatment response, and clinical outcomes.
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Affiliation(s)
- A Seo
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - W Xiao
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - O Gjyshi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - K Court
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - T Cisneros Napravnik
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - A Venkatesan
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - E J Lynn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - J Sammouri
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - L Colbert
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - A Jhingran
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - M M Joyner
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - L L Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - M Gillison
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - A H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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12
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Andring LM, Bailard N, Domingo M, Varkey J, Foster-Mills T, Lin LL, Jhingran A, Colbert L, Eifel PJ, Klopp AH, Joyner MM. Predictors of Poor Treatment Experience in Cervical Cancer Patients Receiving Definitive Chemoradiation and Brachytherapy Boost: A Prospective Study. Int J Radiat Oncol Biol Phys 2023; 117:e502-e503. [PMID: 37785578 DOI: 10.1016/j.ijrobp.2023.06.1749] [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) Cervical cancer patients experience high overall symptom burden. Here, we analyzed patient reported outcomes (PROs) to identify disease, treatment, or patient-related characteristics that can predict poor treatment experience. MATERIALS/METHODS Cervical cancer patients treated with definitive chemoradiation (CRT) at a single institution enrolled on a prospective trial evaluating PROs between 2021-2023 were included. Patients received PRO questionnaires at baseline (BL) and 2-7 days after final brachytherapy implant (post-BT). Data was collected using the EORTC-QLQ-C30, which is a validated metric scored on a 4-point Likert scale (1 = not at all, 2 = a little, 3 = quite a bit, 4 = very much). Poor treatment experience was defined as low physical function [score >2], significant overall symptom burden [> population mean], or substantial nausea/vomiting (N/V), diarrhea, pain, or fatigue [score >2] after BT. Potential predictors included age, menopause status, stage, radiation field size, BT modality (PDR vs HDR), marital status, high baseline financial toxicity [score >2], depression [score >2], worse social function [score >2] and poor emotional function [score >2]. Logistic regression modeling was performed and p<0.05 were considered significant. RESULTS A total of 36 patients completed BL and post-BT PRO metrics. Median age was 42 (range, 18-85), 22% (n = 8) of patients had localized disease, 75% (n = 27) had regional disease, and 3% (n = 1) had distant disease. Low BL social function was associated with high symptom burden after BT (HR 12.5, 95% CI 2.3-68.2, p = 0.004), significant N/V (HR 19.0, 95% CI 1.9-191.0, p = 0.012), high rates of fatigue (HR 9.29, 95% CI 1.6-54.8, p = 0.014), and overall poor physical function after treatment (HR 5.67, 95% CI 1.1-30.1, p = 0.042). High BL financial toxicity was predictive of elevated symptom burden after BT (HR 12.0, 95% CI 2.2-66.0, p = 0.004) and substantial fatigue (HR 7.33, 95% CI 1.5-36.7, p = 0.015). Significant depression at BL was also associated with high rates of N/V (HR 9.78, 95% CI 1.4-66.9, p = 0.02). Patient age, menopausal status, disease stage, radiation field size, BT modality, and marital status were not significantly predictive for symptom burden or physical function after treatment. CONCLUSION Patients with poor baseline social function, high financial toxicity, and depression are at risk for increased symptom burden. Screening for these factors may provide an opportunity to intervene early and improve patient treatment experience.
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Affiliation(s)
- L M Andring
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - N Bailard
- Department of Anesthesiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - M Domingo
- Department of Gynecologic Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - J Varkey
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - T Foster-Mills
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - L L Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - A Jhingran
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - L Colbert
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - P J Eifel
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - A H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - M M Joyner
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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13
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El Alam MB, Sammouri J, Lin D, Lynn EJ, Harris T, Lo DK, Wang R, Karpinets T, Ajami NJ, Wong M, Grover S, Kantelhardt EJ, Firdawoke E, Abebe T, Teka B, Romaguera J, Godoy-Vitorino F, Dorta-Estremera S, Klopp AH, Colbert L. Association of Bacterial Composition and Diversity in the Cervical Tumor Microbiome with HPV Genotype in a Large, International Patient Cohort. Int J Radiat Oncol Biol Phys 2023; 117:S130. [PMID: 37784335 DOI: 10.1016/j.ijrobp.2023.06.478] [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) Tumor bacterial composition is strongly associated with response to cancer therapy, and is impacted by environment, including geography. Human papillomavirus (HPV) genotypic diversity composition and load are dynamic during pelvic radiation (RT) and correlate with differential responses to RT in cervical cancer patients. In this multi-institutional, collaborative study, we aimed to explore associations between bacterial composition, HPV serotypes, and geographical distribution in an international patient population. MATERIALS/METHODS Cervical swabs were collected from 287 patients diagnosed with cervical cancer/ dysplasia in four locations: Houston, USA (TX; N = 94), Ethiopia (ETH; N = 85), Puerto Rico (PR; N = 71), and Botswana (BOT; N = 37). Swabs were collected prior to treatment and were subjected to 16S V4 rRNA gene sequencing and HPV genotyping. We compared HPV types and geography via Chi-squared test. We analyzed bacterial composition, alpha diversity (ANOVA), and beta diversity (principal coordinates analysis [PCoA] with PERMANOVA) for HPV type and geography. We used Linear Discriminant Effect Size (LEfSe) analysis to distinguish taxa associated with HPV types. RESULTS Overall, the global bacterial composition for patients with cancer or dysplasia did not significantly vary by location. However, the proportion of patients with each HPV type varied by location (p<0.01); HPV16 was most frequent in TX (54%), BOT (70%) and ETH (61%), while HPV18 was most frequent in PR (62%). The proportion of patients with HPV low-risk/negative tumors was highest in ETH (25%) compared to other sites (2% - 14%). Patients with HPV 16 had significantly higher bacterial alpha diversity across locations (all p<0.01). The bacterial composition also differed by HPV type across locations (p = 0.01). On LEfSe, bacterial genera enriched in HPV 16 samples were Bacteroides, Clostridium, and Prevotella. Non-HPV16 tumors were enriched in species of Lactobacillus and Gardnerella and HPV 18 and high-risk type tumors were enriched in Escherichia. CONCLUSION In thislarge, international cohort of cervical cancer and dysplasia patients, bacterial composition was more closely associated with cervical HPV genotype than with geography. This finding has implications for the development of biomarkers and interventions aimed at improving chemotherapy and radiation response through manipulation of the microbiome.
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Affiliation(s)
- M B El Alam
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - J Sammouri
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - D Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - E J Lynn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - T Harris
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - D K Lo
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - R Wang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - T Karpinets
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - N J Ajami
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - M Wong
- The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - S Grover
- Princess Marina Hospital, Gaborone, Botswana
| | | | - E Firdawoke
- Addis Ababa University, Addis Ababa, Ethiopia
| | - T Abebe
- Addis Ababa University, Addis Ababa, Ethiopia
| | - B Teka
- Addis Ababa University, Addis Ababa, Ethiopia
| | - J Romaguera
- University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico
| | - F Godoy-Vitorino
- University of Puerto Rico, School of Medicine, San Juan, Puerto Rico
| | - S Dorta-Estremera
- University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
| | - A H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - L Colbert
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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Konski A, Deshmukh S, Klopp AH, Yeung AR, Westin SN, Thompson JS, Doncals DE, Cantuaria GHC, D'Souza DP, Chang A, Kundapur V, Mohan DS, Haas ML, Kim YB, Ferguson CL, Pugh SL, Kachnic LA, Bruner DW. Quality-adjusted survival in women with gynecologic malignancies receiving IMRT after surgery: A Ppatient Rreported Ooutcome study of NRG oncology's RTOG 1203. Gynecol Oncol 2023; 175:176-181. [PMID: 37393743 PMCID: PMC10527270 DOI: 10.1016/j.ygyno.2023.05.074] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/21/2023] [Accepted: 05/31/2023] [Indexed: 07/04/2023]
Abstract
INTRODUCTION NRG/RTOG 1203 compared 3-D conformal radiotherapy (3D CRT) to intensity-modulated radiotherapy (IMRT) in patients with endometrial or cervical cancer requiring post-operative radiotherapy after hysterectomy. The purpose of this study was to report the first quality-adjusted survival analysis comparing the two treatments. METHODS NRG/RTOG 1203 randomized patients having undergone hysterectomy to either 3DCRT or IMRT. Stratification factors included RT dose, chemotherapy, and disease site. The EQ-5D, both index and visual analog scale (VAS), were obtained at baseline, 5 weeks after the start of RT, 4-6 weeks post RT and 1 and 3-years post RT. EQ-5D index and VAS scores along with quality-adjusted survival (QAS) were compared between treatment arms using the t-test at a two-sided significance level of 0.05. RESULTS NRG/RTOG 1203 enrolled 289 patients of which 236 consented to participate in the patient reported outcome (PRO) assessments. QAS was higher in women treated with IMRT, 1374 vs 1333 days (p = 0.5) compared to patients treated with 3DCRT, but this difference was not statistically different. Patients treated with IMRT had less of a decline in VAS score 5 weeks post RT, -5.04, compared to patients treated with 3DCRT, -7.48, although not statistically significant (p = 0.38). CONCLUSION This is the first report of the use of the EQ-5D comparing two radiotherapy techniques in the treatment of gynecologic malignancies after surgery. While there were no significant differences in QAS and VAS scores between patients who received IMRT vs. 3DCRT, RTOG 1203 was not powered to show statistical differences in these secondary endpoints.
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Affiliation(s)
- Andre Konski
- Department of Radiation Oncology, University of Pennsylvania, Senior Fellow Leonard Davis Institute of Health Economics, University of Pennsylvania, The Chester County Hospital, 701 E. Marshall Ave, West Chester, PA 19380, USA; Senior Fellow, Leonard Davis Institute for Health Economics, University of Pennsylvania, Department of Radiation Oncology, University of Pennsylvania, The Chester County Hospital, 701 E. Marshall Ave, West Chester, PA 19380, USA.
| | - Snehal Deshmukh
- American College of Radiology, NRG Statistical and Data Management Center, NRG Oncology, 50 South 16th Street, Suite 2800, Philadelphia, PA 19102, USA
| | - Ann H Klopp
- Department of Radiation Oncology, MD Anderson Cancer Center, Division of Radiation Oncology, 1515 Holcombe Boulevard, The University of Texas, Unit 1422, Houston, TX 77030, USA
| | - Anamaria R Yeung
- Department of Radiation Oncology, University of Florida, 2000 Southwest Archer Road PO Box 100385 Gainesville, FL 32610, USA
| | - Shannon N Westin
- Department of Radiation Oncology, MD Anderson Cancer Center, Division of Radiation Oncology, 1515 Holcombe Boulevard, The University of Texas, Unit 1422, Houston, TX 77030, USA
| | - J Spencer Thompson
- Department of Radiation Oncology, University of Oklahoma Health Sciences Center, Stephenson Cancer Center, 800 Northeast Tenth Street, Fifth Floor, Oklahoma City, OK 73104, USA
| | - Desiree E Doncals
- SUMMA Akron City Hospital/ Cooper Cancer Center, 161 North Forge Street, Suite G90, Akron, OH 44304, USA
| | - Guilherme H C Cantuaria
- Northside Hospital, University Gynecologic Oncology 960 Johnson Ferry Road Northeast Suite 130 Atlanta, GA 30342, USA
| | - David P D'Souza
- London Regional Cancer Program, London Health Sciences Centre, 339 Windermere Road, P.O. Box 5339, Stn Z, London, Ontario N6A 5A5, Canada
| | - Amy Chang
- Pamela Youde Nethersole Eastern Hospital, Main Block, Lok Man Rd, Chai Wan, Hong Kong
| | - Vijayananda Kundapur
- Saskatoon Cancer Center, University of Saskatchewan, 20 Campus Drive, Saskatoon, SK S7N 4H4, Canada
| | - Dasarahally S Mohan
- Kaiser Permanente Cancer Treatment Center, Department of Radiation Oncology, 220 Oyster Point Boulevard South, San Francisco, CA 94080, USA
| | - Michael L Haas
- Department of Radiation Oncology, McGlinn Cancer Institute Reading, Reading Hospital Radiation Oncology Department, 420 South Fifth Avenue West Reading, PA 19611, USA
| | - Yong Bae Kim
- Yonsei University Health System, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, South Korea
| | - Catherine L Ferguson
- Georgia Regents University, Augusta University Medical Center, Section of Hematology and Oncology, 1120 15th Street, BAA-5407 Augusta, GA 30912, USA
| | - Stephanie L Pugh
- American College of Radiology, NRG Statistical and Data Management Center, NRG Oncology, 50 South 16th Street, Suite 2800, Philadelphia, PA 19102, USA
| | - Lisa A Kachnic
- Department of Radiation Oncology, Columbia University, Herbert Irving Comprehensive Cancer Center, NYP/Columbia University Medical Center, Department of Radiation Oncology, 622 West 168th Street, New York, NY 10032, USA
| | - Deborah W Bruner
- Emory University Hospital/Winship Cancer Institute, 1599, Clifton Road, Northeast, Fourth Floor, Atlanta, GA 30322, USA
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Jacobsen MC, Maheshwari E, Klopp AH, Venkatesan AM. Image-Guided Radiotherapy for Gynecologic Malignancies: What the Radiologist Needs to Know. Radiol Clin North Am 2023; 61:725-747. [PMID: 37169434 DOI: 10.1016/j.rcl.2023.02.012] [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: 05/13/2023]
Abstract
Pelvic imaging is integral to contemporary radiotherapy (RT) management of gynecologic malignancies. For cervical, endometrial, vulvar, and vaginal cancers, three-dimensional imaging modalities aid in tumor staging and RT candidate selection and inform treatment strategy, including RT planning, execution, and posttherapy surveillance. State-of-the-art care routinely incorporates magnetic resonance (MR) imaging, 18F-fluorodeoxyglucose-PET/computed tomography (CT), and CT to guide external beam RT and brachytherapy, allowing the customization of RT plans to maximize patient outcomes and reduce treatment-related toxicities. Follow-up imaging identifies radiation-resistant and recurrent disease as well as short-term and long-term toxicities from RT.
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Affiliation(s)
- Megan C Jacobsen
- Division of Diagnostic Imaging, Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Unit 1472, Houston, TX 77030, USA. https://twitter.com/megjacobsen
| | - Ekta Maheshwari
- Division of Abdominal Imaging, Department of Radiology, University of Pittsburgh Medical Center, PUH Suite E204, 200 Lothrop St, Pittsburgh, PA 15213, USA. https://twitter.com/dr_ektam
| | - Ann H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX 77030, USA. https://twitter.com/AnnKloppMD
| | - Aradhana M Venkatesan
- Division of Diagnostic Imaging, Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Unit 1473, Houston, TX 77030, USA.
