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Gebrael G, Jo Y, Mathew Thomas V, Li H, Sayegh N, Tripathi N, Srivastava A, Nordblad B, Dal E, Narang A, Brundage J, Campbell P, Galarza Fortuna G, Hage Chehade C, Maughan BL, Agarwal N, Swami U. Cabozantinib with immune checkpoint inhibitor versus cabozantinib monotherapy in patients with metastatic clear cell renal cell carcinoma progressing after prior immune checkpoint inhibitor. Cancer 2024. [PMID: 38564301 DOI: 10.1002/cncr.35302] [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: 12/04/2023] [Revised: 03/01/2024] [Accepted: 03/05/2024] [Indexed: 04/04/2024]
Abstract
INTRODUCTION Rechallenge with antibodies targeting programmed cell death protein-1 or its ligand (PD-1/L1) after discontinuation or disease progression in solid tumors following a prior PD-1/L1 treatment is often practiced in clinic. This study aimed to investigate if adding PD-1/L1 inhibitors to cabozantinib, the most used second-line treatment in real-world patients with metastatic clear cell renal cell carcinoma (mccRCC), offers additional benefits. METHODS Using de-identified patient-level data from a large real-world US-based database, patients diagnosed with mccRCC, who received any PD-1/L1-based combination in first-line (1L) setting, followed by second-line (2L) therapy with either cabozantinib alone or in combination with PD-1/L1 inhibitors were included. Patients given a cabozantinib-containing regimen in 1L were excluded. The study end points were real-world time to next therapy (rwTTNT) and real-world overall survival (rwOS) by 2L. RESULTS Of 12,285 patients with metastatic renal cell carcinoma in the data set, 348 patients met eligibility and were included in the analysis. After propensity score matching weighting, cabozantinib with PD-1/L1 inhibitors versus cabozantinib (ref.) had similar rwTTNT and rwOS in the 2L setting. Hazard ratios and 95% confidence interval (CI) for rwTTNT and rwOS are 0.74 (95% CI, 0.49-1.12) and 1.15 (95% CI, 0.73-1.79), respectively. CONCLUSION In this study, the results align with the phase 3 CONTACT-03 trial results, which showed no additional benefit of adding PD-L1 inhibitor to cabozantinib compared to cabozantinib alone in 2L following PD-1/L1-based therapies in 1L. These results from real-world patients strengthen the evidence regarding the futility of rechallenge with PD-1/L1 inhibitors.
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Affiliation(s)
- Georges Gebrael
- Division of Medical Oncology, Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Yeonjung Jo
- Division of Medical Oncology, Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Vinay Mathew Thomas
- Division of Medical Oncology, Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Haoran Li
- Division of Medical Oncology, University of Kansas Cancer Center, Kansas City, Kansas, USA
| | - Nicolas Sayegh
- Division of Medical Oncology, Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Nishita Tripathi
- Division of Medical Oncology, Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Ayana Srivastava
- Division of Medical Oncology, Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Blake Nordblad
- Division of Medical Oncology, Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Emre Dal
- Division of Medical Oncology, Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Arshit Narang
- Division of Medical Oncology, Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - James Brundage
- Division of Medical Oncology, Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Patrick Campbell
- Division of Medical Oncology, Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Gliceida Galarza Fortuna
- Division of Medical Oncology, Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Chadi Hage Chehade
- Division of Medical Oncology, Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Benjamin L Maughan
- Division of Medical Oncology, Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Neeraj Agarwal
- Division of Medical Oncology, Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Umang Swami
- Division of Medical Oncology, Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
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Gebrael G, Hage Chehade C, Sayegh N, Tripathi N, Chigarira B, Goel D, Nordblad B, McFarland TR, Narang A, Srivastava A, Tandar C, Dal E, Jo Y, Galarza Fortuna G, Mathew Thomas V, Sahu KK, Li H, Maughan BL, Swami U, Agarwal N. Natural course of metastatic castration-resistant prostate cancer in the era of intensified androgen deprivation therapy in the hormone-sensitive setting. Prostate 2024. [PMID: 38561317 DOI: 10.1002/pros.24696] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 03/06/2024] [Accepted: 03/19/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Androgen deprivation therapy (ADT) intensification (ADTi) (i.e., ADT with androgen receptor pathway inhibitor or docetaxel, or both) has significantly improved survival outcomes of patients with metastatic hormone-sensitive prostate cancer (mHSPC). However, the impact of prior ADTi in the mHSPC setting on the disease presentation and survival outcomes in metastatic castration-resistant prostate cancer (mCRPC) is not well characterized. In this study, our objective was to compare the disease characteristics and survival outcomes of patients with new mCRPC with respect to receipt of intensified or nonintensified ADT in the mHSPC setting. METHODS In this institutional review board-approved retrospective study, eligibility criteria were as follows: patients diagnosed with mCRPC, treated with an approved first-line mCRPC therapy, and who received either intensified or nonintensified ADT in the mHSPC setting. Progression-free survival (PFS) was defined from the start of first-line therapy for mCRPC to progression per Prostate Cancer Working Group 2 criteria or death, and overall survival (OS) was defined from the start of first-line therapy for mCRPC to death or censored at the last follow-up. A multivariable analysis using the Cox proportional hazards model was used, adjusting for potential confounders. RESULTS Patients (n = 387) treated between March 20, 2008, and August 18, 2022, were eligible and included: 283 received nonintensified ADT, whereas 104 were treated with ADTi. At mCRPC diagnosis, patients in the ADTi group were significantly younger, had more visceral metastasis, lower baseline prostate-specific antigen (all p < 0.01), and lower hemoglobin (p = 0.027). Furthermore, they had significantly shorter PFS (median 4.8 vs. 8.4 months, adjusted hazard ratio [HR]: 1.46, 95% confidence interval [95% CI]: 1.07-2, p = 0.017) and OS (median 21.3 vs. 33.1 months, adjusted HR: 1.53, 95% CI: 1.06-2.21, p = 0.022) compared to patients in the nonintensified ADT group. CONCLUSION Patients treated with ADTi in the mHSPC setting and experiencing disease progression to mCRPC had more aggressive disease features of mCRPC (characterized by a higher number of poor prognostic factors at mCRPC presentation). They also had shorter PFS on first-line mCRPC treatment and shorter OS after the onset of mCRPC compared to those not receiving ADTi in the mHSPC setting. Upon external validation, these findings may impact patient counseling, prognostication, treatment selection, and design of future clinical trials in the mCRPC setting. There remains an unmet need to develop novel life-prolonging therapies with new mechanisms of action to improve mCRPC prognosis in the current era.
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Affiliation(s)
- Georges Gebrael
- Department of Internal Medicine, Division of Medical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Chadi Hage Chehade
- Department of Internal Medicine, Division of Medical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Nicolas Sayegh
- Department of Internal Medicine, Division of Medical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
- Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - Nishita Tripathi
- Department of Internal Medicine, Division of Medical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Beverly Chigarira
- Department of Internal Medicine, Division of Medical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Divyam Goel
- Department of Internal Medicine, Division of Medical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Blake Nordblad
- Department of Internal Medicine, Division of Medical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Taylor R McFarland
- Department of Internal Medicine, Division of Medical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Arshit Narang
- Department of Internal Medicine, Division of Medical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Ayana Srivastava
- Department of Internal Medicine, Division of Medical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Clara Tandar
- Department of Internal Medicine, Division of Medical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Emre Dal
- Department of Internal Medicine, Division of Medical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Yeonjung Jo
- Department of Internal Medicine, Division of Medical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Gliceida Galarza Fortuna
- Department of Internal Medicine, Division of Medical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Vinay Mathew Thomas
- Department of Internal Medicine, Division of Medical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Kamal K Sahu
- Department of Internal Medicine, Division of Medical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Haoran Li
- Department of Internal Medicine, Division of Medical Oncology, University of Kansas Cancer Center, Westwood, Kansas, USA
| | - Benjamin L Maughan
- Department of Internal Medicine, Division of Medical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Umang Swami
- Department of Internal Medicine, Division of Medical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Neeraj Agarwal
- Department of Internal Medicine, Division of Medical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
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Al-Akhras A, Hage Chehade C, Narang A, Swami U. PARP Inhibitors in Metastatic Castration-Resistant Prostate Cancer: Unraveling the Therapeutic Landscape. Life (Basel) 2024; 14:198. [PMID: 38398706 PMCID: PMC10890352 DOI: 10.3390/life14020198] [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: 12/07/2023] [Revised: 01/21/2024] [Accepted: 01/24/2024] [Indexed: 02/25/2024] Open
Abstract
The treatment landscape of metastatic prostate cancer (mPCa) is rapidly evolving with the recent approvals of poly-ADP ribose polymerase inhibitors (PARPis) as monotherapy or as part of combination therapy with androgen receptor pathway inhibitors in patients with metastatic castration-resistant prostate cancer (mCRPC). Already part of the therapeutic armamentarium in different types of advanced cancers, these molecules have shaped a new era in mPCa by targeting genomic pathways altered in these patients, leading to promising responses. These agents act by inhibiting poly-ADP ribose polymerase (PARP) enzymes involved in repairing single-strand breaks in the DNA. Based on the PROfound and TRITON3 trials, olaparib and rucaparib were respectively approved as monotherapy in pretreated patients with mCRPC and alterations in prespecified genes. The combinations of olaparib with abiraterone (PROpel) and niraparib with abiraterone (MAGNITUDE) were approved as first-line options in patients with mCRPC and alterations in BRCA1/2, whereas the combination of talazoparib with enzalutamide (TALAPRO-2) was approved in the same setting in patients with alterations in any of the HRR genes, which are found in around a quarter of patients with advanced prostate cancer. Additional trials are already underway to assess these agents in an earlier hormone-sensitive setting. Future directions will include refining the treatment sequencing in patients with mCRPC in the clinic while taking into account the financial toxicity as well as the potential side effects encountered with these therapies and elucidating their mechanism of action in patients with non-altered HRR genes. Herein, we review the biological rationale behind using PARPis in mCRPC and the key aforementioned clinical trials that paved the way for these approvals.