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Elnaggar JH, Huynh VO, Lin D, Hillman RT, Abana CO, El Alam MB, Tomasic KC, Karpinets TV, Kouzy R, Phan JL, Wargo J, Holliday EB, Das P, Mezzari MP, Ajami NJ, Lynn EJ, Minsky BD, Morris VK, Milbourne A, Messick CA, Klopp AH, Futreal PA, Taniguchi CM, Schmeler KM, Colbert LE. HPV-related anal cancer is associated with changes in the anorectal microbiome during cancer development. Front Immunol 2023; 14:1051431. [PMID: 37063829 PMCID: PMC10090447 DOI: 10.3389/fimmu.2023.1051431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 09/22/2022] [Accepted: 03/13/2023] [Indexed: 03/30/2023] Open
Abstract
BackgroundSquamous cell carcinoma of the anus (SCCA) is a rare gastrointestinal cancer. Factors associated with progression of HPV infection to anal dysplasia and cancer are unclear and screening guidelines and approaches for anal dysplasia are less clear than for cervical dysplasia. One potential contributing factor is the anorectal microbiome. In this study, we aimed to identify differences in anal microbiome composition in the settings of HPV infection, anal dysplasia, and anal cancer in this rare disease.MethodsPatients were enrolled in two prospective studies. Patients with anal dysplasia were part of a cross-sectional cohort that enrolled women with high-grade lower genital tract dysplasia. Anorectal tumor swabs were prospectively collected from patients with biopsy-confirmed locally advanced SCCA prior to receiving standard-of-care chemoradiotherapy (CRT). Patients with high-grade lower genital tract dysplasia without anal dysplasia were considered high-risk (HR Normal). 16S V4 rRNA Microbiome sequencing was performed for anal swabs. Alpha and Beta Diversity and composition were compared for HR Normal, anal dysplasia, and anal cancer.Results60 patients with high-grade lower genital tract dysplasia were initially enrolled. Seven patients had concurrent anal dysplasia and 44 patients were considered HR Normal. Anorectal swabs from 21 patients with localized SCCA were included, sequenced, and analyzed in the study. Analysis of weighted and unweighted UniFrac distances demonstrated significant differences in microbial community composition between anal cancer and HR normal (p=0.018). LEfSe identified that all three groups exhibited differential enrichment of specific taxa. Peptoniphilus (p=0.028), Fusobacteria (p=0.0295), Porphyromonas (p=0.034), and Prevotella (p=0.029) were enriched in anal cancer specimens when compared to HR normal.ConclusionAlthough alpha diversity was similar between HR Normal, dysplasia and cancer patients, composition differed significantly between the three groups. Increased anorectal Peptoniphilus, Fusobacteria, Porphyromonas, and Prevotella abundance were associated with anal cancer. These organisms have been reported in various gastrointestinal cancers with roles in facilitating the proinflammatory microenvironment and neoplasia progression. Future work should investigate a potential role of microbiome analysis in screening for anal dysplasia and investigation into potential mechanisms of how these microbial imbalances influence the immune system and anal carcinogenesis.
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Affiliation(s)
- Jacob H. Elnaggar
- School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, United States
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Victoria O. Huynh
- School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, United States
| | - Daniel Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - R. Tyler Hillman
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
- Cancer Prevention Research Institute of Texas Scholar in Cancer Research, Austin, TX, United States
| | - Chike O. Abana
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Molly B. El Alam
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Katarina C. Tomasic
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Tatiana V. Karpinets
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Ramez Kouzy
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Jae L. Phan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Jennifer Wargo
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Emma B. Holliday
- Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Prajnan Das
- Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Melissa P. Mezzari
- The Alkek Center for Metagenomics and Microbiome Research, Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, United States
| | - Nadim J. Ajami
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Erica J. Lynn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Bruce D. Minsky
- Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Van K. Morris
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Andrea Milbourne
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Craig A. Messick
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Ann H. Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - P. Andrew Futreal
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Cullen M. Taniguchi
- Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Kathleen M. Schmeler
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Lauren E. Colbert
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
- *Correspondence: Lauren E. Colbert,
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Teka B, Yoshida-Court K, Firdawoke E, Chanyalew Z, Gizaw M, Addissie A, Mihret A, Colbert LE, Napravnik TC, El Alam MB, Lynn EJ, Mezzari M, Anuja J, Kantelhardt EJ, Kaufmann AM, Klopp AH, Abebe T. Cervicovaginal Microbiota Profiles in Precancerous Lesions and Cervical Cancer among Ethiopian Women. Microorganisms 2023; 11:microorganisms11040833. [PMID: 37110255 PMCID: PMC10144031 DOI: 10.3390/microorganisms11040833] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/15/2023] [Accepted: 03/17/2023] [Indexed: 03/30/2023] Open
Abstract
Although high-risk human papillomavirus infection is a well-established risk factor for cervical cancer, other co-factors within the local microenvironment may play an important role in the development of cervical cancer. The current study aimed to characterize the cervicovaginal microbiota in women with premalignant dysplasia or invasive cervical cancer compared with that of healthy women. The study comprised 120 Ethiopian women (60 cervical cancer patients who had not received any treatment, 25 patients with premalignant dysplasia, and 35 healthy women). Cervicovaginal specimens were collected using either an Isohelix DNA buccal swab or an Evalyn brush, and ribosomal RNA sequencing was used to characterize the cervicovaginal microbiota. Shannon and Simpson diversity indices were used to evaluate alpha diversity. Beta diversity was examined using principal coordinate analysis of weighted UniFrac distances. Alpha diversity was significantly higher in patients with cervical cancer than in patients with dysplasia and in healthy women (p < 0.01). Beta diversity was also significantly different in cervical cancer patients compared with the other groups (weighted UniFrac Bray-Curtis, p < 0.01). Microbiota composition differed between the dysplasia and cervical cancer groups. Lactobacillus iners was particularly enriched in patients with cancer, and a high relative abundance of Lactobacillus species was identified in the dysplasia and healthy groups, whereas Porphyromonas, Prevotella, Bacteroides, and Anaerococcus species predominated in the cervical cancer group. In summary, we identified differences in cervicovaginal microbiota diversity, composition, and relative abundance between women with cervical cancer, women with dysplasia, and healthy women. Additional studies need to be carried out in Ethiopia and other regions to control for variation in sample collection.
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Affiliation(s)
- Brhanu Teka
- Department of Microbiology, Immunology and Parasitology School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa P.O. Box 9086, Ethiopia
- Global Health Working Group, Martin-Luther-University, Halle-Wittenberg, 06097 Halle, Germany
- Correspondence: ; Tel.: +251-913500065
| | - Kyoko Yoshida-Court
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Ededia Firdawoke
- Department of Microbiology, Immunology and Parasitology School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa P.O. Box 9086, Ethiopia
| | - Zewditu Chanyalew
- Department of Pathology, St. Paul Hospital Millennium Medical College, Addis Ababa P.O. Box 1271, Ethiopia
| | - Muluken Gizaw
- Global Health Working Group, Martin-Luther-University, Halle-Wittenberg, 06097 Halle, Germany
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa P.O. Box 34, Ethiopia
- Institute for Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University, Halle-Wittenberg, 06120 Halle, Germany
- NCD Working Group, Addis Ababa University, Addis Ababa P.O. Box 34, Ethiopia
| | - Adamu Addissie
- Global Health Working Group, Martin-Luther-University, Halle-Wittenberg, 06097 Halle, Germany
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa P.O. Box 34, Ethiopia
| | - Adane Mihret
- Department of Microbiology, Immunology and Parasitology School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa P.O. Box 9086, Ethiopia
- Armauer Hansen Research Institute, Addis Ababa P.O. Box 1005, Ethiopia
| | - Lauren E. Colbert
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Tatiana Cisneros Napravnik
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Molly B. El Alam
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Erica J. Lynn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Melissa Mezzari
- Molecular Virology and Microbiology, Baylor College of Medicine Alkek, Center for Molecular Discovery, Houston, TX 77030, USA
| | - Jhingran Anuja
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Eva Johanna Kantelhardt
- Global Health Working Group, Martin-Luther-University, Halle-Wittenberg, 06097 Halle, Germany
- Institute for Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University, Halle-Wittenberg, 06120 Halle, Germany
| | - Andreas M. Kaufmann
- Department of Gynecology, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany
| | - Ann H. Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Tamrat Abebe
- Department of Microbiology, Immunology and Parasitology School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa P.O. Box 9086, Ethiopia
- Global Health Working Group, Martin-Luther-University, Halle-Wittenberg, 06097 Halle, Germany
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Gjyshi O, Grippin A, Andring L, Jhingran A, Lin LL, Bronk J, Eifel PJ, Joyner MM, Sastry JK, Yoshida-Court K, Solley TN, Napravnik TC, O'Hara MP, Hegde VL, Colbert LE, Klopp AH. Circulating neutrophils and tumor-associated myeloid cells function as a powerful biomarker for response to chemoradiation in locally advanced cervical cancer. Clin Transl Radiat Oncol 2023; 39:100578. [PMID: 36935860 PMCID: PMC10014332 DOI: 10.1016/j.ctro.2023.100578] [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] [Received: 10/13/2022] [Revised: 01/06/2023] [Accepted: 01/08/2023] [Indexed: 01/12/2023] Open
Abstract
Purpose The immune system's role in mediating the cytotoxic effects of chemoradiotherapy remains not completely understood. The integration of immunotherapies into treatment will require insight into features and timing of the immune microenvironment associated with treatment response. Here, we investigated the role of circulating neutrophils and tumor-associated myeloid cells (TSAMs) as potential agents and biomarkers for disease-related outcomes in locally advanced cervical cancer (LACC). Material and Methods Hematologic parameters for two LACC patient cohorts, a retrospective clinical and a prospective translational cohort, were obtained at baseline, weekly during chemoradiotherapy for the retrospective cohort, biweekly during chemoradiotherapy for the prospective cohort, and at the first follow-up visit for both cohorts (mean 14.7 weeks, range 8.1-25.1 weeks for the prospective cohort and 5.3 weeks with a range of 2.7-9.0 weeks for the retrospective cohort). In both cohorts, baseline as well as mean and lowest on-treatment values for platelets, hemoglobin, absolute neutrophil count (ANC), and absolute lymphocyte count (ALC) were analyzed for correlations with disease-related outcomes. In the prospective cohort, circulating myeloid cells were isolated from peripheral blood mononuclear cells (PBMCs), and TSAMs were isolated from tumor tissue via a novel serial cytobrush sampling assay. The samples were analyzed by flow cytometry. Results In both cohorts, the only hematologic parameter significantly associated with survival was elevated on-treatment mean ANC (mANC), which was associated with lower local failure-free and overall survival rates in the retrospective and prospective cohorts, respectively. mANC was not associated with a difference in distant metastases. CD11b+CD11c- TSAMs, which act as a surrogate marker for intratumoral neutrophils, steadily decreased during the course of chemoRT and nadier'd at week 5 of treatment. Conversely, circulating myeloid cells identified from PBMCs steadily increased through week 5 of treatment. Regression analysis confirmed an inverse relationship between circulating myeloid cells and TSAMs at this time point. Conclusions These findings identify on-treatment mean neutrophil count as a predictor of disease-related outcomes, suggest that neutrophils contribute to chemoradiation treatment resistance, and demonstrate the importance of techniques to measure intratumoral immune activity.
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Affiliation(s)
- Olsi Gjyshi
- Department of Radiation Oncology, Saint Elizabeth Cancer Center, Edgewood, KY, United States
| | - Adam Grippin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas Department of Medicine, United States
| | - Lauren Andring
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas Department of Medicine, United States
| | - Anuja Jhingran
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas Department of Medicine, United States
| | - Lilie L. Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas Department of Medicine, United States
| | - Julianna Bronk
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas Department of Medicine, United States
| | - Patricia J. Eifel
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas Department of Medicine, United States
| | - Melissa M. Joyner
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas Department of Medicine, United States
| | - Jagannadha K. Sastry
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Kyoko Yoshida-Court
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas Department of Medicine, United States
| | - Travis N. Solley
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Tatiana Cisneros Napravnik
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas Department of Medicine, United States
| | - Madison P. O'Hara
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Venkatesh L Hegde
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Lauren E. Colbert
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas Department of Medicine, United States
- Corresponding authors at: Department of Radiation Oncology, Unit 1052, The University of Texas MD Anderson Cancer Center, 6565 MD Anderson Blvd., Houston, TX, 77030, United States, (L.E. Colbert); Department of Radiation Oncology, Unit 1422, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Houston, TX, 7703, United States, (A.H. Klopp).
| | - Ann H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas Department of Medicine, United States
- Corresponding authors at: Department of Radiation Oncology, Unit 1052, The University of Texas MD Anderson Cancer Center, 6565 MD Anderson Blvd., Houston, TX, 77030, United States, (L.E. Colbert); Department of Radiation Oncology, Unit 1422, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Houston, TX, 7703, United States, (A.H. Klopp).
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19
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Sammouri J, Wong MC, Lynn EJ, El Alam MB, Lo DK, Lin D, Harris TH, Karpinets TV, Court K, Napravnik TC, Wu X, Zhang J, Klopp AH, Ajami NJ, Colbert LE. Serial Genotyping of the Human Papillomavirus in Cervical Cancer: An Insight Into Virome Dynamics During Chemoradiation Therapy. Int J Radiat Oncol Biol Phys 2023:S0360-3016(23)00163-3. [PMID: 36801350 DOI: 10.1016/j.ijrobp.2023.02.018] [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] [Received: 12/09/2022] [Revised: 01/19/2023] [Accepted: 02/07/2023] [Indexed: 02/18/2023]
Abstract
PURPOSE Human papillomavirus (HPV) is the primary driver of cervical cancer. Although studies in other malignancies correlated peripheral blood DNA clearance with favorable outcomes, research on the prognostic value of HPV clearance in gynecologic cancers using intratumoral HPV is scarce. We aimed to quantify the intratumoral HPV virome in patients undergoing chemoradiation therapy (CRT) and associate this with clinical characteristics and outcomes. METHODS AND MATERIALS This prospective study enrolled 79 patients with stage IB-IVB cervical cancer undergoing definitive CRT. Cervical tumor swabs collected at baseline and week 5 (end of intensity modulated radiation therapy) were sent for shotgun metagenome sequencing and processed via VirMAP, a viral genome sequencing and identification tool for all known HPV types. The data were categorized into HPV groups (16, 18, high risk [HR], and low risk [LR]). We used independent t tests and Wilcoxon signed-rank to compare continuous variables and χ2 and Fisher exact tests to compare categorical variables. Kaplan-Meier survival modeling was performed with log-rank testing. HPV genotyping was verified using quantitative polymerase chain reaction to validate VirMAP results using receiver operating characteristic curve and Cohen's kappa. RESULTS At baseline, 42%, 12%, 25%, and 16% of patients were positive for HPV 16, HPV 18, HPV HR, and HPV LR, respectively, and 8% were HPV negative. HPV type was associated with insurance status and CRT response. Patients with HPV 16+ and other HPV HR+ tumors were significantly more likely to have a complete response to CRT versus patients with HPV 18 and HPV LR/HPV-negative tumors. Overall HPV viral loads predominantly decreased throughout CRT, except for HPV LR viral load. CONCLUSIONS Rarer, less well-studied HPV types in cervical tumors are clinically significant. HPV 18 and HPV LR/negative tumors are associated with poor CRT response. This feasibility study provides a framework for a larger study of intratumoral HPV profiling to predict outcomes in patients with cervical cancer.