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Affiliation(s)
- Ashaar Al-Akhras
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan;
| | - Chadi Hage Chehade
- Division of Medical Oncology, Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT 84112, USA; (C.H.C.); (A.N.)
| | - Arshit Narang
- Division of Medical Oncology, Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT 84112, USA; (C.H.C.); (A.N.)
| | - Umang Swami
- Division of Medical Oncology, Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT 84112, USA; (C.H.C.); (A.N.)
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Narang A, Agarwal N. Editorial Comment. Urol Pract 2024; 11:161. [PMID: 38117973 DOI: 10.1097/upj.0000000000000487.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 10/18/2023] [Indexed: 12/22/2023]
Affiliation(s)
- Arshit Narang
- Division of Medical Oncology, Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Neeraj Agarwal
- Division of Medical Oncology, Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
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Wang J, Lin T, Reddy AV, Hill C, Sehgal S, McPhaul T, Herman JM, He J, Zheng L, Meyer JJ, Narang A. Pathway Mutations are Associated with Clinical Outcomes in Localized Pancreatic Cancer Treated with Neoadjuvant Chemoradiation Followed by Surgery. Int J Radiat Oncol Biol Phys 2023; 117:e348-e349. [PMID: 37785208 DOI: 10.1016/j.ijrobp.2023.06.2419] [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 purpose of this study was to determine if mutations in biological pathways are associated with clinical outcomes in patients with localized pancreatic cancer who undergo neoadjuvant chemoradiation followed by surgical resection. MATERIALS/METHODS Patients treated with neoadjuvant chemoradiation followed by oncologic resection from 2015-2019 who also underwent next generation sequencing (NGS) of the primary tumor were included in this retrospective analysis. NGS was done using either Foundation One (n = 20), in-house Solid Tumor Panel (n = 121), or Tempus XT (n = 1). Genes were included in pathway analysis if at least one patient harbored a mutation in the gene. Pathways were defined from the Molecular Signatures Database Hallmark, KEGG, and Reactome gene sets. A pathway was deemed mutated if at least one gene within the pathway was mutated. Univariable Cox regression was performed to determine the association between pathway mutation status and overall survival (OS) as well as progression-free survival (PFS). RESULTS In total, 142 patients met criteria for study inclusion. For pathway analysis, 329 genes met inclusion criteria. Patients were typically treated with neoadjuvant chemotherapy (either 5-fluorouracil-based or gemcitabine-based) followed by radiation. Patients received SBRT (n = 104, most commonly 33 Gy in 5 fractions) or conventionally fractionated radiation (n = 38, most commonly 50.4 Gy in 28 fractions). For clinical variables, worse OS was significantly associated with T stage (p = 0.036), N stage (p = 0.044), and lymphovascular invasion (LVI, p = 0.011); worse PFS was significantly associated with T stage (p = 0.0008), N stage (p = 0.022), LVI (p = 0.026), and conventional RT (p = 0.007). Mutations in major pathways were associated with worse OS, notably hedgehog signaling (p = 0.001), chromatin modifying enzymes (p = 0.002), WNT/beta-catenin signaling (p = 0.005), mismatch repair (0.006), E2F targets (p = 0.008), FLT signaling (p = 0.012), VEGF signaling (0.025), innate immune system (p = 0.026), and NOTCH signaling (p = 0.029). Pathway mutations associated with worse PFS included mismatch repair (p = 0.007) and hedgehog signaling (p = 0.013). CONCLUSION For pancreatic cancer patients that undergo neoadjuvant chemoradiation followed by oncologic resection of the primary tumor, mutations in key biological pathways are associated with OS and PFS. Characterizing the importance of common pathway mutations may become increasingly valuable to help categorize less commonly mutated genes assayed by NGS.
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Affiliation(s)
- J Wang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - T Lin
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A V Reddy
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - C Hill
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - S Sehgal
- Johns Hopkins Medical Institute, Department of Radiation Oncology, Baltimore, MD
| | - T McPhaul
- Department of Medical Oncology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - J M Herman
- Department of Radiation Medicine, Northwell Health Cancer Institute, New Hyde Park, NY
| | - J He
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - L Zheng
- Department of Medical Oncology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - J J Meyer
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
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Voong KR, Shokek OB, Hill C, Hu C, Hales RK, Greco SC, Meyer JJ, Wright JL, Lowe K, McNutt TR, Narang A, PhD CS, Lee SM. Improving Cancer Care by Incorporating the Patient's Voice in Symptom Management (IMPROVE): A Multicenter-Prospective Pilot Study. Int J Radiat Oncol Biol Phys 2023; 117:e264-e265. [PMID: 37785007 DOI: 10.1016/j.ijrobp.2023.06.1222] [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) IMPROVE is a prospective multicenter pilot study. It evaluates whether routine physician review of patient-reported outcomes measures (PROMs) during radiotherapy alters physicians' perception of cancer patients' treatment-related toxicity and influences symptom management. MATERIALS/METHODS We are enrolling patients with thoracic or gastrointestinal cancers amenable to conventional-fractionated radiotherapy. Patients may receive concurrent chemotherapy. Patients report (1) symptoms, using PRO-CTCAE measures, (2) the most burdensome symptom, and (3) how symptoms interfere with daily activities. Patients complete the measures before seeing their physician during each on-treatment visit. During weekly visits and before reviewing the patient's PROMs, physicians rate the symptom burden for each patient from 0 to 10, using available clinical data. These data include vital signs, lab work, physical exams, nursing assessments, and physicians' clinical judgment. After reviewing the patients' PROMs, physicians re-rate each patient's symptom burden and report any changes in recommended interventions. Changes could include (1) additional counseling, (2) new medications or interventions, (3) referrals to other services, or (4) further testing or evaluation. After each patient's course of radiotherapy, providers complete a Clinician Feedback Form about the impact of PROM review on symptom perception and management during treatment. This study commenced November 11, 2020 at a multi-site tertiary academic cancer center (using electronic or paper questionnaires) and July 21, 2021 at a multi-site community cancer center (using paper forms). RESULTS To be determined. CONCLUSION To be determined.