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Affiliation(s)
| | - Matthew C Wong
- Genomic Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | | | | | | | | | - Tatiana V Karpinets
- Genomic Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | | | - Xiaogang Wu
- Genomic Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jianhua Zhang
- Genomic Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Nadim J Ajami
- Genomic Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas
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Yoder AK, Lakomy DS, Wu J, Andring LM, Fellman B, Colbert LE, Jhingran A, Klopp AH, Soliman P, Peterson SK, Lin LL. Impact of Treatment Modality on Quality of Life Among Uterine Cancer Survivors. Clin Oncol (R Coll Radiol) 2023; 35:e215-e226. [PMID: 36494250 PMCID: PMC9904419 DOI: 10.1016/j.clon.2022.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 11/11/2022] [Indexed: 12/12/2022]
Abstract
AIMS Our understanding of the impact of adjuvant therapy on longitudinal quality of life (QoL) following surgery for patients with uterine cancer is limited. The purpose of this study was to compare QoL in patients who have undergone surgery with or without radiation therapy for uterine cancer. MATERIALS AND METHODS This was a cross-sectional cohort study that examined women treated for uterine cancer at MD Anderson Cancer Center from 2006 to 2017. Participants included those who underwent hysterectomy/bilateral salphingo-oophorectomy alone, with brachytherapy or external beam radiation therapy (EBRT). A non-cancer cohort of women who underwent a hysterectomy/bilateral salphingo-oophorectomy for benign indications was also identified (non-CA). To compare QoL we used the Functional Assessment of Cancer Therapy - Endometrial survey (FACT-En), a validated survey used to assess QoL. The survey has five subscales: physical, social, emotional, functional and an endometrial cancer-specific subscale. Cohorts were compared using ANOVA tests. RESULTS In total, 309 women responded to the questionnaire (hysterectomy/bilateral salphingo-oophorectomy 64, brachytherapy 77, EBRT 96, non-CA 72). The median time from surgery to survey completion was 6.7 years. The mean total FACT-En score for the entire cohort was 144 [standard deviation 22]. Overall QoL was different between cohorts, with the EBRT cohort reporting the lowest QoL (mean 139.4 [21.6]) and the brachytherapy cohort the highest (150.6 [18.2], P = 0.006). Among patients who had undergone cancer treatment, the EBRT cohort reported the worst endometrial-specific QoL (53.5 [8.6]), while again the brachytherapy group reported the highest score (57.5 [6.1], P = 0.007). CONCLUSIONS QoL differences in women who have undergone different treatments for uterine cancer may persist years after treatment. In women with endometrial cancer who require adjuvant therapy, brachytherapy does not appear to have any long-term detriments on QoL.
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Affiliation(s)
- A K Yoder
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - D S Lakomy
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Dartmouth College Geisel School of Medicine, Hanover, NH, USA
| | - J Wu
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; The University of Texas School of Public Health, Houston, TX, USA
| | - L M Andring
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - B Fellman
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - L E Colbert
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - A Jhingran
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - A H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - P Soliman
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - S K Peterson
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - L L Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Simiele S, Starks C, Jacobsen MC, Venkatesan AM, Klopp AH, Colbert L. PO42 Presentation Time: 4:45 PM. Brachytherapy 2022. [DOI: 10.1016/j.brachy.2022.09.148] [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] [Indexed: 12/05/2022]
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22
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Simiele S, Jacobsen MC, Bruno T, Venkatesan AM, Lin L, Colbert L, Klopp AH. PO24 Presentation Time: 7:40 AM. Brachytherapy 2022. [DOI: 10.1016/j.brachy.2022.09.130] [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] [Indexed: 12/03/2022]
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Bronk JK, Kapadia C, Wu X, Chapman BV, Wang R, Karpinets TV, Song X, Futreal AM, Zhang J, Klopp AH, Colbert LE. Feasibility of a novel non-invasive swab technique for serial whole-exome sequencing of cervical tumors during chemoradiation therapy. PLoS One 2022; 17:e0274457. [PMID: 36201462 PMCID: PMC9536567 DOI: 10.1371/journal.pone.0274457] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 08/29/2022] [Indexed: 11/06/2022] Open
Abstract
Background Clinically relevant genetic predictors of radiation response for cervical cancer are understudied due to the morbidity of repeat invasive biopsies required to obtain genetic material. Thus, we aimed to demonstrate the feasibility of a novel noninvasive cervical swab technique to (1) collect tumor DNA with adequate throughput to (2) perform whole-exome sequencing (WES) at serial time points over the course of chemoradiation therapy (CRT). Methods Cervical cancer tumor samples from patients undergoing chemoradiation were collected at baseline, at week 1, week 3, and at the completion of CRT (week 5) using a noninvasive swab-based biopsy technique. Swab samples were analyzed with whole-exome sequencing (WES) with mutation calling using a custom pipeline optimized for shallow whole-exome sequencing with low tumor purity (TP). Tumor mutation changes over the course of treatment were profiled. Results 216 samples were collected and successfully sequenced for 70 patients (94% of total number of tumor samples collected). A total of 33 patients had a complete set of samples at all four time points. The mean mapping rate was 98% for all samples, and the mean target coverage was 180. Estimated TP was greater than 5% for all samples. Overall mutation frequency decreased during CRT but mapping rate and mean target coverage remained at >98% and >180 reads at week 5. Conclusion This study demonstrates the feasibility and application of a noninvasive swab-based technique for WES analysis which may be applied to investigate dynamic tumor mutational changes during treatment to identify novel genes which confer radiation resistance.
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Affiliation(s)
- Julianna K. Bronk
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Chiraag Kapadia
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, Texas, United States of America
| | - Xiaogang Wu
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Bhavana V. Chapman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Rui Wang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Tatiana V. Karpinets
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Xingzhi Song
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Andrew M. Futreal
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Jianhua Zhang
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Ann H. Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
- * E-mail: (LEC); (AHK)
| | - Lauren E. Colbert
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
- * E-mail: (LEC); (AHK)
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Yeung AR, Deshmukh S, Klopp AH, Gil KM, Wenzel L, Westin SN, Konski AA, Gaffney DK, Small W, Thompson JS, Doncals DE, Cantuaria GH, D'Souza DP, Chang A, Kundapur V, Mohan DS, Haas ML, Kim YB, Ferguson CL, Pugh SL, Kachnic LA, Bruner DW. Intensity-Modulated Radiation Therapy Reduces Patient-Reported Chronic Toxicity Compared With Conventional Pelvic Radiation Therapy: Updated Results of a Phase III Trial. J Clin Oncol 2022; 40:3115-3119. [PMID: 35960897 PMCID: PMC9851703 DOI: 10.1200/jco.21.02831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 12/09/2021] [Revised: 05/18/2022] [Accepted: 06/28/2022] [Indexed: 01/22/2023] Open
Abstract
Clinical trials frequently include multiple end points that mature at different times. The initial report, typically based on the primary end point, may be published when key planned coprimary or secondary analyses are not yet available. Clinical Trial Updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported.The purpose of this update was to determine differences in patient-reported chronic toxicity and disease outcomes with intensity-modulated radiation therapy (IMRT) compared with conventional pelvic radiation. Patients with cervical and endometrial cancers who received postoperative pelvic radiation were randomly assigned to conventional radiation therapy (CRT) or IMRT. Toxicity and quality of life were assessed using Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events, Expanded Prostate Cancer Index Composite (EPIC) bowel and urinary domains, and Functional Assessment of Cancer Therapy-General. Between 2012 and 2015, 279 eligible patients were enrolled to the study with a median follow-up of 37.8 months. There were no differences in overall survival (P = .53), disease-free survival (P = .21), or locoregional failure (P = .81). One year after RT, patients in the CRT arm experienced more high-level diarrhea frequency (5.8% IMRT v 15.1% CRT, P = .042) and a greater number had to take antidiarrheal medication two or more times a day (1.2% IMRT v 8.6% CRT, P = .036). At 3 years, women in the CRT arm reported a decline in urinary function, whereas the IMRT arm continued to improve (mean change in EPIC urinary score = 0.5, standard deviation = 13.0, IMRT v -6.0, standard deviation = 14.3, CRT, P = .005). In conclusion, IMRT reduces patient-reported chronic GI and urinary toxicity with no difference in treatment efficacy at 3 years.
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Affiliation(s)
| | - Snehal Deshmukh
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA
| | | | - Karen M. Gil
- Summa Akron City Hospital/Cooper Cancer Center, Akron, OH
| | - Lari Wenzel
- UC Irvine Health/Chao Family Comprehensive Cancer Center, Irvine, CA
| | | | - Andre A. Konski
- Chester County Hospital/University of Pennsylvania, West Chester, PA
| | - David K. Gaffney
- Huntsman Cancer Institute/University of Utah, Salt Lake City, UT
| | | | | | | | | | | | - Amy Chang
- Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong, China
| | | | | | | | - Yong Bae Kim
- Yonsei University Health System ACCRUALS UNDER MD Anderson Cancer Center, Yonsei-ro Seodaemun-gu, Seoul, South Korea
| | | | - Stephanie L. Pugh
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA
| | - Lisa A. Kachnic
- NYP/Columbia University/Herbert Irving Comprehensive Cancer Center, New York, NY
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Karpinets TV, Wu X, Solley T, El Alam MB, Sims TT, Yoshida-Court K, Lynn E, Ahmed-Kaddar M, Biegert G, Yue J, Song X, Sun H, Petrosino JF, Mezzari MP, Okhuysen P, Eifel PJ, Jhingran A, Lin LL, Schmeler KM, Ramondetta L, Ajami N, Jenq RR, Futreal A, Zhang J, Klopp AH, Colbert LE. Metagenomes of rectal swabs in larger, advanced stage cervical cancers have enhanced mucus degrading functionalities and distinct taxonomic structure. BMC Cancer 2022; 22:945. [PMID: 36050658 PMCID: PMC9438314 DOI: 10.1186/s12885-022-09997-0] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 08/11/2022] [Indexed: 11/10/2022] Open
Abstract
Background Gut microbiome community composition differs between cervical cancer (CC) patients and healthy controls, and increased gut diversity is associated with improved outcomes after treatment. We proposed that functions of specific microbial species adjoining the mucus layer may directly impact the biology of CC. Method Metagenomes of rectal swabs in 41 CC patients were examined by whole-genome shotgun sequencing to link taxonomic structures, molecular functions, and metabolic pathway to patient’s clinical characteristics. Results Significant association of molecular functions encoded by the metagenomes was found with initial tumor size and stage. Profiling of the molecular function abundances and their distributions identified 2 microbial communities co-existing in each metagenome but having distinct metabolism and taxonomic structures. Community A (Clostridia and Proteobacteria predominant) was characterized by high activity of pathways involved in stress response, mucus glycan degradation and utilization of degradation byproducts. This community was prevalent in patients with larger, advanced stage tumors. Conversely, community B (Bacteroidia predominant) was characterized by fast growth, active oxidative phosphorylation, and production of vitamins. This community was prevalent in patients with smaller, early-stage tumors. Conclusions In this study, enrichment of mucus degrading microbial communities in rectal metagenomes of CC patients was associated with larger, more advanced stage tumors. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-09997-0.
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Affiliation(s)
- Tatiana V Karpinets
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xiaogang Wu
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Travis Solley
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Molly B El Alam
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Travis T Sims
- Department of Gynecologic Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kyoko Yoshida-Court
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Erica Lynn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mustapha Ahmed-Kaddar
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Greyson Biegert
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jingyan Yue
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xingzhi Song
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Huandong Sun
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph F Petrosino
- Alkek Center for Metagenomics and Microbiome Research, Baylor College of Medicine, Houston, TX, USA
| | - Melissa P Mezzari
- Alkek Center for Metagenomics and Microbiome Research, Baylor College of Medicine, Houston, TX, USA
| | - Pablo Okhuysen
- Department of Infectious Diseases, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Patricia J Eifel
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anuja Jhingran
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lilie L Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kathleen M Schmeler
- Department of Gynecologic Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lois Ramondetta
- Department of Gynecologic Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nadim Ajami
- Program for Innovative Microbiome and Translational Research, Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Robert R Jenq
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Program for Innovative Microbiome and Translational Research, Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew Futreal
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jianhua Zhang
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Ann H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Lauren E Colbert
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Maheshwari E, Nougaret S, Stein EB, Rauch GM, Hwang KP, Stafford RJ, Klopp AH, Soliman PT, Maturen KE, Rockall AG, Lee SI, Sadowski EA, Venkatesan AM. Update on MRI in Evaluation and Treatment of Endometrial Cancer. Radiographics 2022; 42:2112-2130. [PMID: 36018785 DOI: 10.1148/rg.220070] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Endometrial cancer is the second most common gynecologic cancer worldwide and the most common gynecologic cancer in the United States, with an increasing incidence in high-income countries. Although the International Federation of Gynecology and Obstetrics (FIGO) staging system for endometrial cancer is a surgical staging system, contemporary published evidence-based data and expert opinions recommend MRI for treatment planning as it provides critical diagnostic information on tumor size and depth, extent of myometrial and cervical invasion, extrauterine extent, and lymph node status, all of which are essential in choosing the most appropriate therapy. Multiparametric MRI using a combination of T2-weighted sequences, diffusion-weighted imaging, and multiphase contrast-enhanced imaging is the mainstay for imaging assessment of endometrial cancer. Identification of important prognostic factors at MRI improves both treatment selection and posttreatment follow-up. MRI also plays a crucial role for fertility-preserving strategies and in patients who are not surgical candidates by helping guide therapy and identify procedural complications. This review is a product of the Society of Abdominal Radiology Uterine and Ovarian Cancer Disease-Focused Panel and reflects a multidisciplinary international collaborative effort to summarize updated information highlighting the role of MRI for endometrial cancer depiction and delineation, treatment planning, and follow-up. The article includes information regarding dedicated MRI protocols, tips for MRI reporting, imaging pitfalls, and strategies for image quality optimization. The roles of MRI-guided radiation therapy, hybrid PET/MRI, and advanced MRI techniques that are applicable to endometrial cancer imaging are also discussed. Online supplemental material is available for this article. ©RSNA, 2022.