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Affiliation(s)
- K R Voong
- Johns Hopkins University, Baltimore, MD
| | - O B Shokek
- Wellspan York Cancer Center, York, PA, United States
| | - C Hill
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - C Hu
- Johns Hopkins Medicine Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | - R K Hales
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - S C Greco
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - J J Meyer
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - J L Wright
- Johns Hopkins Medicine, Department of Radiation Oncology, Baltimore, MD
| | - K Lowe
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - T R McNutt
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - C Snyder PhD
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - S M Lee
- Department of Biostatistics, Columbia University School of Medicine, New York, NY
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Madan V, Lin TA, Reddy AV, Hill C, Sehgal S, Hacker-Prietz A, McPhaul T, He J, Zheng L, Ngwa W, Herman JM, Meyer JJ, Narang A. Characterization of DNA Damage Response-Associated Somatic Mutations in Borderline Resectable and Locally Advanced Pancreatic Cancer. Int J Radiat Oncol Biol Phys 2023; 117:e321. [PMID: 37785147 DOI: 10.1016/j.ijrobp.2023.06.2361] [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 role of radiation for pancreatic cancer remains controversial, with recent studies showing conflicting results, highlighting the need to develop biomarkers of radiation response. Despite its potential utility in predicting radiosensitivity, the landscape of somatic mutations in borderline resectable pancreatic cancer (BRPC) and locally advanced pancreatic cancer (LAPC), as related to DNA damage response (DDR), has not been well characterized. This study aimed to characterize the frequency of such mutations in a cohort of patients with BRPC/LAPC treated with neoadjuvant chemotherapy and stereotactic body radiotherapy (SBRT). MATERIALS/METHODS Mutational data was collected from patients with BRPC/LAPC treated at a single institution with neoadjuvant chemotherapy and SBRT, followed by surgical resection from 2016-2021. Chemotherapy consisted of modified FOLFIRINOX or gemcitabine/nab-paclitaxel, and patients were treated with SBRT in 33 Gy in 5 fractions. Genomic data was obtained from either endoscopic biopsy or surgical specimens, and next-generation sequencing was performed either in-house with a Solid Tumor Panel or with FoundationOne CDx. Specific emphasis was placed on the characterization of double-strand DNA break (DSB) repair genes, as this is the type of tumor cell damage traditionally induced by radiation therapy. Genes associated with the two main pathways of DSB repair, non-homologous end joining (NHEJ) and homologous repair (HR), were analyzed. Specific HR pathway mutations assessed were BLM, BRCA1/2, MRE11, NBN, PALB2, RAD50, RAD51B-D, and RAD54L, while PRKDC mutations were assessed for the NHEJ pathway. Mutations in ATM, an important initiator of DDR pathways, were also analyzed. Additionally, the frequency of mutations in TP53, CDKN2A and SMAD4 in patients with concomitant KRAS mutations was assessed. RESULTS Eighty-five patients were included in the study. Five (5.9%) patients had mutations in the NHEJ pathway of the PRKDC gene. Twenty (23.5%) patients had mutations in the HR pathway, including BRCA2 (10/85; 11.8%), PALB2 (5/85; 5.9%), BRCA1 (3/85; 3.5%), and RAD50 (1/85; 1.2%). Six (7.1%) patients had mutations in ATM. No patients were found to have mutations in BLM, RAD51B-D, RAD54L, or NBN. Amongst patients with KRAS mutations (72/85), concomitant mutations were observed in TP53 (47/85; 55.3%), CDKN2A (16/85; 18.8%), and SMAD4 (9/85; 10.6%). CONCLUSION Herein, we characterized the frequency of somatic mutations associated with DSB repair genes in patients with BRPC/LAPC. Data analysis on outcomes related to radiation response in patients with mutations in DDR pathways is ongoing, but will likely also benefit from multi-institutional efforts to increase the power to answer this question.
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Affiliation(s)
- V Madan
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - T A Lin
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - A V Reddy
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - C Hill
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - S Sehgal
- Johns Hopkins Medical Institute, Department of Radiation Oncology, Baltimore, MD
| | - A Hacker-Prietz
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - T McPhaul
- Department of Medical Oncology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - J He
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - L Zheng
- Department of Medical Oncology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - W Ngwa
- John Hopkins University Hospital, Baltimore, MD
| | - J M Herman
- Department of Radiation Medicine, Northwell Health Cancer Institute, New Hyde Park, NY
| | - J J Meyer
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
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Mao S, Lin TA, Sehgal S, Reddy AV, Hill C, Herman JM, Meyer JJ, Narang A. Utilization of the Triangle Volume in Patients with Localized PDAC Undergoing Pre-Operative SBRT: Report of Early Outcomes. Int J Radiat Oncol Biol Phys 2023; 117:S14. [PMID: 37784357 DOI: 10.1016/j.ijrobp.2023.06.230] [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) In patients with borderline resectable or locally advanced pancreatic adenocarcinoma (BRPC/LAPC), advances in neoadjuvant therapy have led to an increased proportion of patients undergoing margin negative resection. Nevertheless, locoregional recurrence rates remain high. We have previously reported that the location of locoregional recurrences in this setting map to the "Triangle Volume (TV)," the anatomical space between the celiac artery, superior mesenteric artery, common hepatic artery, and portal vein, which is enriched in extrapancreatic perineural tracts at risk for microscopic residual disease after resection. At the beginning of 2021, we systematically changed our target volume to include the TV, in addition to gross disease and involved vasculature. Herein, we report early locoregional failure outcomes after resection in the setting of BRPC or LAPC treated with pre-operative stereotactic body radiation therapy (SBRT) to the TV, as compared to historical rates. MATERIALS/METHODS Patients who received a diagnosis of BRPC or LAPC and who were treated at our institution with neoadjuvant chemotherapy (CTX) and SBRT between 2016 and 2022 were retrospectively reviewed. Between 2016 and 2020, the SBRT clinical tumor volume (CTV) included gross disease and full circumference of involved vasculature at the level of involvement. From 2021 onward, the CTV also included the TV. Survival was estimated using the Kaplan-Meier method. Statistical analyses were performed using scientific 2-D graphing and statistics software. RESULTS From January 2016 to December 2022, 204 patients with localized PDAC underwent neoadjuvant CTX followed by SBRT. After completion of SBRT, all patients proceeded with surgical exploration. Of these patients, 111 (54%) had LAPC and 92 (45%) had BRPC disease. All patients were treated with induction CTX, mostly commonly with FOLFIRINOX (N = 166, 81%). Following CTX, the most frequently used SBRT regimen was 33 Gy in 5 fractions (N = 191, 94%). 155 (67%) patients were treated between 2016 and 2020 to the traditional CTV, while 49 (24%) patients were treated after 2020 to a CTV that included the TV. The 2-year local progression free survival rate of patients treated with SBRT using the TV was 77.6% as compared to 47.5% in patients treated with the traditional CTV. Over a median follow up of 15.7 months (range: 1 to 78.2 months), 47% (N = 73 out of 155) of patients who underwent SBRT with the traditional CTV developed locoregional recurrence, but only 12% (N = 6 out of 49) treated with SBRT to the TV have thus far developed locoregional recurrence (p<0.0001). CONCLUSION In patients with localized PDAC who undergo pre-operative SBRT for BRPC/LAPC, targeting the TV may help reduce locoregional recurrence. More data and longer follow-up are needed to verify these findings and inform whether the TV may serve as a new standard for target volume delineation in this setting.
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Affiliation(s)
- S Mao
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - T A Lin
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - S Sehgal
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A V Reddy
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - C Hill
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - J M Herman
- Department of Radiation Medicine, Northwell Health Cancer Institute, New Hyde Park, NY
| | - J J Meyer
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
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Lin TA, Mao S, Anker C, Herman JM, Meyer JJ, Narang A, Hu C. Local Time-to-Event Endpoint Under-Reporting and Variability in Pancreatic Cancer Trials Involving Radiotherapy. Int J Radiat Oncol Biol Phys 2023; 117:e316-e317. [PMID: 37785136 DOI: 10.1016/j.ijrobp.2023.06.2351] [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 role of radiotherapy (RT) for pancreatic adenocarcinoma (PDAC) remains controversial, with recent studies showing conflicting results. Importantly, endpoints used to evaluate efficacy in recent RT trials for PDAC have been highly variable. As variability in time-to-event (TTE) endpoint definitions is demonstrated to influence outcomes in other cancers, it is critical that radiation oncologists develop consensus around optimal endpoint definitions to use in future PDAC trial design. Thus, we conducted a systematic review of PDAC trials involving RT to characterize the frequency and variability in local TTE endpoint reporting. MATERIALS/METHODS An electronic database search was conducted of PubMed, EMBASE, and Cochrane Library to identify phase 2 and 3 clinical trials published from 2010-2022 of localized PDAC involving RT that reported any TTE endpoint (e.g., local control). After excluding duplicates, two independent reviewers screened full-text manuscripts for inclusion. Trial characteristics and local TTE endpoints/definitions were tabulated. RESULTS Three hundred twenty references were screened and 79 trials were included, of which 73 (92%) were phase 2 and 26 (33%) were randomized. Twenty (25%) trials reported a local TTE endpoint; these were local control (LC; N = 6), local progression-free survival (LPFS; N = 4), freedom from local progression (N = 6), locoregional progression-free interval (N = 1), cumulative incidence of local recurrence (N = 1), time to failure of sustained LC (N = 1), and local disease-free survival (N = 1). LC (N = 6) had 5 unique definitions and was undefined once; 1 definition included death as an event. LPFS (N = 4) had 3 definitions; 2 did not consider death an event. Among trials with local TTE endpoints, 9 trials specified the definition of a local recurrence/progression. Four trials defined local recurrence based on RT volumes; one counted clinical evidence of recurrence (e.g., tumor bleed); and one counted a rise in tumor markers without evidence of distant metastases. The index time ("time-zero") was defined for local TTE endpoints in 10 trials, including start of RT (N = 4) or chemo (N = 1), end of RT (N = 1), diagnosis (N = 1), enrollment (N = 1), and time of surgery (N = 1). CONCLUSION Few pancreatic cancer trials involving RT report local TTE endpoints, with significant heterogeneity in endpoints used and their definitions. Development of consensus endpoint definitions will be critical for future PDAC trial design.