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Affiliation(s)
- Ekta Maheshwari
- From the Department of Radiology, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA 15213 (E.M.); Department of Abdominal Imaging, Montpellier Cancer Research Institute (IRCM), Montpellier, France (S.N.); Department of Radiology, University of Michigan, Ann Arbor, Mich (E.B.S., K.E.M.); Department of Abdominal Imaging, Division of Diagnostic Imaging (G.M.R., A.M.V.), Department of Imaging Physics (K.P.H., R.J.S.), Department of Radiation Oncology (A.H.K.), and Department of Gynecologic Oncology and Reproductive Medicine (P.T.S.), University of Texas MD Anderson Cancer Center, Houston, Tex; Department of Radiology, Imperial College, London, United Kingdom (A.G.R.); Department of Diagnostic Radiology, Massachusetts General Hospital, Boston, Mass (S.I.L.); and Department of Radiology, University of Wisconsin-Madison, Madison, Wis (E.A.S.)
| | - Stephanie Nougaret
- From the Department of Radiology, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA 15213 (E.M.); Department of Abdominal Imaging, Montpellier Cancer Research Institute (IRCM), Montpellier, France (S.N.); Department of Radiology, University of Michigan, Ann Arbor, Mich (E.B.S., K.E.M.); Department of Abdominal Imaging, Division of Diagnostic Imaging (G.M.R., A.M.V.), Department of Imaging Physics (K.P.H., R.J.S.), Department of Radiation Oncology (A.H.K.), and Department of Gynecologic Oncology and Reproductive Medicine (P.T.S.), University of Texas MD Anderson Cancer Center, Houston, Tex; Department of Radiology, Imperial College, London, United Kingdom (A.G.R.); Department of Diagnostic Radiology, Massachusetts General Hospital, Boston, Mass (S.I.L.); and Department of Radiology, University of Wisconsin-Madison, Madison, Wis (E.A.S.)
| | - Erica B Stein
- From the Department of Radiology, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA 15213 (E.M.); Department of Abdominal Imaging, Montpellier Cancer Research Institute (IRCM), Montpellier, France (S.N.); Department of Radiology, University of Michigan, Ann Arbor, Mich (E.B.S., K.E.M.); Department of Abdominal Imaging, Division of Diagnostic Imaging (G.M.R., A.M.V.), Department of Imaging Physics (K.P.H., R.J.S.), Department of Radiation Oncology (A.H.K.), and Department of Gynecologic Oncology and Reproductive Medicine (P.T.S.), University of Texas MD Anderson Cancer Center, Houston, Tex; Department of Radiology, Imperial College, London, United Kingdom (A.G.R.); Department of Diagnostic Radiology, Massachusetts General Hospital, Boston, Mass (S.I.L.); and Department of Radiology, University of Wisconsin-Madison, Madison, Wis (E.A.S.)
| | - Gaiane M Rauch
- From the Department of Radiology, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA 15213 (E.M.); Department of Abdominal Imaging, Montpellier Cancer Research Institute (IRCM), Montpellier, France (S.N.); Department of Radiology, University of Michigan, Ann Arbor, Mich (E.B.S., K.E.M.); Department of Abdominal Imaging, Division of Diagnostic Imaging (G.M.R., A.M.V.), Department of Imaging Physics (K.P.H., R.J.S.), Department of Radiation Oncology (A.H.K.), and Department of Gynecologic Oncology and Reproductive Medicine (P.T.S.), University of Texas MD Anderson Cancer Center, Houston, Tex; Department of Radiology, Imperial College, London, United Kingdom (A.G.R.); Department of Diagnostic Radiology, Massachusetts General Hospital, Boston, Mass (S.I.L.); and Department of Radiology, University of Wisconsin-Madison, Madison, Wis (E.A.S.)
| | - Ken-Pin Hwang
- From the Department of Radiology, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA 15213 (E.M.); Department of Abdominal Imaging, Montpellier Cancer Research Institute (IRCM), Montpellier, France (S.N.); Department of Radiology, University of Michigan, Ann Arbor, Mich (E.B.S., K.E.M.); Department of Abdominal Imaging, Division of Diagnostic Imaging (G.M.R., A.M.V.), Department of Imaging Physics (K.P.H., R.J.S.), Department of Radiation Oncology (A.H.K.), and Department of Gynecologic Oncology and Reproductive Medicine (P.T.S.), University of Texas MD Anderson Cancer Center, Houston, Tex; Department of Radiology, Imperial College, London, United Kingdom (A.G.R.); Department of Diagnostic Radiology, Massachusetts General Hospital, Boston, Mass (S.I.L.); and Department of Radiology, University of Wisconsin-Madison, Madison, Wis (E.A.S.)
| | - R Jason Stafford
- From the Department of Radiology, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA 15213 (E.M.); Department of Abdominal Imaging, Montpellier Cancer Research Institute (IRCM), Montpellier, France (S.N.); Department of Radiology, University of Michigan, Ann Arbor, Mich (E.B.S., K.E.M.); Department of Abdominal Imaging, Division of Diagnostic Imaging (G.M.R., A.M.V.), Department of Imaging Physics (K.P.H., R.J.S.), Department of Radiation Oncology (A.H.K.), and Department of Gynecologic Oncology and Reproductive Medicine (P.T.S.), University of Texas MD Anderson Cancer Center, Houston, Tex; Department of Radiology, Imperial College, London, United Kingdom (A.G.R.); Department of Diagnostic Radiology, Massachusetts General Hospital, Boston, Mass (S.I.L.); and Department of Radiology, University of Wisconsin-Madison, Madison, Wis (E.A.S.)
| | - Ann H Klopp
- From the Department of Radiology, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA 15213 (E.M.); Department of Abdominal Imaging, Montpellier Cancer Research Institute (IRCM), Montpellier, France (S.N.); Department of Radiology, University of Michigan, Ann Arbor, Mich (E.B.S., K.E.M.); Department of Abdominal Imaging, Division of Diagnostic Imaging (G.M.R., A.M.V.), Department of Imaging Physics (K.P.H., R.J.S.), Department of Radiation Oncology (A.H.K.), and Department of Gynecologic Oncology and Reproductive Medicine (P.T.S.), University of Texas MD Anderson Cancer Center, Houston, Tex; Department of Radiology, Imperial College, London, United Kingdom (A.G.R.); Department of Diagnostic Radiology, Massachusetts General Hospital, Boston, Mass (S.I.L.); and Department of Radiology, University of Wisconsin-Madison, Madison, Wis (E.A.S.)
| | - Pamela T Soliman
- From the Department of Radiology, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA 15213 (E.M.); Department of Abdominal Imaging, Montpellier Cancer Research Institute (IRCM), Montpellier, France (S.N.); Department of Radiology, University of Michigan, Ann Arbor, Mich (E.B.S., K.E.M.); Department of Abdominal Imaging, Division of Diagnostic Imaging (G.M.R., A.M.V.), Department of Imaging Physics (K.P.H., R.J.S.), Department of Radiation Oncology (A.H.K.), and Department of Gynecologic Oncology and Reproductive Medicine (P.T.S.), University of Texas MD Anderson Cancer Center, Houston, Tex; Department of Radiology, Imperial College, London, United Kingdom (A.G.R.); Department of Diagnostic Radiology, Massachusetts General Hospital, Boston, Mass (S.I.L.); and Department of Radiology, University of Wisconsin-Madison, Madison, Wis (E.A.S.)
| | - Katherine E Maturen
- From the Department of Radiology, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA 15213 (E.M.); Department of Abdominal Imaging, Montpellier Cancer Research Institute (IRCM), Montpellier, France (S.N.); Department of Radiology, University of Michigan, Ann Arbor, Mich (E.B.S., K.E.M.); Department of Abdominal Imaging, Division of Diagnostic Imaging (G.M.R., A.M.V.), Department of Imaging Physics (K.P.H., R.J.S.), Department of Radiation Oncology (A.H.K.), and Department of Gynecologic Oncology and Reproductive Medicine (P.T.S.), University of Texas MD Anderson Cancer Center, Houston, Tex; Department of Radiology, Imperial College, London, United Kingdom (A.G.R.); Department of Diagnostic Radiology, Massachusetts General Hospital, Boston, Mass (S.I.L.); and Department of Radiology, University of Wisconsin-Madison, Madison, Wis (E.A.S.)
| | - Andrea G Rockall
- From the Department of Radiology, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA 15213 (E.M.); Department of Abdominal Imaging, Montpellier Cancer Research Institute (IRCM), Montpellier, France (S.N.); Department of Radiology, University of Michigan, Ann Arbor, Mich (E.B.S., K.E.M.); Department of Abdominal Imaging, Division of Diagnostic Imaging (G.M.R., A.M.V.), Department of Imaging Physics (K.P.H., R.J.S.), Department of Radiation Oncology (A.H.K.), and Department of Gynecologic Oncology and Reproductive Medicine (P.T.S.), University of Texas MD Anderson Cancer Center, Houston, Tex; Department of Radiology, Imperial College, London, United Kingdom (A.G.R.); Department of Diagnostic Radiology, Massachusetts General Hospital, Boston, Mass (S.I.L.); and Department of Radiology, University of Wisconsin-Madison, Madison, Wis (E.A.S.)
| | - Susanna I Lee
- From the Department of Radiology, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA 15213 (E.M.); Department of Abdominal Imaging, Montpellier Cancer Research Institute (IRCM), Montpellier, France (S.N.); Department of Radiology, University of Michigan, Ann Arbor, Mich (E.B.S., K.E.M.); Department of Abdominal Imaging, Division of Diagnostic Imaging (G.M.R., A.M.V.), Department of Imaging Physics (K.P.H., R.J.S.), Department of Radiation Oncology (A.H.K.), and Department of Gynecologic Oncology and Reproductive Medicine (P.T.S.), University of Texas MD Anderson Cancer Center, Houston, Tex; Department of Radiology, Imperial College, London, United Kingdom (A.G.R.); Department of Diagnostic Radiology, Massachusetts General Hospital, Boston, Mass (S.I.L.); and Department of Radiology, University of Wisconsin-Madison, Madison, Wis (E.A.S.)
| | - Elizabeth A Sadowski
- From the Department of Radiology, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA 15213 (E.M.); Department of Abdominal Imaging, Montpellier Cancer Research Institute (IRCM), Montpellier, France (S.N.); Department of Radiology, University of Michigan, Ann Arbor, Mich (E.B.S., K.E.M.); Department of Abdominal Imaging, Division of Diagnostic Imaging (G.M.R., A.M.V.), Department of Imaging Physics (K.P.H., R.J.S.), Department of Radiation Oncology (A.H.K.), and Department of Gynecologic Oncology and Reproductive Medicine (P.T.S.), University of Texas MD Anderson Cancer Center, Houston, Tex; Department of Radiology, Imperial College, London, United Kingdom (A.G.R.); Department of Diagnostic Radiology, Massachusetts General Hospital, Boston, Mass (S.I.L.); and Department of Radiology, University of Wisconsin-Madison, Madison, Wis (E.A.S.)
| | - Aradhana M Venkatesan
- From the Department of Radiology, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA 15213 (E.M.); Department of Abdominal Imaging, Montpellier Cancer Research Institute (IRCM), Montpellier, France (S.N.); Department of Radiology, University of Michigan, Ann Arbor, Mich (E.B.S., K.E.M.); Department of Abdominal Imaging, Division of Diagnostic Imaging (G.M.R., A.M.V.), Department of Imaging Physics (K.P.H., R.J.S.), Department of Radiation Oncology (A.H.K.), and Department of Gynecologic Oncology and Reproductive Medicine (P.T.S.), University of Texas MD Anderson Cancer Center, Houston, Tex; Department of Radiology, Imperial College, London, United Kingdom (A.G.R.); Department of Diagnostic Radiology, Massachusetts General Hospital, Boston, Mass (S.I.L.); and Department of Radiology, University of Wisconsin-Madison, Madison, Wis (E.A.S.)
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Jacobsen MC, Beriwal S, Dyer BA, Klopp AH, Lee SI, McGinnis GJ, Robbins JB, Rauch GM, Sadowski EA, Simiele SJ, Stafford RJ, Taunk NK, Yashar CM, Venkatesan AM. Contemporary image-guided cervical cancer brachytherapy: Consensus imaging recommendations from the Society of Abdominal Radiology and the American Brachytherapy Society. Brachytherapy 2022; 21:369-388. [PMID: 35725550 DOI: 10.1016/j.brachy.2022.04.005] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 04/15/2022] [Accepted: 04/24/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE To present recommendations for the use of imaging for evaluation and procedural guidance of brachytherapy for cervical cancer patients. METHODS An expert panel comprised of members of the Society of Abdominal Radiology Uterine and Ovarian Cancer Disease Focused Panel and the American Brachytherapy Society jointly assessed the existing literature and provide data-driven guidance on imaging protocol development, interpretation, and reporting. RESULTS Image-guidance during applicator implantation reduces rates of uterine perforation by the tandem. Postimplant images may be acquired with radiography, computed tomography (CT), or magnetic resonance imaging (MRI), and CT or MRI are preferred due to a decrease in severe complications. Pre-brachytherapy T2-weighted MRI may be used as a reference for contouring the high-risk clinical target volume (HR-CTV) when CT is used for treatment planning. Reference CT and MRI protocols are provided for reference. CONCLUSIONS Image-guided brachytherapy in locally advanced cervical cancer is essential for optimal patient management. Various imaging modalities, including orthogonal radiographs, ultrasound, computed tomography, and magnetic resonance imaging, remain integral to the successful execution of image-guided brachytherapy.
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Affiliation(s)
- Megan C Jacobsen
- The University of Texas MD Anderson Cancer Center, Department of Imaging Physics, Houston, TX
| | - Sushil Beriwal
- Allegheny Health Network, Department of Radiation Oncology, Pittsburgh, PA; Varian Medical Systems, Palo Alto, CA
| | - Brandon A Dyer
- Legacy Health, Department of Radiation Oncology, Portland, OR
| | - Ann H Klopp
- The University of Texas MD Anderson Cancer Center, Department of Radiation Oncology, Houston, TX
| | - Susanna I Lee
- Massachusetts General Hospital, Department of Radiology, Boston, MA
| | - Gwendolyn J McGinnis
- The University of Texas MD Anderson Cancer Center, Department of Radiation Oncology, Houston, TX
| | | | - Gaiane M Rauch
- The University of Texas MD Anderson Cancer Center, Department of Abdominal Imaging, Houston, TX
| | | | - Samantha J Simiele
- The University of Texas MD Anderson Cancer Center, Department of Radiation Physics, Houston, TX
| | - R Jason Stafford
- The University of Texas MD Anderson Cancer Center, Department of Imaging Physics, Houston, TX
| | - Neil K Taunk
- University of Pennsylvania, Department of Radiation Oncology, Philadelphia, PA
| | - Catheryn M Yashar
- University of California San Diego, Department of Radiation Oncology, San Diego, CA
| | - Aradhana M Venkatesan
- The University of Texas MD Anderson Cancer Center, Department of Abdominal Imaging, Houston, TX.
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Lakomy DS, Yoder AK, Wu J, Hernandez M, Ayoola-Adeola M, Jhingran A, Klopp AH, Soliman P, Peterson SK, Lin LL. Impact of treatment modality on pelvic floor dysfunction among uterine cancer survivors. Int J Gynecol Cancer 2022; 32:ijgc-2022-003417. [PMID: 35680139 PMCID: PMC9732149 DOI: 10.1136/ijgc-2022-003417] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Pelvic floor dysfunction is a common adverse effect of uterine cancer treatment. In this study we compared patient-reported outcomes regarding pelvic floor dysfunction among uterine cancer survivors after hysterectomy and bilateral salpingo-oophorectomy, surgery and brachytherapy, or surgery and external beam radiotherapy with or without brachytherapy versus women who had a hysterectomy for benign indications. METHODS We used the validated 20-item Pelvic Floor Distress Inventory to assess lower urinary distress, colorectal distress, and pelvic organ prolapse dysfunction in each treatment group. Pelvic floor dysfunction-related quality of life in these domains was compared across treatment modalities using the Pelvic Floor Impact Questionnaire-7. Treatment type, body mass index, comorbidities, and number of vaginal births were obtained from medical records. A zero-inflated negative binomial regression model was used to assess the association of treatment regimens and covariates relative to the non-cancer cohort. RESULTS A total of 309 surveys were analyzed. The median age of the patients at surgery was 58 years (range 20-87) and the median age at survey completion was 66 years (range 34-92). Most participants reported experiencing at least one symptom of pelvic floor dysfunction (76% by Pelvic Floor Distress Inventory-2). The type of treatment had no effect on overall pelvic floor dysfunction on multivariate analysis (all p>0.05). Worse urinary-related symptoms were associated with higher body mass index at surgery (OR 1.41), higher age at time of survey (OR 1.07), and higher numbers of vaginal births (OR 1.43) (all p<0.05). CONCLUSIONS Overall, pelvic floor dysfunction did not significantly vary by treatment modality. Our findings suggest complex interactions among age, body mass index, and parity as to how uterine cancer treatment affects pelvic floor quality of life, which should be considered in the choice of treatment strategy and patient counseling.
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Affiliation(s)
- David S. Lakomy
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Dartmouth College Geisel School of Medicine, Hanover, NH
| | - Alison K. Yoder
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Juliana Wu
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- The University of Texas School of Public Health, Houston, TX, USA
| | - Mike Hernandez
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Martins Ayoola-Adeola
- Department of Obstetrics & Gynecology, Wayne State University, Detroit, Michigan, USA
| | - Anuja Jhingran
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ann H. Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pamela Soliman
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susan K. Peterson
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lilie L. Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Lin D, Alam MBE, Jaoude JA, Kouzy R, Phan JL, Elnaggar JH, Resendiz B, Medrano AYD, Lynn EJ, Nguyen ND, Noticewala SS, Mathew GG, Holliday EB, Minsky BD, Das P, Morris VK, Eng C, Mezzari MP, Petrosino JF, Ajami NJ, Klopp AH, Taniguchi CM, Colbert LE. Microbiome Dynamics During Chemoradiotherapy for Anal Cancer. Int J Radiat Oncol Biol Phys 2022; 113:974-984. [DOI: 10.1016/j.ijrobp.2022.04.037] [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: 12/03/2021] [Revised: 04/22/2022] [Accepted: 04/27/2022] [Indexed: 10/18/2022]
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Wu J, Lakomy DS, Fellman BM, Salcedo MP, Sood AK, Jhingran A, Klopp AH, Iyer RB, Jimenez C, Colbert LE, Eifel PJ, Schmeler KM, Lin LL. Longitudinal Changes in Bone Mineral Measurements Inside and Outside Radiation Fields Used for Cervical Cancer Treatment. Pract Radiat Oncol 2022; 12:e423-e433. [PMID: 35390531 DOI: 10.1016/j.prro.2022.03.013] [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] [Received: 01/05/2022] [Revised: 03/18/2022] [Accepted: 03/31/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE We compared the magnitude of changes in bone mineral density (BMD), within and outside the radiation field, among women who received pelvic radiotherapy (RT) with or without chemotherapy for cervical cancer. PATIENTS & METHODS In this secondary analysis of a prospective study, we analyzed serial CT scans and dual-energy X-ray absorptiometry (DXA) scans from 78 patients who received definitive RT or chemoradiation (CRT) for cervical cancer at a single institution from 2008 to 2015. BMD values at L1, L2, L3 and L4 were measured. We compared changes in BMD within the radiation field (i.e., at L4) with those outside the field (i.e., at L1). Linear mixed models were also used to examine the effect of RT on changes in BMD over time and covariate adjustment. RESULTS The median age of the 78 patients was 45.5 years (range 23-88); all received RT and 76 (97%) received concurrent CRT. Treatment was associated with significant declines in BMD in all 4 lumbar vertebral bodies over time (P<0.05), with nadir at 3 months for L4 and at 1 year for L1. Pairwise comparisons at 3 months and 2 years after treatment indicated that BMD in L4 (within the RT field) had improved (P=0.037), but BMD in L1 (outside the RT field) was no different at 3 months and 2 years. CONCLUSIONS Significant BMD declines were observed in all lumbar vertebral bodies immediately following RT. However, in-field vertebral bodies reached nadir BMD earlier than those located outside the RT field. Our results suggest that treatment and patient-related factors other than RT may contribute to declines in BMD after treatment for cervical cancer. Routine bone density screening and post-RT therapy with hormones may be beneficial for selected patients who receive CRT for cervical cancer.
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Affiliation(s)
- Juliana Wu
- University of Texas Medical Branch, Galveston, TX; Departments of Radiation Oncology, Houston, TX
| | - David S Lakomy
- Departments of Radiation Oncology, Houston, TX; Dartmouth Geisel School of Medicine, Hanover, NH
| | | | - Mila P Salcedo
- Departments of Gynecologic Oncology and Reproductive Medicine, Houston, TX; Obstetrics and Gynecology Department, Federal University of Health Sciences/Irmandade Santa Casa de Misericordia, Porto Alegre, Brazil
| | - Anil K Sood
- Departments of Gynecologic Oncology and Reproductive Medicine, Houston, TX
| | | | - Ann H Klopp
- Departments of Radiation Oncology, Houston, TX
| | | | - Camilo Jimenez
- Departments of Endocrinology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | - Lilie L Lin
- Departments of Radiation Oncology, Houston, TX.
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Lakomy DS, Yang J, Vedam S, Wang J, Lee B, Sobremonte A, Castillo P, Hughes N, Mohammadsaid M, Jhingran A, Klopp AH, Choi S, Fuller CD, Lin LL. Clinical implementation and initial experience with a 1.5 Tesla MR-linac for MR-guided radiotherapy for gynecologic cancer: An R-IDEAL stage 1/2a first in humans/feasibility study of new technology implementation. Pract Radiat Oncol 2022; 12:e296-e305. [PMID: 35278717 DOI: 10.1016/j.prro.2022.03.002] [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: 11/15/2021] [Revised: 02/23/2022] [Accepted: 03/01/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Magnetic resonance imaging-guided linear accelerator systems (MR-linacs) can facilitate the daily adaptation of radiotherapy plans. Here, we report our early clinical experience using an MR-linac for adaptive radiotherapy of gynecologic malignancies. METHODS AND MATERIALS Treatments were planned with an Elekta Monaco v5.4.01 and delivered by a 1.5 Tesla Elekta Unity MR-linac. The system offers a choice of daily adaptation based on either position (ATP) or shape (ATS) of the tumor and surrounding normal structures. The ATS approach has the option of manually editing the contours of tumors and surrounding normal structures before the plan is adapted. Here we documented the duration of each treatment fraction; set-up variability (assessed by isocenter shifts in each plan) between fractions; and, for quality assurance, calculated the percentage of plans meeting the γ-criterion of 3%/3-mm distance to agreement. Deformable accumulated dose calculations were used to compare accumulated versus planned dose for patient treated with exclusively ATP fractions. RESULTS Of the 10 patients treated with 90 fractions on the MR-linac, most received boost doses to recurrence in nodes or isolated tumors. Each treatment fraction lasted a median 32 minutes; fractions were shorter with ATP than with ATS (30 min vs 42 min, P<0.0001). The γ criterion for all fraction plans exceeded >90% (median 99.9%, range 92.4%-100%), i.e., all plans passed quality assurance testing. The average extent of isocenter shift was <0.5 cm in each axis. The accumulated dose to the gross tumor volume was within 5% of the reference plan for all ATP cases. Accumulated doses for lesions in the pelvic periphery were within <1% of the reference plan as opposed to -1.6% to -4.4% for central pelvic tumors. CONCLUSIONS The MR-linac is a reliable and clinically feasible tool for treating patients with gynecologic cancer.
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Affiliation(s)
- David S Lakomy
- Departments of Radiation Oncology; Dartmouth Geisel School of Medicine, Hanover, NH, USA
| | - Jinzhong Yang
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sastry Vedam
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jihong Wang
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Belinda Lee
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Angela Sobremonte
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pamela Castillo
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Neil Hughes
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mustefa Mohammadsaid
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Lakomy DS, Wu J, Chapman BV, Yu ZH, Lee B, Klopp AH, Jhingran A, Eifel PJ, Lin LL. Use of specific duodenal dose constraints during treatment planning reduces toxicity after definitive para-aortic radiotherapy for cervical cancer. Pract Radiat Oncol 2021; 12:e207-e215. [PMID: 34958984 DOI: 10.1016/j.prro.2021.12.008] [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] [Received: 09/06/2021] [Revised: 11/21/2021] [Accepted: 12/03/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To validate the safety of paraaortic nodal (PAN) radiation therapy (RT) for patients with cervical cancer when the duodenal dose is limited to V55<15 cm3 and V60<2 cm3. METHODS AND MATERIALS Ninety-seven patients who were treated with RT for cervical cancer between 2010 and 2018, received at least 56 Gy to grossly involved PANs. Patients were treated with concurrent chemoradiation (n=88, 91%), with 93% (n=90) receiving intensity-modulated RT (IMRT) to the initial PAN field, and 98% (n=95) receiving IMRT to a sequential PAN boost. V55<15 cm3 and V60 <2 cm3 criteria were implemented in 2014. Normal tissues were contoured on CT simulation datasets; the duodenum was contoured from the gastric outlet to the duodenojejunal flexure. Sixty-six patients (68%) had a resimulation scan after approximately 20 fractions. Composite duodenal doses were calculated using the initial CT for 50 patients (52%) and the resimulation CT for 47 patients (48%) depending on anatomic changes throughout treatment. RESULTS The median duodenal V55 was 3.5 cm3 (interquartile range [IQR] 0.2-8.1 cm3) and the median V60 was 0.3 cm3 (IQR 0.0-1.8). Constraints were exceeded in 18 patients, 16 (89%) of whom had been treated before 2014. Treatment for the 2 patients treated after 2014 had been complicated by significant weight loss and reduced anterior-posterior diameter, which likely overestimated the true dose on the composite plan. Only 1 patient experienced grade 3 duodenal toxicity (stricture requiring endoscopic balloon dilation 3 months after treatment); however, the stricture was outside the high-dose boost volume and the patient had a history of gastritis. Six patients (6%) had a first recurrence within the PAN region. CONCLUSIONS Limiting duodenal dose to V55<15 cm3 and V60<2 cm3 for patients with cervical cancer and PAN involvement is feasible and minimizes duodenal toxicity while maintaining acceptable local control rates.
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Affiliation(s)
- David S Lakomy
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Dartmouth Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Juliana Wu
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; The University of Texas School of Public Health, Houston, TX, USA
| | - Bhavana V Chapman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Zhiqian Henry Yu
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Belinda Lee
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ann H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Anuja Jhingran
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Patricia J Eifel
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Lilie L Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
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Boyce-Fappiano D, Nguyen KA, Gjyshi O, Manzar G, Abana CO, Klopp AH, Kamrava M, Orio PF, Thaker NG, Mourtada F, Venkat P, Chang AJ. Socioeconomic and Racial Determinants of Brachytherapy Utilization for Cervical Cancer: Concerns for Widening Disparities. JCO Oncol Pract 2021; 17:e1958-e1967. [PMID: 34550749 PMCID: PMC8678033 DOI: 10.1200/op.21.00291] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [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] [Indexed: 01/05/2023] Open
Abstract
PURPOSE Cervical cancer (CC) disproportionately affects minorities who have higher incidence and mortality rates. Standard of care for locally advanced CC involves a multimodality approach including brachytherapy (BT), which independently improves oncologic outcomes. Here, we examine the impact of insurance status and race on BT utilization with the SEER database. MATERIALS AND METHODS In total, 7,266 patients with stage I-IV CC diagnosed from 2007 to 2015 were included. BT utilization, overall survival (OS), and disease-specific survival (DSS) were compared. RESULTS Overall, 3,832 (52.7%) received combined external beam radiation therapy (EBRT) + BT, whereas 3,434 (47.3%) received EBRT alone. On multivariate logistic regression analysis, increasing age (OR, 0.98; 95% CI, 0.98 to 0.99; P < .001); Medicaid (OR, 0.80; 95% CI, 0.72 to 0.88; P < .001), uninsured (OR, 0.67; 95% CI, 0.56 to 0.80; P < .001), and unknown versus private insurance (OR, 0.61; 95% CI, 0.43 to 0.86; P < .001); Black (OR, 0.68; 95% CI, 0.60 to 0.77; P < .001) and unknown versus White race (OR, 0.30; 95% CI, 0.13 to 0.77; P = .047); and American Joint Committee on Cancer stage II (OR, 1.07; 95% CI, 0.93 to 1.24; P = .36), stage III (OR, 0.82; 95% CI, 0.71 to 0.94; P = .006), stage IV (OR, 0.30; 95% CI, 0.23 to 0.40; P < .001), and unknown stage versus stage I (OR, 0.36; 95% CI, 0.28 to 0.45; P < .001) were associated with decreased BT utilization. When comparing racial survival differences, the 5-year OS was 44.2% versus 50.9% (P < .0001) and the 5-year DSS was 55.6% versus 60.5% (P < .0001) for Black and White patients, respectively. Importantly, the racial survival disparities resolved when examining patients who received combined EBRT + BT, with the 5-year OS of 57.3% versus58.5% (P = .24) and the 5-year DSS of 66.3% versus 66.6% (P = .53) for Black and White patients, respectively. CONCLUSION This work demonstrates notable inequities in BT utilization for CC that particularly affects patients of lower insurance status and Black race, which translates into inferior oncologic outcomes. Importantly, the use of BT was able to overcome racial survival differences, thus highlighting its essential value.