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Affiliation(s)
- T A Lin
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - S Mao
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - C Anker
- The University of Vermont Medical Center, Burlington, VT
| | - J M Herman
- Department of Radiation Medicine, Northwell Health Cancer Institute, New Hyde Park, NY
| | - J J Meyer
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - C Hu
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD; Division of Quantitative Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
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10
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Liu IC, Lin TA, Sehgal S, Reddy AV, Hill C, Herman JM, Meyer JJ, Narang A. Visceral Artery Pseudoaneurysm Rates after Pancreatoduodenectomy in Patients Who Received Pre-Operative Radiation for Pancreatic Cancer. Int J Radiat Oncol Biol Phys 2023; 117:e317. [PMID: 37785138 DOI: 10.1016/j.ijrobp.2023.06.2352] [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 role of pre-operative radiation therapy (RT) for localized pancreatic ductal adenocarcinoma (PDAC) with peri-pancreatic vascular involvement remains controversial, with two recent randomized controlled trials, namely PREOPANC-1 and Alliance A021501, showing conflicting results. Opponents of pre-operative radiation point towards the unclear oncologic benefit and potential added toxicity. While hemorrhage from a pseudoaneurysm (PsA) rupture is a known rare but potentially fatal complication after pancreaticoduodenectomy (PD), with published incidence rates of around 2 to 5%, it has been increasingly common in the pancreatic cancer surgical community for pre-operative RT to be cited as a risk factor for PsA development, despite the absence of data supporting this notion. Certainly, accurate characterization of relevant RT-related toxicities is critical to prevent inaccurate decision-making regarding foregoing its use. As such, we aim to report on the incidence of PsA in a cohort of patients with PDAC who underwent pre-operative RT prior to PD at a high-volume center. MATERIALS/METHODS Consecutive patients treated with pre-operative RT via stereotactic body radiation therapy (SBRT) or intensity modulated radiation therapy (IMRT) prior to PD for borderline resectable or locally advanced PDAC were retrospectively reviewed. Incidence of radiographic or clinically apparent PsA was reported. We also characterized the timing of PsA identification in relation to surgery and RT, the artery in which the PsA developed, and the clinical outcomes of patients after PsA identification. RESULTS One hundred seventy-five patients met eligibility criteria for our analysis. Most of our cohort (163 patients, 93%) received SBRT to a median dose of 6.6 Gy x 5 (median BED10 54.78 Gy, range: 48 Gy - 61.92 Gy), and only 12 patients (7%) received IMRT in various fractionation and dose patterns (median BED10 62.94 Gy, range 59.47 Gy - 97.5 Gy). The median time between surgery and last contrast-enhanced abdominal imaging was 17 months (range: 0.23 - 68 months). There were fourteen visceral arteries among thirteen patients (7%) that were found to have a PsA on routine follow-up imaging or after a post-PD hemorrhage. The median time between completion of radiation and surgery to PsA were 19.5 weeks (range: 8.6 to 98.1 weeks) and 13 weeks (range: 1.6 to 87.9 weeks), respectively. The two most commonly involved arteries were the gastroduodenal and superior mesenteric arteries. Rate of PsA development was similar among patients treated with SBRT (7%) and IMRT (8%). In terms of Clavien-Dindo classification of complications, there were six patients with grade 3a complications, five patients with grade 4b complications, and two patients with grade 5 complications. CONCLUSION Compared to historical data, pre-operative RT does not appear to significantly increase the risk of PsA development after PD. More data on the impact of pre-operative radiation dose-fraction regimen and longer follow-up are needed.
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Affiliation(s)
- I C Liu
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - T A Lin
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - S Sehgal
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A V Reddy
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - C Hill
- Department of Radiation Oncology, New York University Grossman School of Medicine, New York, NY
| | - J M Herman
- Department of Radiation Medicine, Northwell Health Cancer Institute, New Hyde Park, NY
| | - J J Meyer
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
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11
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Tchelebi L, Korah B, Goodman KA, Hoffe S, Stricker C, Pinto DM, Deperalta D, Hong TS, Hacker-Prietz A, Narang A, Aguilera TA, Roberts H, Raldow A, Tempero M, Murphy JD, Malik NK, Herman J. Pancreas Cancer Learning Health Network Established to Share Best Practice Across 14 Centers and Improve Patient Outcomes. Int J Radiat Oncol Biol Phys 2023; 117:e343-e344. [PMID: 37785197 DOI: 10.1016/j.ijrobp.2023.06.2408] [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) Pancreas cancer (PC) survival is among the lowest of all malignancies. Clinical trials have failed to significantly improve outcomes. Individual and institutional biases in care result in significant variation in practice, further hindering progress. Learning health networks (LHNs) prospectively collect real world data across centers and test improvements that can rapidly be expanded across centers if deemed successful. Herein, we report preliminary progress from the Pancreas Cancer Canopy Cancer Collective (PC-CCC), the first oncology LHN, established to improve duration and quality of survival in PC. MATERIALS/METHODS In 2019, we established the PC-CCC with six care centers who engaged in a collaborative design process to create a set of improvement aims, change ideas, and outcome measures. Center team members receive training and coaching in collaborative quality improvement methods, applied to local improvement efforts. Eight more centers joined in 2021, and a shared Canopy outcomes database was built and implemented to inform center-specific and network-wide improvement efforts and allow the LHN to undertake research using real-world data. Current improvement efforts are focused on proactively screening new PC patients for: (1) Clinical trials, (2) pancreas enzymes, (3) palliative care needs, and (4) goals of care conversations. RESULTS Currently, 14 care centers are active participants in the PC-CCC LHN. Data on a total of 2,002 PC patients are available to date. At presentation to the care center, most patients are female (51%) and have biopsy proven PC (83.9%). Average age is 68 years, and presenting disease status is metastatic (14.5%), resectable (11.4%), locally advanced (10.9%), borderline resectable (8.1%), or not yet staged (40%). For those who received radiation, 75.8% received stereotactic body radiation therapy. Among patients whose chemotherapy regimen was documented, most received 5-fluorouracilbased treatment (52%). Descriptive follow up data (including treatment and outcomes) are being actively updated, to be reported at time of presentation. CONCLUSION Creation of a cancer LHN for PC is feasible and has set the stage for improving patient and provider outcomes through iterative community-building, continuous improvement, and sharing of data and multidisciplinary best practices. Additionally, the data obtained from the CCC database can rapidly inform the network how variation in clinical practice across centers can influence outcomes.