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Affiliation(s)
| | - Kevin A. Nguyen
- David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA
| | - Olsi Gjyshi
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Gohar Manzar
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Chike O. Abana
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ann H. Klopp
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Peter F. Orio
- Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | | | | | - Puja Venkat
- David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA
| | - Albert J. Chang
- David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA,Albert J. Chang, MD, PhD; e-mail:
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Spiotto MT, Taniguchi CM, Klopp AH, Colbert LE, Lin SH, Wang L, Frederick MJ, Osman AA, Pickering CR, Frank SJ. Biology of the Radio- and Chemo-Responsiveness in HPV Malignancies. Semin Radiat Oncol 2021; 31:274-285. [PMID: 34455983 DOI: 10.1016/j.semradonc.2021.02.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In multiple anatomic sites, patients with cancers associated with the Human Papillomavirus (HPV) experience better locoregional control and overall survival after radiotherapy and/or chemoradiotherapy than patients with HPV-negative cancers. These improved outcomes suggest that relatively unique biological features in HPV-positive cancers may increase sensitivity to DNA damaging agents as well as an impaired DNA damage response. This review will address potential biological mechanisms driving this increased sensitivity of HPV-positive cancer to radiation and/or chemotherapy. This review will discuss the clinical and preclinical observations that support the intrinsic radiosensitivity and/or chemosensitivity of HPV-positive cancers. Furthermore, this review will highlight the molecular mechanisms for increased radiation sensitivity using the classical "4 Rs" of radiobiology: repair, reassortment, repopulation, and reoxygenation. First, HPV-positive cancers have increased DNA damage due to increased oxidative stress and impaired DNA damage repair due to the altered activity TP53, p16, TIP60, and other repair proteins. Second, irradiated HPV-positive cancer cells display increased G2/M arrest leading to reassortment of cancer cells in more radiosensitive phases of the cell cycle. In addition, HPV-positive cancers have less radioresistant cancer stem cell subpopulations that may limit their repopulation during radiotherapy. Finally, HPV-positive cancers may also have less hypoxic tumor microenvironments that make these cancers more sensitive to radiation than HPV-negative cells. We will also discuss extrinsic immune and microenvironmental factors enriched in HPV-positive cancers that facilities responses to radiation. Therefore, these potential biological mechanisms may underpin the improved clinical outcomes often observed in these virally induced cancers.
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Affiliation(s)
- Michael T Spiotto
- Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX.
| | - Cullen M Taniguchi
- Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Ann H Klopp
- Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Lauren E Colbert
- Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Steven H Lin
- Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Li Wang
- Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | | | - Abdullah A Osman
- Department of Head and Neck Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Curtis R Pickering
- Department of Head and Neck Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX
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Anakwenze Akinfenwa CP, Ibraheem A, Nwankwo K, Lasebikan N, Ali-Gombe M, Aliyu UM, Ikhile E, Adegboyega O, Abdullahi A, Klopp AH, Schmeler K, Lin LL, Jhingran A, Page BR, Leng J, Grover S, Ntekim A. Emerging Use of Public-Private Partnerships in Public Radiotherapy Facilities in Nigeria. JCO Glob Oncol 2021; 7:1260-1269. [PMID: 34351813 PMCID: PMC8389883 DOI: 10.1200/go.21.00066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Radiotherapy (RT) treatment at public hospitals in Nigeria is often interrupted by prolonged periods of machine breakdown because of insufficient funds for maintenance and repair. These delays have prompted the uptake of public-private partnerships (PPPs) to acquire and maintain RT equipment. This study aimed to understand Nigeria's current RT capacity and the impact of PPPs on RT availability and cost. METHODS Eleven radiation oncologists, each representing one of the 11 RT centers in Nigeria (eight public and three private), were invited to complete a survey on the type, status, acquisition, and maintenance plan of existing RT equipment, cost incurred by patients for external-beam radiation (EBRT) and brachytherapy treatment, and number of patients treated per year on each machine. Type and status of equipment at nonresponding facilities were obtained through literature review and confirmed with the facility. RESULTS A total of eight (81%) respondents completed the survey, all representing public centers, three of which reported PPP use. They reported 11 megavoltage units in total (seven linear accelerators [LINACs] and four Cobalt-60s) and 10 brachytherapy afterloaders. Of those, 57% (4/7) of the LINACs, 100% (4/4) of the Cobalt-60s, and 63% (7/11) of the afterloaders were in clinical use. All commissioned equipment supported by PPPs (three LINACs and one afterloader) were in operation. The public EBRT equipment were nonfunctional 35% of the year (resulting in 60% fewer patients treated per year). The PPP EBRT and afterloaders did not experience any periods of breakdown, but PPP costs were 338% higher than public equipment. CONCLUSION This study characterizes the use of PPP as a more reliable method of RT delivery in Nigeria, albeit at higher costs.
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Affiliation(s)
| | - Abiola Ibraheem
- Section of Hematology Oncology, University of Chicago, Chicago, IL
| | - Kenneth Nwankwo
- Department of Radiation Medicine, College of Medicine, University of Nigeria, Nsukka, Nigeria
| | - Nwamaka Lasebikan
- Department of Radiation Medicine, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Musa Ali-Gombe
- Radiology Department, Gombe State University, Gombe, Gombe State, Nigeria
| | - Usman Malami Aliyu
- Department of Radiotherapy and Oncology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Sokoto State, Nigeria
| | - Emmanuel Ikhile
- Department of Radiation Oncology, University of Benin Teaching Hospital, Benin, Edo State, Nigeria
| | | | - Adamu Abdullahi
- Department of Radiotherapy and Oncology, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria
| | - Ann H Klopp
- Division of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Kathleen Schmeler
- Gynecologic Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lilie L Lin
- Division of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Anuja Jhingran
- Division of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Brandi R Page
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jim Leng
- The University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Surbhi Grover
- Department of Radiation Oncology, Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania; Botswana-UPENN Partnership, Gaborone, Botswana
| | - Atara Ntekim
- Department of Radiation Oncology, College of Medicine, University of Ibadan, Ibadan, Oyo State, Nigeria
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Sims TT, Colbert LE, Klopp AH. The Role of the Cervicovaginal and Gut Microbiome in Cervical Intraepithelial Neoplasia and Cervical Cancer. J Immunother Precis Oncol 2021; 4:72-78. [PMID: 35663536 PMCID: PMC9153260 DOI: 10.36401/jipo-20-17] [Citation(s) in RCA: 2] [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] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/23/2020] [Accepted: 06/26/2020] [Indexed: 04/19/2023]
Abstract
The microbiome, which refers to the microbiota within a host and their collective genomes, has recently been demonstrated to play a critical role in cancer progression, metastasis, and therapeutic response. The microbiome is known to affect host immunity, but its influence on human papilloma virus (HPV) gynecologic malignancies remains limited and poorly understood. To date, studies have largely focused on the cervicovaginal microbiome; however, there is growing evidence that the gut microbiome may interact and substantially affect therapeutic response in gynecologic cancers. Importantly, new developments in microbiome sequencing and advanced bioinformatics technologies have enabled rapid advances in our understanding of the gut and local tumor microbiota. In this review, we examine the evidence supporting the role of the microbiome in HPV-associated cervical intraepithelial neoplasia (CIN) and cervical cancer, explore characteristics that influence and shape the host microbiota that impact HPV-driven carcinogenesis, and highlight potential approaches and considerations for future and ongoing research of the microbiome's effect on HPV-associated cancer.
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Affiliation(s)
- Travis T. Sims
- Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lauren E. Colbert
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ann H. Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Mitra A, Yoshida-Court K, Solley TN, Mikkelson M, Yeung CLA, Nick A, Lu K, Klopp AH. Extracellular vesicles derived from ascitic fluid enhance growth and migration of ovarian cancer cells. Sci Rep 2021; 11:9149. [PMID: 33911091 PMCID: PMC8080718 DOI: 10.1038/s41598-021-88163-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [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: 01/09/2020] [Accepted: 04/01/2021] [Indexed: 12/22/2022] Open
Abstract
Ovarian cancer is associated with a high mortality rate due to diagnosis at advanced stages. Dissemination often occurs intraperitoneally within the ascites fluid. The microenvironment can support dissemination through several mechanisms. One potential ascites factor which may mediate dissemination are EVs or extracellular vesicles that can carry information in the form of miRNAs, proteins, lipids, and act as mediators of cellular communication. We present our observations on EVs isolated from ascitic supernatants from patients diagnosed with high grade serous ovarian carcinoma in augmenting motility, growth, and migration towards omental fat. MicroRNA profiling of EVs from malignant ascitic supernatant demonstrates high expression of miR 200c-3p, miR18a-5p, miR1246, and miR1290 and low expression of miR 100- 5p as compared to EVs isolated from benign ascitic supernatant. The migration of ovarian cancer spheroids towards omental fat is enhanced in the presence of malignant ascitic EVs. Gene expression of these cells showed increased expression of ZBED2, ZBTB20, ABCC3, UHMK1, and low expression of Transgelin and MARCKS. We present evidence that ovarian ascitic EVs increase the growth of ovarian cancer spheroids through miRNAs.
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Affiliation(s)
- Aparna Mitra
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Kyoko Yoshida-Court
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Travis N Solley
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Megan Mikkelson
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Chi Lam Au Yeung
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Alpa Nick
- Tennessee Oncology, Nashville, TN, 37203, USA
| | - Karen Lu
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Ann H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA.
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Ning MS, Das P, Rosenthal DI, Dabaja BS, Liao Z, Chang JY, Gomez DR, Klopp AH, Gunn GB, Allen PK, Nitsch PL, Natter RB, Briere TM, Herman JM, Wells R, Koong AC, McAleer MF. Early and Midtreatment Mortality in Palliative Radiotherapy: Emphasizing Patient Selection in High-Quality End-of-Life Care. J Natl Compr Canc Netw 2021; 19:805-813. [PMID: 33878727 DOI: 10.6004/jnccn.2020.7664] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 09/28/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Palliative radiotherapy (RT) is effective, but some patients die during treatment or too soon afterward to experience benefit. This study investigates end-of-life RT patterns to inform shared decision-making and facilitate treatment consistent with palliative goals. MATERIALS AND METHODS All patients who died ≤6 months after initiating palliative RT at an academic cancer center between 2015 and 2018 were identified. Associations with time-to-death, early mortality (≤30 days), and midtreatment mortality were analyzed. RESULTS In total, 1,620 patients died ≤6 months from palliative RT initiation, including 574 (34%) deaths at ≤30 days and 222 (14%) midtreatment. Median survival was 43 days from RT start (95% CI, 41-45) and varied by site (P<.001), ranging from 36 (head and neck) to 53 days (dermal/soft tissue). On multivariable analysis, earlier time-to-death was associated with osseous (hazard ratio [HR], 1.33; P<.001) and head and neck (HR, 1.45; P<.001) sites, multiple RT courses ≤6 months (HR, 1.65; P<.001), and multisite treatments (HR, 1.40; P=.008), whereas stereotactic technique (HR, 0.77; P<.001) and more recent treatment year (HR, 0.82; P<.001) were associated with longer survival. No difference in time to death was noted among patients prescribed conventional RT in 1 to 10 versus >10 fractions (median, 40 vs 47 days; P=.272), although the latter entailed longer courses. The 30-day mortality group included 335 (58%) inpatients, who were 27% more likely to die midtreatment (P=.031). On multivariable analysis, midtreatment mortality among these inpatients was associated with thoracic (odds ratio [OR], 2.95; P=.002) and central nervous system (CNS; OR, 2.44; P=.002) indications, >5-fraction courses (OR, 3.27; P<.001), and performance status of 3 to 4 (OR, 1.63; P=.050). Conversely, palliative/supportive care consultation was associated with decreased midtreatment mortality (OR, 0.60; P=.045). CONCLUSIONS Earlier referrals and hypofractionated courses (≤5-10 treatments) should be routinely considered for palliative RT indications, given the short life expectancies of patients at this stage in their disease course. Providers should exercise caution for emergent thoracic and CNS indications among inpatients with poor prognoses due to high midtreatment mortality.
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Affiliation(s)
| | | | | | | | | | | | - Daniel R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | | | - Paige L Nitsch
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Tina M Briere
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Joseph M Herman
- Department of Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, Lake Success, New York
| | - Rebecca Wells
- Department of Management, Policy, and Community Health, University of Texas Health Science Center School of Public Health, Houston, Texas; and
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Biegert G, El Alam MB, Karpinets T, Wu X, Sims TT, Yoshida-Court K, Lynn EJ, Yue J, Medrano AD, Petrosino J, Mezzari MP, Ajami NJ, Solley T, Ahmed-Kaddar M, Klopp AH, Colbert LE. Diversity and composition of gut microbiome of cervical cancer patients: Do results of 16S rRNA sequencing and whole genome sequencing approaches align? J Microbiol Methods 2021; 185:106213. [PMID: 33785357 DOI: 10.1016/j.mimet.2021.106213] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 03/26/2021] [Accepted: 03/26/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Next generation sequencing has progressed rapidly, characterizing microbial communities beyond culture-based or biochemical techniques. 16S ribosomal RNA gene sequencing (16S) produces reliable taxonomic classifications and relative abundances, while shotgun metagenome sequencing (WMS) allows higher taxonomic and functional resolution at greater cost. The purpose of this study was to determine if 16S and WMS provide congruent information for our patient population from paired fecal microbiome samples. RESULTS Comparative indices were highly congruent between 16S and WMS. The most abundant genera for 16S and WMS data did not overlap. Overlap was observed at the Phylum level, as expected. However, relative abundances correlated poorly between the two methodologies (all P-value>0.05). Hierarchical clustering of both sequencing analyses identified overlapping enterotypes. Both approaches were in agreement with regard to demographic variables. CONCLUSION Diversity, evenness and richness are comparable when using 16S and WMS techniques, however relative abundances of individual genera are not. Clinical associations with diversity and evenness metrics were similarly identified with WMS or 16S.