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Affiliation(s)
- L Tchelebi
- Department of Radiation Medicine, Northwell Health Cancer Institute, New Hyde Park, NY
| | - B Korah
- 1440 Foundation Canopy Cancer Collective, Scotts Valley, CA
| | - K A Goodman
- Icahn School of Medicine at Mount Sinai, Department of Radiation Oncology, New York, NY
| | - S Hoffe
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
| | - C Stricker
- 1440 Foundation Canopy Cancer Collective, Scotts Valley, CA
| | | | | | - T S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - A Hacker-Prietz
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - T A Aguilera
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - H Roberts
- Dana Farber Cancer Institute, Boston, MA
| | - A Raldow
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA
| | - M Tempero
- University of California San Francisco, San Francisco, CA
| | - J D Murphy
- Department of Radiation Medicine and Applied Sciences, UC San Diego, La Jolla, CA
| | - N K Malik
- Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - J Herman
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY
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12
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Gogineni E, Chen H, Li H, Istl AC, Johnston F, Narang A, Deville C. Comparison of Estimated Late Toxicities between IMRT and IMPT when Treating Retroperitoneal Sarcoma Preoperatively with Ultra-Hypofractionation. Int J Radiat Oncol Biol Phys 2023; 117:e298-e299. [PMID: 37785090 DOI: 10.1016/j.ijrobp.2023.06.2311] [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) While preoperative radiation did not improve abdominal recurrence-free survival for retroperitoneal sarcoma (RPS) in the randomized STRASS trial, it did reduce rates of local recurrence. The risk of radiation-associated toxicity is substantial, with 77% of irradiated patients experiencing grade ≥3 lymphopenia in STRASS. Thus, finding methods to mitigate the issues of delaying surgery and irradiating normal tissue may provide a path towards affording the benefits of radiation while limiting its downside. One potential solution involves the use of hypofractionation to limit delay from radiation initiation to surgery, and proton therapy to limit dose to surrounding organs at risk (OARs). We conducted a dosimetric comparison of preoperative ultra-hypofractionated intensity-modulated photon radiotherapy (IMRT) and proton therapy (IMPT) for RPS, comparing estimated rates of late toxicity using published normal tissue complication probability (NTCP) models. MATERIALS/METHODS Volumetric modulated arc therapy IMRT and IMPT plans were generated on 10 RPS patients previously treated with preoperative radiation. The prescription was 25 Gy radiobiological equivalent (GyE) to the clinical target volume (CTV) and 30 GyE to the margin-at-risk, all in five fractions. Proton doses were calculated using a radiobiological effective dose of 1.1. NTCPs were calculated for each OAR as a function of equivalent uniform dose. The ΔNTCP (difference in absolute NTCP between IMRT and IMPT plans) for each of the toxicity domains was calculated. Student T-tests were used to compare differences in dosimetric and NTCP outcomes. RESULTS CTV coverage was met for all IMRT and IMPT plans with >99% of CTVs receiving ≥100% of prescription doses. The following endpoints were significantly lower with IMPT than IMRT: mean doses to liver, bone, and all analyzed genitourinary and gastrointestinal OARs; bowel, kidney, and bone V5-V20; stomach V15; liver V5; maximum doses to stomach, spinal canal, and body; and whole-body integral dose. No OAR endpoint was significantly higher with IMPT. The average ΔNTCP for grade 3 bowel ulceration/perforation and renal toxicity was 1.9% (p = .037) and 43.0% (p = .023), respectively, favoring IMPT. Using a model-based selection threshold of any ΔNTCP >10%, 50% (n = 5) of patients would be eligible for IMPT. CONCLUSION IMPT maintained target coverage while significantly reducing dose to adjacent OARs and integral dose compared to IMRT. This translated to significantly lower risks of estimated late gastrointestinal and renal toxicities with IMPT. Further investigation is warranted to validate these findings and potential clinical benefit in the management of RPS. A prospective trial treating RPS with preoperative ultra-hypofractionated IMPT at our institution is currently being pursued (NCT05302570).
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Affiliation(s)
- E Gogineni
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - H Chen
- Provision Healthcare, Knoxville, TN
| | - H Li
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A C Istl
- Department of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - F Johnston
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - C Deville
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
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13
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Chen H, Gogineni E, Li H, Han-Oh S, Jia X, Deville C, Narang A. Inaugural Experience with Real-time Gated Liver Proton SBRT and Treatment Plan Quality Improvement. Int J Radiat Oncol Biol Phys 2023; 117:e286. [PMID: 37785061 DOI: 10.1016/j.ijrobp.2023.06.1274] [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) DIBH SBRT is routinely used for liver proton therapy. While intra-fraction target motion is limited with DIBH, acquisition of DIBH CT simulations in triplicate, as is done at our institution, reveals that variation does exist between each DIBH scan. The related target position can also vary correspondingly. The most common setup uncertainty for robust proton SBRT liver plan used at our institution is 5 mm sup-inf (SI) and 3 mm radially. Real-time gated proton therapy (RGPT) has the potential to provide instantaneous feedback for intra-fraction target motion to maximize patient safety and inform optimal treatment planning. Our first RGPT liver SBRT with intra-fraction motion under deep inspiration breath hold (DIBH). The potential treatment plan quality improvement brought by RGPT is investigated. MATERIALS/METHODS The following metrics were used in establishing our RGPT proton DIBH SBRT liver program: the iso center is always set at the fiducial mark; the beam orientation is selected to achieve both good plan quality and tracking performance; daily CBCTs are acquired and verified using fiducial maker position with kV images; robust uncertainty is determined by the gating tolerance; SBRT plan has three beams with uniform dose. Target motion was monitored throughout treatment. To evaluate dose sparing for surrounding OARs, a plan with tighter gating tolerance (3 mm SI and 2 mm radially) is optimized for dosimetric comparison. Statistical analyses were conducted using a programming environment. RESULTS Each of the three proton beams were delivered using DIBH over a total of 120-140 seconds. The average beam on time were 61.4, 66.9 and 62.8 seconds. The intra-fraction motion showed that targets could move up to 3 mm within the same DIBH. The motion increased with time. The table details the mean, maximum, standard deviation, and estimated upper 95% of directional shifts for three beams. Based on these results, plan delivery efficiency was maintained even with tighter gating tolerance. The comparison plan with tight gating tolerance showed significantly less dose (-25%) to the stomach in coronal view. CONCLUSION RGPT successfully tracked fiducial marker motion for DIBH SBRT liver treatment. Despite target drift during DIBH, the uncertainty of our DIBH SBRT procedure was sufficient to cover target motion throughout treatment. Based on the target drift value, a maximum of 25 seconds for breath hold time should be employed. Utilizing a tighter gating tolerance of 3 mm SI and 2 mm radially has the potential to maintain target coverage while significantly reducing OAR dose. Aggregated RGPT-derived data may provide optimal treatment planning parameters such as variable uncertainty based on target location.
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Affiliation(s)
- H Chen
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - E Gogineni
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - H Li
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - S Han-Oh
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - X Jia
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - C Deville
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
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14
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Sforza D, Miles D, Villano J, Narang A, Rezaee M. Preclinical Intraoperative FLASH Radiotherapy. Int J Radiat Oncol Biol Phys 2023; 117:e258. [PMID: 37784991 DOI: 10.1016/j.ijrobp.2023.06.1209] [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) Intraoperative radiation therapy (IORT) is a method of delivering high radiation doses to an internal target with low dose to adjacent organs. Most organs at risk can often be moved out of the radiation field, so dose is usually limited by in-field vascular and/or nerve structures. It is known that ultra-high (FLASH) dose rate (>40 Gy/s) radiation reduces normal tissue toxicity compared to conventional, while preserving tumor control. We hypothesize that FLASH radiation can increase the dose tolerance of vascular and nerve structures, thus permitting for dose escalation in IORT. Here, we present a novel platform using orthovoltage x-rays to study FLASH effects in preclinical IORT. The experimental setup and dosimetry of the system have been established for FLASH irradiation of the abdominal aorta in rats to investigate dose tolerance. MATERIALS/METHODS A 150 kVp rotating anode x-ray source with a 75-kW generator was used to deliver FLASH and conventional irradiation. A 3D printed immobilization platform was designed to reproducibly place a surgically exposed rat abdominal aorta at 55mm SSD. A 3-mm thick lead collimator with a 10mm x 10mm aperture was placed into a flange adapter, which docks into the immobilization platform. Phantom and in vivo dosimetry were performed using both calibrated radiographic film and thermoluminescent dosimeters (TLD). Anesthetized 2-month-old Wistar rats underwent laparotomy to expose the abdomen for irradiation. A 10x12x1 mm3 tungsten plate was placed under the aorta to reduce spinal cord dose. Animals were then docked into the irradiator using the immobilization platform. Radiation dose in the range of 20 - 50 Gy were delivered to the abdominal aorta at FLASH and conventional dose-rates. Following treatment, animals undergo MR angiography every two months for 6 months, at which a histological evaluation of aorta wall will be performed. RESULTS The FLASH dose rate measured at the aorta wall in a rat carcass was 49.7 ± 1.2 Gy/s distal to the collimator. Dose measurements between the films and TLDs showed an agreement within ±3%. Positional uncertainty mainly depends on the visual localization of the aorta on the collimator window, which is verified before irradiation. Vertical uncertainty is less than 1 mm, which is important given the rapid dose fall off of the system. Eight animals went successfully through the procedure, are healthy and currently being follow up with MR angiography. More animals are being treated for meaningful statistical results. MR angiography and IORT are performed on different days to avoid longer times under anesthesia, which initially resulted on mortality. Results of the MR angiography and histological analysis will be presented. CONCLUSION The proposed platform has been successfully utilized for precision setup for FLASH IORT in a preclinical laboratory setting. Evaluation of FLASH effects in IORT setup will be an important step in the potential translation of FLASH IORT, where only one high-dose fraction can be delivered.
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Affiliation(s)
- D Sforza
- Department of Radiation Oncology and Molecular Radiation Sciences, School of Medicine, Johns Hopkins University, Sibley Memorial Hospital Proton Therapy Center, Washington, DC
| | - D Miles
- Department of Radiation Oncology and Molecular Radiation Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - J Villano
- Department of Molecular and Comparative Pathobiology, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - A Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - M Rezaee
- Department of Radiation Oncology and Molecular Radiation Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD
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15
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Lin TA, Paul N, Cheung D, Saberi B, Ottman S, Gurakar A, Yarchoan M, Narang A, Kim AK, Meyer JJ. Impact of Local Therapy on Outcomes in Patients with Recurrent Hepatocellular Carcinoma after Liver Transplantation. Int J Radiat Oncol Biol Phys 2023; 117:e316. [PMID: 37785135 DOI: 10.1016/j.ijrobp.2023.06.2350] [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) Patients with hepatocellular carcinoma (HCC) who recur after liver transplantation have limited systemic therapy options in part due to ineligibility for immune checkpoint inhibition. Thus, assessing the benefit of local, metastasis-directed therapy (MDT) is imperative. We aimed to evaluate the impact of MDT on outcomes in patients with post-transplant HCC recurrence. MATERIALS/METHODS Patients at a single center with recurrent HCC after liver transplant were identified. Recurrence/progression were assessed via RECIST criteria. At initial recurrence, patients with < = 3 metastases (mets) were considered oligorecurrent (oligoM1); those with >3 mets were polyrecurrent. Progression was defined as growth of existing mets or appearance of new mets. Poly-progression-free survival (polyPFS) was the time from oligorecurrence to polyprogression (>3 progressive mets) or death. Survival was estimated with the Kaplan-Meier method. Univariable Cox regression was used to identify covariates associated with outcomes; those with p<.05 were included in multivariable regression. RESULTS From 2005-2022, 43 patients with HCC who underwent liver transplantation experienced recurrence; 27 (63%) had oligoM1 disease at the time of recurrence. The most common sites of recurrence were liver (N = 14), abdominal nodes (N = 14), and lungs (N = 11). Low AFP (<400 ng/mL) and oligoM1 disease were associated with a favorable OS (P<.05) and these associations remained significant in multivariable analysis. Among patients with oligoM1 recurrence, 15/27 received MDT to all sites of disease (MDT-All). MDT consisted of stereotactic ablative radiotherapy (N = 6), intensity-modulated radiotherapy (N = 2), TACE (N = 1), microwave ablation (N = 3), cryoablation (N = 2), and surgery (N = 2). Among oligoM1 patients, more patients with MDT-All had liver involvement than those who did not have MDT-All (33% vs 0%, P = .047), but there was no difference in performance status, AFP, or systemic therapy receipt. Among oligoM1 patients, MDT-All was associated with improved polyPFS (median 11.7 vs 4.8 mos; P = .025), and OS (38.4 vs 16.1 mos; P = .021) compared to those who did not receive MDT-All. Two patients who received MDT-All remained alive at >4 years of follow-up from recurrence, while 1 patient remained alive at >14 years of follow-up. CONCLUSION Local therapy in patients with post-transplantation oligorecurrence (<3 mets) of HCC may delay disease progression and improve survival.
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Affiliation(s)
- T A Lin
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - N Paul
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - D Cheung
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - B Saberi
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - S Ottman
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A Gurakar
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - M Yarchoan
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A K Kim
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - J J Meyer
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
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Sehgal S, Reddy A, Hill C, Lin T, Zheng L, He J, Herman J, Meyer J, Narang A. Neoadjuvant Chemotherapy and Stereotactic Body Radiation Therapy in Patients with Early Onset Pancreatic Cancer: Clinical Outcomes and Toxicity. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.1120] [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: 12/01/2022]
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Gogineni E, Chen H, Narang A, Deville C. In Silico Dosimetric Comparison of Intensity-Modulated Proton Radiotherapy (IMPT) vs. Intensity-Modulated Photon Radiotherapy (IMRT) in the Preoperative Treatment of Retroperitoneal Sarcoma. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.1811] [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: 10/31/2022]
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Reddy A, Hill C, Sehgal S, He J, Zheng L, Herman J, Meyer J, Narang A. Stereotactic Body Radiation Therapy is Safe and Feasible for the Treatment of Locally Recurrent Pancreatic Adenocarcinoma after Curative Resection. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.1116] [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: 10/31/2022]
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Reddy A, Safar B, Jia A, Azad N, Christenson E, Atallah C, Efron J, Gearhart S, Zaheer A, Narang A, Meyer J. Non-Operative Management is Feasible and Safe in Patients with Rectal Cancer Who Achieve Clinical Complete Response to Short-Course Radiation Therapy and Consolidation Chemotherapy. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.630] [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: 11/15/2022]
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Lin T, Reddy A, Hill C, Sehgal S, He J, Zheng L, Herman J, Meyer J, Narang A. The Optimal Timing of Surgery Following Stereotactic Body Radiation Therapy for Borderline Resectable or Locally Advanced Pancreatic Cancer. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.1109] [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: 11/30/2022]
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Narang A, Shin E, Ding K, Krishnan K, Casey B, Bhutani M, Herman J, Meyer J, Hong T, Koay E. Using Hydrogel to Create Spatial Separation between the Pancreas and Duodenum in Patients with Pancreatic Cancer: A Multi-Institutional Safety and Feasibility Study. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.1110] [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: 11/29/2022]
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22
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Narang A, Hill C, Ghaly M, Korah B, Miller E, Malik N, Raldow A, Anwar M, Sanford N, Aguilera T, Kim E, Apisarnthanarax S, Murphy J, Frakes J, Hoffe S, Schefter T, Chang D, Hong T, Herman J, Goodman K. Current Practice Patterns among Radiation Oncologists at High-Volume Pancreatic Cancer Centers Participating in the Canopy Cancer Collective Learning Health Network. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.1111] [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: 11/16/2022]
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23
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Hutfless S, Jasper RA, Tilak A, Ghosh T, Kedia S, Liu S, Urrunaga NH, Josephson M, Narang A, Miller S, Chen PH, Joseph S, Brant SR. A Systematic Review of Crohn's Disease Case Definitions in Administrative or Claims Databases. Inflamm Bowel Dis 2022; 29:705-715. [PMID: 35857336 PMCID: PMC10152279 DOI: 10.1093/ibd/izac131] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND We sought to review Crohn's disease (CD) case definitions that use diagnosis, procedure, and medication claims. METHODS We searched PubMed and Embase from inception through January 31, 2022, using terms related to CD, inflammatory bowel disease, administrative claims, or validity. Each article was scrutinized by 2 authors independently screening and abstracting data. Collected data included participant characteristics, case definition characteristics, and case definition validity. When diagnostic accuracy was provided for multiple case definitions, we extracted the case definition selected by the authors. All diagnostic accuracy characteristics were captured. RESULTS We identified 30 studies that evaluated a case definition using claims data to identify CD patients. The most common case definition included counts of diagnosis codes (57%) followed by a combination of diagnosis codes and medications (20%). All but 1 study validated the case definition with a medical chart review. In 2 studies, the patient's primary care provider completed a survey to confirm disease status. The positive predictive value of the case definitions ranged from 18% (≥1 code at a single U.S. health plan) to 100% (≥1 code plus a relevant prescription at a U.S. hospital). More complex case definitions (eg, ≥1 code + prescription or ≥2 codes) had lower variability in positive predictive value (≥80%) and specificity (≥85%) than the ≥1 code requirement. CONCLUSIONS Health services researchers should validate case definitions in their research cohorts. When such validation cannot be performed, we recommend using a more complex case definition. Studies without a validated CD case definition should use sensitivity analyses to confirm the robustness of their results.