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Affiliation(s)
- Greyson Biegert
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Molly B El Alam
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tatiana Karpinets
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xiaogang Wu
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Travis T Sims
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kyoko Yoshida-Court
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Erica J Lynn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jingyan Yue
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrea Delgado Medrano
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph Petrosino
- Department of Molecular Virology and Microbiology, Alkek Center for Metagenomics and Microbiome Research, Baylor College of Medicine, Houston, TX, USA
| | - Melissa P Mezzari
- Department of Molecular Virology and Microbiology, Alkek Center for Metagenomics and Microbiome Research, Baylor College of Medicine, Houston, TX, USA
| | - Nadim J Ajami
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Travis Solley
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mustapha Ahmed-Kaddar
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ann H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Lauren E Colbert
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Rigaud B, Anderson BM, Yu ZH, Gobeli M, Cazoulat G, Söderberg J, Samuelsson E, Lidberg D, Ward C, Taku N, Cardenas C, Rhee DJ, Venkatesan AM, Peterson CB, Court L, Svensson S, Löfman F, Klopp AH, Brock KK. Automatic Segmentation Using Deep Learning to Enable Online Dose Optimization During Adaptive Radiation Therapy of Cervical Cancer. Int J Radiat Oncol Biol Phys 2021; 109:1096-1110. [DOI: 10.1016/j.ijrobp.2020.10.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 10/24/2020] [Accepted: 10/29/2020] [Indexed: 02/08/2023]
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Sims TT, El Alam MB, Karpinets TV, Dorta-Estremera S, Hegde VL, Nookala S, Yoshida-Court K, Wu X, Biegert GWG, Delgado Medrano AY, Solley T, Ahmed-Kaddar M, Chapman BV, Sastry KJ, Mezzari MP, Petrosino JF, Lin LL, Ramondetta L, Jhingran A, Schmeler KM, Ajami NJ, Wargo J, Colbert LE, Klopp AH. Gut microbiome diversity is an independent predictor of survival in cervical cancer patients receiving chemoradiation. Commun Biol 2021; 4:237. [PMID: 33619320 PMCID: PMC7900251 DOI: 10.1038/s42003-021-01741-x] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 01/13/2021] [Indexed: 02/07/2023] Open
Abstract
Diversity of the gut microbiome is associated with higher response rates for cancer patients receiving immunotherapy but has not been investigated in patients receiving radiation therapy. Additionally, current studies investigating the gut microbiome and outcomes in cancer patients may not have adjusted for established risk factors. Here, we sought to determine if diversity and composition of the gut microbiome was independently associated with survival in cervical cancer patients receiving chemoradiation. Our study demonstrates that the diversity of gut microbiota is associated with a favorable response to chemoradiation. Additionally, compositional variation among patients correlated with short term and long-term survival. Short term survivor fecal samples were significantly enriched in Porphyromonas, Porphyromonadaceae, and Dialister, whereas long term survivor samples were significantly enriched in Escherichia Shigella, Enterobacteriaceae, and Enterobacteriales. Moreover, analysis of immune cells from cervical tumor brush samples by flow cytometry revealed that patients with a high microbiome diversity had increased tumor infiltration of CD4+ lymphocytes as well as activated subsets of CD4 cells expressing ki67+ and CD69+ over the course of radiation therapy. Modulation of the gut microbiota before chemoradiation might provide an alternative way to enhance treatment efficacy and improve treatment outcomes in cervical cancer patients.
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Affiliation(s)
- Travis T Sims
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Molly B El Alam
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tatiana V Karpinets
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Stephanie Dorta-Estremera
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center and the UTHealth Graduate School of Biomedical Sciences at Houston, Houston, TX, USA
| | - Venkatesh L Hegde
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center and the UTHealth Graduate School of Biomedical Sciences at Houston, Houston, TX, USA
| | - Sita Nookala
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center and the UTHealth Graduate School of Biomedical Sciences at Houston, Houston, TX, USA
| | - Kyoko Yoshida-Court
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xiaogang Wu
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Greyson W G Biegert
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrea Y Delgado Medrano
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Travis Solley
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mustapha Ahmed-Kaddar
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bhavana V Chapman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - K Jagannadha Sastry
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center and the UTHealth Graduate School of Biomedical Sciences at Houston, Houston, TX, USA
| | - Melissa P Mezzari
- Department of Molecular Virology and Microbiology, Alkek Center for Metagenomics and Microbiome Research, Baylor College of Medicine, Houston, TX, USA
| | - Joseph F Petrosino
- Department of Molecular Virology and Microbiology, Alkek Center for Metagenomics and Microbiome Research, Baylor College of Medicine, Houston, TX, USA
| | - Lilie L Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lois Ramondetta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anuja Jhingran
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kathleen M Schmeler
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nadim J Ajami
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jennifer Wargo
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lauren E Colbert
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Ann H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Iwase T, Parikh A, Sahin O, Raghavendra AS, Sapon ME, James A, Shrimanker TV, Chainitikun S, Kida K, Adams DL, Tang CM, Medrano AYD, Klopp AH, Ueno NT. Abstract PS2-23: Prospective study of circulating cancer-associated macrophage-like cells (CAMLs) in obese patients with advanced breast cancer. Cancer Res 2021. [DOI: 10.1158/1538-7445.sabcs20-ps2-23] [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
Background
Cancer-associated macrophage-like cells (CAMLs) are rare circulating gigantic atypical cells exclusively found in the peripheral blood of patients with solid cancers. CAMLs potentially originate from tumor-associated macrophages in the tumor microenvironment and may have a prognostic role in breast cancer. Obesity-induced local hypoxia attracts macrophages to the tumor microenvironment and activates macrophages to induce chronic inflammation, which can lead to breast cancer progression. However, little is known about the relationship between CAMLs, obesity, and body fat distribution. Also, the role of the CAMLs on breast cancer development needs to be investigated. We hypothesized that the number and size of CAMLs are correlated with body mass index (BMI), and we investigated the relationship between CAMLs and body composition.
Materials and methods
We prospectively collected 10 ml of peripheral blood from 30 patients initially diagnosed with advanced breast cancer who underwent computed tomography. Blood samples were drawn in CellSave tubes to preserve peripheral blood mononuclear cells. We used the CellSieve microfiltering system to isolate and identify CAMLs. After enumerating cells, we analyzed immunofluorescent staining for DAPI, CD14, CD45, CXCR4, and cytokeratin. CAMLs were identified by cell surface markers (CD14+, CD45+, and cytokeratin+) and morphology (multinuclear and giant cells >30 µm). BMI was measured at the time of diagnosis. The in-house 3D imaging analysis software Medical Executable for the Efficient and Robust Quantification of Adipose Tissue was used to calculate the total amount of abdominal visceral fat tissue (VAT) and subcutaneous fat tissue (SAT) between the upper diaphragm and pelvic end using multi-detector computed tomography data. The VAT:SAT ratio was also calculated. We quantified the expression of C-X-C chemokine receptor type 4 (CXCR4) in CAMLs to investigate the metastatic potential of the cells. Finally, we determined the relationship between the characteristics of CAMLs and BMI, body composition parameters, and CXCR4 using the Pearson correlation test.
Results
Of 30 collected samples, two had an inadequate amount of blood for evaluation. Among the remaining 28, we detected CAMLs in 24. The median BMI was 30.4 kg/m2, and half of the patients were categorized as obese by the World Health Organization BMI classification. BMI was correlated with the number (r=0.39, p=0.043), average size (r=0.42, p=0.039), and maximum size (r=0.50, p=0.013) of CAMLs. In body composition analysis, the maximum size of CAMLs was correlated with the total amount of VAT (r=0.51, p=0.012) and SAT (r=0.44, p=0.037) but not the VAT:SAT ratio. The number of CAMLs was correlated with maximum CXCR4 expression in CAMLs (r=0.58, p=0.004). CAMLs size and CXCR4 expression were inversely correlated.
Conclusion
The number and size of CAMLs are correlated with BMI, but CAMLs characteristics are not related to body composition. The number of CAMLs was associated with CXCR4, which indicated its metastatic potential. Further studies are needed to elucidate the biological role of CAMLs, especially whether the increased number and size of CAMLs in obesity reflect the tumor microenvironment.
Citation Format: Toshiaki Iwase, Aaroh Parikh, Onur Sahin, Akshara S Raghavendra, Maryanne E Sapon, Anjali James, Tushaar V Shrimanker, Sudpreeda Chainitikun, Kumiko Kida, Daniel L Adams, Cha-Mei Tang, Andrea YD Medrano, Ann H Klopp, Naoto T Ueno. Prospective study of circulating cancer-associated macrophage-like cells (CAMLs) in obese patients with advanced breast cancer [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS2-23.
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Affiliation(s)
- Toshiaki Iwase
- 1Section of Translational Breast Cancer Research, Department of Breast Medical Oncology, MD Anderson Cancer Center, Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, Houston, TX
| | - Aaroh Parikh
- 2Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Onur Sahin
- 1Section of Translational Breast Cancer Research, Department of Breast Medical Oncology, MD Anderson Cancer Center, Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, Houston, TX
| | - Akshara S Raghavendra
- 1Section of Translational Breast Cancer Research, Department of Breast Medical Oncology, MD Anderson Cancer Center, Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, Houston, TX
| | - Maryanne E Sapon
- 1Section of Translational Breast Cancer Research, Department of Breast Medical Oncology, MD Anderson Cancer Center, Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, Houston, TX
| | - Anjali James
- 1Section of Translational Breast Cancer Research, Department of Breast Medical Oncology, MD Anderson Cancer Center, Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, Houston, TX
| | - Tushaar V Shrimanker
- 1Section of Translational Breast Cancer Research, Department of Breast Medical Oncology, MD Anderson Cancer Center, Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, Houston, TX
| | - Sudpreeda Chainitikun
- 1Section of Translational Breast Cancer Research, Department of Breast Medical Oncology, MD Anderson Cancer Center, Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, Houston, TX
| | - Kumiko Kida
- 1Section of Translational Breast Cancer Research, Department of Breast Medical Oncology, MD Anderson Cancer Center, Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, Houston, TX
| | | | | | - Andrea YD Medrano
- 2Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ann H Klopp
- 2Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Naoto T Ueno
- 1Section of Translational Breast Cancer Research, Department of Breast Medical Oncology, MD Anderson Cancer Center, Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, Houston, TX
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Armbruster SD, Fellman BM, Jhingran A, Eifel PJ, Klopp AH, Coleman RL, Ramondetta LM, Frumovitz M. A phase III study of transdermal granisetron versus oral ondansetron for women with gynecologic cancers receiving pelvic chemoradiation. Support Care Cancer 2021; 29:213-222. [PMID: 32338316 DOI: 10.1007/s00520-020-05484-z] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 04/20/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE To compare rates of complete response (no emesis, retching, or rescue antiemetics) in the late phase (days 4-7 post-chemotherapy) of cycle 1 between transdermal granisetron and oral ondansetron in cervical, endometrial, or vaginal cancer survivors undergoing chemoradiation at The University of Texas MD Anderson Cancer Center and LBJ Hospital in Houston, TX. METHODS In this non-blinded parallel design trial, eligible patients received a granisetron patch replaced every 7 days or 8 mg of ondansetron thrice daily continued for 72 h after chemotherapy completion. Data were collected on medication compliance, episodes of chemotherapy-induced nausea and vomiting (CINV), use of rescue antiemetics, and effects of CINV on quality of life. RESULTS Seventy-five survivors receiving chemoradiation for cervical (n = 61), endometrial (n = 12), or vaginal (n = 2) cancer were electronically randomized to transdermal granisetron (n = 41) or oral ondansetron (n = 34). In the late phase of cycle 1, the rate of complete response was 49.8% (95% CI, 35.2-64.3%) for transdermal granisetron and 39.7% (95% CI, 24.4-56.1%) for oral ondansetron. The posterior probability that transdermal granisetron achieved a higher success rate in controlling late-onset CINV compared with oral ondansetron was 82%. During the acute phase (day 1 post-chemotherapy) of cycles 2 and 3, transdermal granisetron patients used more rescue antiemetics than oral ondansetron patients (p = 0.006 and p = 0.003, respectively). Otherwise, no between-group differences in CINV events were observed. Medication compliance and the effect of CINV on quality of life were similar between groups. CONCLUSION Transdermal granisetron was 82% more like to control CINV than oral ondansetron in the late phase of cycle 1 and performed similarly to oral ondansetron in all other cycles. Transdermal granisetron should be considered an option as prophylactic antiemetic therapy for gynecologic cancer survivors undergoing chemoradiation.