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Affiliation(s)
- Susan Hutfless
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA.,Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Ryan A Jasper
- Department of Applied Mathematics and Statistics, Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Aman Tilak
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Tamoghna Ghosh
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Kedia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Simon Liu
- Medical Genomics Unit, National Human Genome Research Institute, Bethesda, MD, USA
| | - Nathalie H Urrunaga
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Matthew Josephson
- Division of Gastroenterology and Hepatology, Albany Medical College, Albany, NY, USA
| | - Arshit Narang
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Steve Miller
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Po-Hung Chen
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Shelly Joseph
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, NYU Grossman School of Medicine, New York, NY, USA
| | - Steven R Brant
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA.,Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
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Reddy A, Hill C, Sehgal S, Ding D, Zheng L, He J, Herman J, Meyer J, Narang A. KRAS and NOTCH1/2 Mutations are Associated With Pathologic and Clinical Outcomes in Localized Pancreatic Cancer Treated With Neoadjuvant Chemotherapy and Stereotactic Body Radiotherapy Followed by Surgical Exploration. Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.426] [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: 10/20/2022]
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25
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Hill C, Fellows A, Hobbs R, Reddy A, Herman J, Meyer J, Narang A. Proposed Model of Dose Escalation in Localized Pancreatic Cancer Patients Eligible for Surgical Exploration: Neoadjuvant Intensity Modulated Radiation Therapy (IMRT) vs. Stereotactic Body Radiation Therapy (SBRT) and Intra-Operative Radiotherapy (IORT). Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.369] [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: 11/24/2022]
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26
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Hill C, Sehgal S, Reddy A, Herman J, Meyer J, Narang A. What Should We Cover Beyond Gross Disease With Radiation Therapy for Localized Pancreatic Ductal Adenocarcinoma (PDAC): Proposal of an Innovative and Standardized Clinical Tumor Volume (CTV) for PDAC of the Head – The Triangle. Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.368] [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: 11/17/2022]
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27
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Narang A, Chan G, Aframian A, Ali Z, Carr A, Goodier H, Morgan C, Park C, Sugand K, Walton T, Wilson M, Belgaumkar A, Gallagher K, Ghosh K, Gibbons C, Keightley A, Nawaz Z, Wakeling C, Sarraf K, Rogers BA, Kieffer WKM. Thirty-day mortality following surgical management of hip fractures during the COVID-19 pandemic: findings from a prospective multi-centre UK study. Int Orthop 2021. [PMID: 32862265 DOI: 10.1007/s00264-020-04739-y/figures/2] [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] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
PURPOSE Thirty-day mortality of patients with hip fracture is well researched and predictive; validated scoring tools have been developed (Nottingham Hip Fracture Score, NHFS). COVID-19 has significantly greater mortality in the elderly and comorbid patients which includes hip fracture patients. Non-operative treatment is not appropriate due to significantly higher mortality, and therefore, these patients are often exposed to COVID-19 in the peri-operative period. What is unclear is the effect of concomitant COVID-19 infection in these patients. METHODS A multicentre prospective study across ten sites in the United Kingdom (responsible for 7% of hip fracture patients per annum in the UK). Demographic and background information were collected by independent chart review. Data on surgical factors included American Society of Anesthesiologists (ASA) score, time to theatre, Nottingham Hip fracture score (NHFS) and classification of fracture were also collected between 1st March 2020 and 30th April 2020 with a matched cohort from the same period in 2019. RESULTS Actual and expected 30-day mortality was found to be significantly higher than expected for 2020 COVID-19 positive patients (RR 3.00 95% CI 1.57-5.75, p < 0.001), with 30 observed deaths compared against the 10 expected from NHFS risk stratification. CONCLUSION COVID-19 infection appears to be an independent risk factor for increased mortality in hip fracture patients. Whilst non-operative management of these fractures is not suggested due to the documented increased risks and mortality, this study provides evidence to the emerging literature of the severity of COVID-19 infection in surgical patients and the potential impact of COVID-19 on elective surgical patients in the peri-operative period.
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Affiliation(s)
- A Narang
- Surrey and Sussex Healthcare NHS Trust, East Surrey Hospital, Canada Avenue, Redhill, Surrey, RH1 5RH, UK
| | - G Chan
- Western Sussex Hospitals NHS Foundation Trust, Chichester, UK
| | - A Aframian
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Z Ali
- Surrey and Sussex Healthcare NHS Trust, East Surrey Hospital, Canada Avenue, Redhill, Surrey, RH1 5RH, UK
| | - A Carr
- Surrey and Sussex Healthcare NHS Trust, East Surrey Hospital, Canada Avenue, Redhill, Surrey, RH1 5RH, UK
| | - H Goodier
- Poole General Hospital & the Royal Bournemouth Hospital, Poole, UK
| | - C Morgan
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - C Park
- St Mary's Hospital, London, London, UK
| | - K Sugand
- St Mary's Hospital, London, London, UK
| | - T Walton
- Brighton and Sussex University Hospitals, Brighton, UK
| | - M Wilson
- Poole General Hospital & the Royal Bournemouth Hospital, Poole, UK
| | - A Belgaumkar
- Surrey and Sussex Healthcare NHS Trust, East Surrey Hospital, Canada Avenue, Redhill, Surrey, RH1 5RH, UK
| | - K Gallagher
- Poole General Hospital & the Royal Bournemouth Hospital, Poole, UK
| | - K Ghosh
- Western Sussex Hospitals NHS Foundation Trust, Chichester, UK
| | - C Gibbons
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - A Keightley
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Z Nawaz
- Frimley Park Hospital, Camberley, UK
| | - C Wakeling
- Western Sussex Hospitals NHS Foundation Trust, Chichester, UK
| | - K Sarraf
- St Mary's Hospital, London, London, UK
| | - B A Rogers
- Brighton and Sussex University Hospitals, Brighton, UK
| | - W K M Kieffer
- Surrey and Sussex Healthcare NHS Trust, East Surrey Hospital, Canada Avenue, Redhill, Surrey, RH1 5RH, UK.
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28
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Affiliation(s)
- S Gupta
- Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
| | - S Sinha
- Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
| | - A Narang
- Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
| | - R K Kanojia
- Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
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Surette S, Narang A, Bae R, Hong H, Thomas Y, Cadieu C, Chaudhry A, Martin R, Rubenson D, Goldstein S, Little S, Lang R, Weissman N, Thomas J. Artificial intelligence-guided image acquisition on patients with implanted electrophysiological devices: results from a pivotal prospective multi-center clinical trial. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.0006] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
A novel, recently FDA-authorized software uses deep learning (DL) to provide prescriptive transthoracic echocardiography (TTE) guidance, allowing novices to acquire standard TTE views. The DL model was trained by >5,000,000 observations of the impact of probe motion on image orientation/quality. This study evaluated whether novice-acquired TTE images guided by this software were of diagnostic quality in patients with and without implanted electrophysiological (EP) devices, focusing on RV size and function, which were thought to be sensitive to EP devices. Some aspects of the study have previously been presented.
Methods
240 patients (61±16 years old, 58% male, 33% BMI >30 kg/m2, 91% with cardiac pathology) were recruited. 8 nurses without echo experience each acquired 10 view TTEs in 30 patients guided by the software. 235 of the patients were also scanned by a trained sonographer without assistance from the software. 5 Level 3 echocardiographers independently assessed the diagnostic quality of the TTEs acquired by the nurses and sonographers to evaluate the effect of EP devices on DL software performance.
Results
Nurses using the AI-guided acquisition software acquired TTEs of sufficient quality to make qualitative assessments of right ventricular (RV) size and function in greater than 80% of cases for patients with and without implanted EP devices (Table). There was no significant difference between nurse- and sonographer-acquired scans.
Conclusion
These results indicate that new DL software can guide novices to obtain TTEs that enable qualitative assessment of RV size even in the presence of implanted EP devices. The results of the comparison to sonographer-acquired exams indicate the software performance is robust to presence of pacemaker/ICD leads visible in the images (Figure).
Nurse-acquired TTE with visible ICD lead
Funding Acknowledgement
Type of funding source: Private company. Main funding source(s): Caption Health, Inc.