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Affiliation(s)
- Shannon D Armbruster
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA. .,Division of Gynecologic Oncology and Reproductive Medicine, Virginia Tech Carilion School of Medicine, 1 Riverside Circle Suite 300, Roanoke, VA, 24016, USA.
| | - Bryan M Fellman
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Anuja Jhingran
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Patricia J Eifel
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Ann H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Robert L Coleman
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Lois M Ramondetta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Michael Frumovitz
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
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Netherton TJ, Rhee DJ, Cardenas CE, Chung C, Klopp AH, Peterson CB, Howell RM, Balter PA, Court LE. Evaluation of a multiview architecture for automatic vertebral labeling of palliative radiotherapy simulation CT images. Med Phys 2020; 47:5592-5608. [PMID: 33459402 PMCID: PMC7756475 DOI: 10.1002/mp.14415] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 06/11/2020] [Accepted: 07/12/2020] [Indexed: 12/21/2022] Open
Abstract
PURPOSE The purpose of this work was to evaluate the performance of X-Net, a multiview deep learning architecture, to automatically label vertebral levels (S2-C1) in palliative radiotherapy simulation CT scans. METHODS For each patient CT scan, our automated approach 1) segmented spinal canal using a convolutional-neural network (CNN), 2) formed sagittal and coronal intensity projection pairs, 3) labeled vertebral levels with X-Net, and 4) detected irregular intervertebral spacing using an analytic methodology. The spinal canal CNN was trained via fivefold cross validation using 1,966 simulation CT scans and evaluated on 330 CT scans. After labeling vertebral levels (S2-C1) in 897 palliative radiotherapy simulation CT scans, a volume of interest surrounding the spinal canal in each patient's CT scan was converted into sagittal and coronal intensity projection image pairs. Then, intensity projection image pairs were augmented and used to train X-Net to automatically label vertebral levels using fivefold cross validation (n = 803). Prior to testing upon the final test set (n = 94), CT scans of patients with anatomical abnormalities, surgical implants, or other atypical features from the final test set were placed in an outlier group (n = 20), whereas those without these features were placed in a normative group (n = 74). The performance of X-Net, X-Net Ensemble, and another leading vertebral labeling architecture (Btrfly Net) was evaluated on both groups using identification rate, localization error, and other metrics. The performance of our approach was also evaluated on the MICCAI 2014 test dataset (n = 60). Finally, a method to detect irregular intervertebral spacing was created based on the rate of change in spacing between predicted vertebral body locations and was also evaluated using the final test set. Receiver operating characteristic analysis was used to investigate the performance of the method to detect irregular intervertebral spacing. RESULTS The spinal canal architecture yielded centroid coordinates spanning S2-C1 with submillimeter accuracy (mean ± standard deviation, 0.399 ± 0.299 mm; n = 330 patients) and was robust in the localization of spinal canal centroid to surgical implants and widespread metastases. Cross-validation testing of X-Net for vertebral labeling revealed that the deep learning model performance (F1 score, precision, and sensitivity) improved with CT scan length. The X-Net, X-Net Ensemble, and Btrfly Net mean identification rates and localization errors were 92.4% and 2.3 mm, 94.2% and 2.2 mm, and 90.5% and 3.4 mm, respectively, in the final test set and 96.7% and 2.2 mm, 96.9% and 2.0 mm, and 94.8% and 3.3 mm, respectively, within the normative group of the final test set. The X-Net Ensemble yielded the highest percentage of patients (94%) having all vertebral bodies identified correctly in the final test set when the three most inferior and superior vertebral bodies were excluded from the CT scan. The method used to detect labeling failures had 67% sensitivity and 95% specificity when combined with the X-Net Ensemble and flagged five of six patients with atypical vertebral counts (additional thoracic (T13), additional lumbar (L6) or only four lumbar vertebrae). Mean identification rate on the MICCAI 2014 dataset using an X-Net Ensemble was increased from 86.8% to 91.3% through the use of transfer learning and obtained state-of-the-art results for various regions of the spine. CONCLUSIONS We trained X-Net, our unique convolutional neural network, to automatically label vertebral levels from S2 to C1 on palliative radiotherapy CT images and found that an ensemble of X-Net models had high vertebral body identification rate (94.2%) and small localization errors (2.2 ± 1.8 mm). In addition, our transfer learning approach achieved state-of-the-art results on a well-known benchmark dataset with high identification rate (91.3%) and low localization error (3.3 mm ± 2.7 mm). When we pre-screened radiotherapy CT images for the presence of hardware, surgical implants, or other anatomic abnormalities prior to the use of X-Net, it labeled the spine correctly in more than 97% of patients and 94% of patients when scans were not prescreened. Automatically generated labels are robust to widespread vertebral metastases and surgical implants and our method to detect labeling failures based on neighborhood intervertebral spacing can reliably identify patients with an additional lumbar or thoracic vertebral body.
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Affiliation(s)
- Tucker J. Netherton
- Department of Radiation PhysicsThe University of Texas MD Anderson Cancer CenterHoustonTX77030USA
- The University of Texas MD Anderson Graduate School of Biomedical ScienceHoustonTX77030USA
| | - Dong Joo Rhee
- Department of Radiation PhysicsThe University of Texas MD Anderson Cancer CenterHoustonTX77030USA
- The University of Texas MD Anderson Graduate School of Biomedical ScienceHoustonTX77030USA
| | - Carlos E. Cardenas
- Department of Radiation PhysicsThe University of Texas MD Anderson Cancer CenterHoustonTX77030USA
| | - Caroline Chung
- Department of Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonTX77030USA
| | - Ann H. Klopp
- Department of Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonTX77030USA
| | - Christine B. Peterson
- Department of BiostatisticsThe University of Texas MD Anderson Cancer CenterHoustonTX77030USA
| | - Rebecca M. Howell
- Department of Radiation PhysicsThe University of Texas MD Anderson Cancer CenterHoustonTX77030USA
| | - Peter A. Balter
- Department of Radiation PhysicsThe University of Texas MD Anderson Cancer CenterHoustonTX77030USA
| | - Laurence E. Court
- Department of Radiation PhysicsThe University of Texas MD Anderson Cancer CenterHoustonTX77030USA
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Affiliation(s)
- Stephen G Chun
- Stephen G. Chun, MD and Ann H. Klopp, MD, PhD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ann H Klopp
- Stephen G. Chun, MD and Ann H. Klopp, MD, PhD, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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Small W, Bosch WR, Harkenrider MM, Strauss JB, Abu-Rustum N, Albuquerque KV, Beriwal S, Creutzberg CL, Eifel PJ, Erickson BA, Fyles AW, Hentz CL, Jhingran A, Klopp AH, Kunos CA, Mell LK, Portelance L, Powell ME, Viswanathan AN, Yacoub JH, Yashar CM, Winter KA, Gaffney DK. NRG Oncology/RTOG Consensus Guidelines for Delineation of Clinical Target Volume for Intensity Modulated Pelvic Radiation Therapy in Postoperative Treatment of Endometrial and Cervical Cancer: An Update. Int J Radiat Oncol Biol Phys 2020; 109:413-424. [PMID: 32905846 DOI: 10.1016/j.ijrobp.2020.08.061] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [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] [Received: 04/10/2020] [Revised: 08/01/2020] [Accepted: 08/29/2020] [Indexed: 01/06/2023]
Abstract
PURPOSE Accurate target definition is critical for the appropriate application of radiation therapy. In 2008, the Radiation Therapy Oncology Group (RTOG) published an international collaborative atlas to define the clinical target volume (CTV) for intensity modulated pelvic radiation therapy in the postoperative treatment of endometrial and cervical cancer. The current project is an updated consensus of CTV definitions, with removal of all references to bony landmarks and inclusion of the para-aortic and inferior obturator nodal regions. METHODS AND MATERIALS An international consensus guideline working group discussed modifications of the current atlas and areas of controversy. A document was prepared to assist in contouring definitions. A sample case abdominopelvic computed tomographic image was made available, on which experts contoured targets. Targets were analyzed for consistency of delineation using an expectation-maximization algorithm for simultaneous truth and performance level estimation with kappa statistics as a measure of agreement between observers. RESULTS Sixteen participants provided 13 sets of contours. Participants were asked to provide separate contours of the following areas: vaginal cuff, obturator, internal iliac, external iliac, presacral, common iliac, and para-aortic regions. There was substantial agreement for the common iliac region (sensitivity 0.71, specificity 0.981, kappa 0.64), moderate agreement in the external iliac, para-aortic, internal iliac and vaginal cuff regions (sensitivity 0.66, 0.74, 0.62, 0.59; specificity 0.989, 0.966, 0.986, 0.976; kappa 0.60, 0.58, 0.52, 0.47, respectively), and fair agreement in the presacral and obturator regions (sensitivity 0.55, 0.35; specificity 0.986, 0.988; kappa 0.36, 0.21, respectively). A 95% agreement contour was smoothed and a final contour atlas was produced according to consensus. CONCLUSIONS Agreement among the participants was most consistent in the common iliac region and least in the presacral and obturator nodal regions. The consensus volumes formed the basis of the updated NRG/RTOG Oncology postoperative atlas. Continued patterns of recurrence research are encouraged to refine these volumes.
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Affiliation(s)
- William Small
- Loyola University Stritch School of Medicine, Maywood, Illinois.
| | - Walter R Bosch
- Washington University School of Medicine, St. Louis, Missouri
| | | | | | | | | | | | | | | | - Beth A Erickson
- Froedtert and the Medical College of Wisconsin, Milwuakee, Wisconsin
| | - Anthony W Fyles
- Princess Margaret Cancer Center, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | - Loren K Mell
- UC San Diego Moores Cancer Center, La Jolla, California
| | | | | | | | - Joseph H Yacoub
- Loyola University Stritch School of Medicine, Maywood, Illinois
| | | | - Kathryn A Winter
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | - David K Gaffney
- Huntsman Cancer Institute/University of Utah, Salt Lake City, Utah
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Affiliation(s)
- Ann H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Abstract
Definitive standard chemoradiation for locoregionally advanced carcinomas of the uterine cervix includes multimodality therapy consisting of concurrent cisplatin based chemoradiation comprising of external-beam radiotherapy with systemic chemotherapy followed by intracavitary brachytherapy. New developments in radiotherapy, such as intensity-modulated radiotherapy, which aim to improve tumor control rates and reduce associated toxicity have reopened the discussion regarding the benefit of intensification of concomitant or sequential systemic therapy in the treatment of cervical cancer. Intensification of systemic chemotherapy used in standard chemoradiation for cervical cancer is an attractive approach to improve disease control, but given the concerns regarding toxicity deserves further evaluation to ensure their safe use in patients. This is a review of published and ongoing studies investigating intensification of systemic chemotherapy in the treatment of locally advanced cervical cancer.
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Affiliation(s)
- Travis T Sims
- Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ann H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Elledge CR, Beriwal S, Chargari C, Chopra S, Erickson BA, Gaffney DK, Jhingran A, Klopp AH, Small W, Yashar CM, Viswanathan AN. Radiation therapy for gynecologic malignancies during the COVID-19 pandemic: International expert consensus recommendations. Gynecol Oncol 2020; 158:244-253. [PMID: 32563593 PMCID: PMC7294297 DOI: 10.1016/j.ygyno.2020.06.486] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 06/10/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To develop expert consensus recommendations regarding radiation therapy for gynecologic malignancies during the COVID-19 pandemic. METHODS An international committee of ten experts in gynecologic radiation oncology convened to provide consensus recommendations for patients with gynecologic malignancies referred for radiation therapy. Treatment priority groups were established. A review of the relevant literature was performed and different clinical scenarios were categorized into three priority groups. For each stage and clinical scenario in cervical, endometrial, vulvar, vaginal and ovarian cancer, specific recommendations regarding dose, technique, and timing were provided by the panel. RESULTS Expert review and discussion generated consensus recommendations to guide radiation oncologists treating gynecologic malignancies during the COVID-19 pandemic. Priority scales for cervical, endometrial, vulvar, vaginal, and ovarian cancers are presented. Both radical and palliative treatments are discussed. Management of COVID-19 positive patients is considered. Hypofractionated radiation therapy should be used when feasible and recommendations regarding radiation dose, timing, and technique have been provided for external beam and brachytherapy treatments. Concurrent chemotherapy may be limited in some countries, and consideration of radiation alone is recommended. CONCLUSIONS The expert consensus recommendations provide guidance for delivering radiation therapy during the COVID-19 pandemic. Specific recommendations have been provided for common clinical scenarios encountered in gynecologic radiation oncology with a focus on strategies to reduce patient and staff exposure to COVID-19.
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Affiliation(s)
- Christen R Elledge
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sushil Beriwal
- Department of Radiation Oncology, University of Pittsburgh Medical Center, Hillman Cancer Center, Pittsburgh, PA, USA
| | - Cyrus Chargari
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France
| | - Supriya Chopra
- Department of Radiation Oncology, Advanced Centre for Treatment, Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Kharghar, Navi Mumbai, India
| | - Beth A Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - David K Gaffney
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Anuja Jhingran
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ann H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William Small
- Department of Radiation Oncology, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
| | - Catheryn M Yashar
- Department of Radiation Oncology, University of California San Diego, San Diego, CA, USA
| | - Akila N Viswanathan
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Sims TT, Biegert GWG, Ramogola-Masire D, Ngoni K, Solley T, Ning MS, El Alam MB, Mezzari M, Petrosino J, Zetola NM, Schmeler KM, Colbert LE, Klopp AH, Grover S. Tumor microbial diversity and compositional differences among women in Botswana with high-grade cervical dysplasia and cervical cancer. Int J Gynecol Cancer 2020; 30:1151-1156. [PMID: 32675252 DOI: 10.1136/ijgc-2020-001547] [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] [Received: 04/28/2020] [Revised: 06/17/2020] [Accepted: 06/22/2020] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION We characterized the cervical 16S rDNA microbiome of patients in Botswana with high-grade cervical dysplasia and locally advanced cervical cancer. METHODS This prospective study included 31 patients: 21 with dysplasia and 10 with cancer. The Shannon diversity index was used to evaluate alpha (intra-sample) diversity, while the UniFrac (weighted and unweighted) and Bray-Curtis distances were employed to evaluate beta (inter-sample) diversity. The relative abundance of microbial taxa was compared among samples using linear discriminant analysis effect size. RESULTS Alpha diversity was significantly higher in patients with cervical cancer than in patients with cervical dysplasia (P<0.05). Beta diversity also differed significantly (weighted UniFrac Bray-Curtis, P<0.01). Neither alpha diversity (P=0.8) nor beta diversity (P=0.19) varied by HIV status. The results of linear discriminant analysis effect size demonstrated that multiple taxa differed significantly between patients with cervical dysplasia vs cancer. Lachnospira bacteria (in the Clostridia class) were particularly enriched among cervical dysplasia patients, while Proteobacteria (members of the Firmicutes phyla and the Comamonadaceae family) were enriched in patients with cervical cancer. DISCUSSION The results of our study suggest that differences exist in the diversity and composition of the cervical microbiota between patients with cervical dysplasia and patients with cervical cancer in Botswana. Additional studies are warranted to validate these findings and elucidate their clinical significance among women living in sub-Saharan Africa, as well as other regions of the world.
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Affiliation(s)
- Travis T Sims
- Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Greyson W G Biegert
- Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Doreen Ramogola-Masire
- Obstetrics and Gynecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Kebatshabile Ngoni
- Department of Biological Sciences, University of Botswana, Gaborone, Botswana
| | - Travis Solley
- Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Matthew S Ning
- Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Molly B El Alam
- Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Melissa Mezzari
- Molecular Virology and Microbiology, Baylor College of Medicine Alkek Center for Molecular Discovery, Houston, Texas, USA
| | - Joseph Petrosino
- Molecular Virology and Microbiology, Baylor College of Medicine Alkek Center for Molecular Discovery, Houston, Texas, USA
| | - Nicola M Zetola
- Radiation Oncology, Botswana-University of Pennsylvania Partnership, Philadelphia, Pennsylvania, USA
| | - Kathleen M Schmeler
- Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Lauren E Colbert
- Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ann H Klopp
- Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Surbhi Grover
- Radiation Oncology, Botswana-University of Pennsylvania Partnership, Philadelphia, Pennsylvania, USA
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