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Affiliation(s)
- S Surette
- Caption Health, Brisbane, United States of America
| | - A Narang
- Northwestern University, Chicago, United States of America
| | - R Bae
- Minneapolis Heart Institute Foundation, Minneapolis, United States of America
| | - H Hong
- Caption Health, Brisbane, United States of America
| | - Y Thomas
- Caption Health, Brisbane, United States of America
| | - C Cadieu
- Caption Health, Brisbane, United States of America
| | - A Chaudhry
- Caption Health, Brisbane, United States of America
| | - R Martin
- Caption Health, Brisbane, United States of America
| | - D Rubenson
- Scripps Clinic, La Jolla, United States of America
| | - S Goldstein
- MedStar Washington Hospital Center, Washington, United States of America
| | - S Little
- Houston Methodist, Houston, United States of America
| | - R Lang
- The University of Chicago, Chicago, United States of America
| | - N Weissman
- MedStar Health Research Institute, Washington, United States of America
| | - J.D Thomas
- Northwestern University, Chicago, United States of America
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Chen H, Meyer J, Narang A, Han-Oh S, Ding K, Wong J, Tsien C, Li H. Delivery Uncertainty Estimation Using Daily Breath-Hold Cone-Beam CTs For Liver Proton Stereotactic Body Radiotherapy. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.1974] [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: 11/30/2022]
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Han-Oh S, Hill C, Wang K, Ding K, Li H, Chen H, Meyer J, Narang A. Dosimetric Impact of Deep Inspiration Breath Hold Uncertainty on Pancreas Stereotactic Body Radiotherapy. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.2386] [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: 10/23/2022]
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32
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Miccio J, Mokhtech M, Jabbour S, Anker C, Patel T, Park H, Cecchini M, Salem R, Kuntsman J, Stein S, Kortmansky J, Lacy J, Narang A, Herman J, Haddock M, Hallemeier C, Johung K, Jethwa K. Association of Neoadjuvant Treatment Modality with Negative Margin and Pathologic Downstaging in Patients Undergoing Pancreatic Cancer Resection: A National Cancer Database Analysis. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.1980] [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: 10/23/2022]
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Narang A, Singh Randhawa S, Kumar Sood N, Chhabra S, Singla LD, Kaur P. Atypical theileriosis with cutaneous involvement in a cow in India: a case report. REV SCI TECH OIE 2020; 38:703-709. [PMID: 32286574 DOI: 10.20506/rst.38.3.3019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Bovine tropical theileriosis caused by Theileria annulata is an overwhelming haemoprotozoan tick-borne disease in taurine and cross-bred cattle in Punjab, India. However, there seems to be no report from India of cutaneous nodules associated with the disease. This report describes a five-year-old cross-bred cow presented to a university clinic with a history of fever, inappetence and malaise for the past six to seven days. Clinical examination revealed normal vital parameters, pale mucous membranes, mild enlargement of the prescapular lymph nodes and multiple subcutaneous nodular masses (2-4 cm) on the neck and abdomen. Haematology revealed mild anaemia and leucopenia with 48% neutrophils, 48% lymphocytes and 4% eosinophils. Romanowsky-stained smears of fineneedle aspiration biopsy samples from swollen lymph nodes and subcutaneous masses showed an increased number of lymphoid cells, suggesting cutaneous lymphomatosis. However, a critical examination of the smears from subcutaneous nodules showed a large number of Koch's blue bodies in macrophages and lymphoblasts, and several piroplasms were also noticed within the red blood cells in lymph node smears. A peripheral blood smear revealed mild to moderate parasitaemia. Extracted DNA from the parasitologically positive blood sample was subjected to nested polymerase chain reaction (nPCR) using T. annulata speciesspecific primers encoding the 30-kiloDalton major sporozoite surface antigen. The desired 572-base pair amplified product of the nPCR was comparable to the positive control. This seems to be a rare case of T. annulata in an adult cross-bred cow, showing cutaneous nodular involvement.
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Pearlman AS, Narang A, Hong H, Hsieh C, Chaudhry A, Chen C, Guttas S, Surette S, Parajuli N, Polivert N, Cadieu C, Martin RP, Thomas JD, Weissman NJ. 547 Point-of-care cardiac assessment using machine learning to guide image acquisition. Eur Heart J Cardiovasc Imaging 2020. [DOI: 10.1093/ehjci/jez319.281] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Bay Labs, Inc; San Francisco, CA
Background/Introduction: When used by experienced examiners, the utility of point-of-care (POC) ultrasound for assessing cardiac anatomy and function has been well established. However, in some clinical circumstances (Primary Care offices, Intensive Care Unit, some Emergency Rooms, or in remote settings) in which a rapid assessment of cardiac anatomy and dynamics can facilitate patient care, an examiner experienced at POC scanning may not be immediately available.
Purpose
To help novice users acquire clinically useful standard cardiac views using novel machine learning (ML) software.
Methods
We used an investigational device that employs ML software to provide real-time adaptive guidance of transducer position and orientation to help novice users acquire tomographic views of the heart. We tested the utility of this approach when 4 nurses with no prior training in sonography performed POC studies on 16 subjects (10 healthy, 6 with cardiac abnormalities; 9 men; body mass index normal in 6, overweight in 6, and obese in 4 subjects). Each nurse underwent didactic training and 4 hours of supervised practice using the ML program. Each nurse scanned each study subject using a scanner equipped with ML software to acquire 10 digital two-dimensional image clips, including: parasternal long axis, short axis at the aortic valve, mitral valve, and mid-left ventricle (LV), apical 2-, 4-, and 5-chamber, subcostal 4-chamber, and longitudinal views of the inferior vena cava (IVC). All video clips (n = 640) were later reviewed independently by 5 level 3-trained cardiologists who were blinded to subject, scanner, and each other"s assessments. The expert readers reviewed each set of 10 clips to determine if the following variables could be assessed qualitatively: LV size and function; right ventricular (RV) size and function; aortic, mitral and tricuspid valves; pericardial effusion; left atrial size; IVC size.
Results
The majority of expert readers concurred, independently, that the sets of images acquired by nurses using ML guidance allowed qualitative assessment of LV size and function in 98%, pericardial effusion in 98%, RV size and function in 92%, and aortic and mitral valve anatomy and dynamics in 94-97% of cases. Qualitative assessment of LA size was feasible in 95%. Images of the IVC were judged as adequate for assessment in 58%.
Conclusion
This preliminary study suggests the potential value of novel ML software by demonstrating that nurses with limited training can acquire tomographic images useful for qualitative assessment of the cardiac chambers and valves in more than 90% of the subjects examined. This approach might be useful when timely POC cardiac assessment is indicated in settings where an experienced examiner is not available. Further refinements in the guiding software are needed to improve the success rate of IVC imaging, since IVC size can be a useful indicator of volume status.
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Affiliation(s)
- A S Pearlman
- University of Washington, Seattle, United States of America
| | - A Narang
- Northwestern University, Chicago, United States of America
| | - H Hong
- Bay Labs, Inc, San Francisco, United States of America
| | - C Hsieh
- Bay Labs, Inc, San Francisco, United States of America
| | - A Chaudhry
- Bay Labs, Inc, San Francisco, United States of America
| | - C Chen
- Bay Labs, Inc, San Francisco, United States of America
| | - S Guttas
- Bay Labs, Inc, San Francisco, United States of America
| | - S Surette
- Bay Labs, Inc, San Francisco, United States of America
| | - N Parajuli
- Bay Labs, Inc, San Francisco, United States of America
| | - N Polivert
- Bay Labs, Inc, San Francisco, United States of America
| | - C Cadieu
- Bay Labs, Inc, San Francisco, United States of America
| | - R P Martin
- Bay Labs, Inc, San Francisco, United States of America
| | - J D Thomas
- Northwestern University, Chicago, United States of America
| | - N J Weissman
- Medstar Research Institute, Washington, DC, United States of America
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Slathia P, Narang D, Chandra M, Sharma A, Narang A. Detection of non-tuberculous mycobacterial species using PCR-RFLP analysis in trans-tracheal washes in cattle and buffaloes with respiratory distress. Iran J Vet Res 2020; 21:136-140. [PMID: 32849894 PMCID: PMC7430363] [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] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 01/11/2020] [Accepted: 01/13/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Bovine tuberculosis (bTB) is a chronic disease of cattle with high economic importance in livestock farming caused by Mycobacterium bovis and bears a zoonotic potential. There are some non-tuberculous mycobacteria (NTM) which cause disease similar to bTB and interfere with diagnosis of bTB. Non-tuberculous mycobacteria are saprophytic in nature but some of them may cause pulmonary infections, mastitis, lesions in respiratory tract and lymph nodes of cattle, due to which they are being recognized worldwide and interfere with the diagnosis of bTB. AIMS The aim of the study was to detect NTM species from cattle and buffaloes with respiratory distress using biochemical test and polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analysis (PRA). METHODS A total of 50 trans-tracheal washes were collected from cattle (n=41) and buffaloes (n=9) with respiratory distress. The samples were inoculated on Middlebrook 7H10 media after proper decontamination with 4% NaOH. The isolate obtained was identified by biochemical testing. Extracted DNA from samples and isolate was subjected to PRA which involved hsp65 gene amplification (439 bp) and RFLP analysis of amplified product. RESULTS Out of 50 trans-tracheal washes only one isolate of Mycobacterium kansasii (n=1) (2%) was obtained which was confirmed by biochemical testing and PRA. Mycobacterium kansasii (n=4) (8%), Mycobacterium intracellulare (n=1) (2%), and Mycobacterium vaccae (n=1) (2%) were identified by PRA. CONCLUSION The study emphasizes the importance of NTM in animals. Polymerase chain reaction-restriction fragment length polymorphism analysis is a more reliable and rapid method for identification of NTM than conventional methods.
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Affiliation(s)
- P. Slathia
- Ph.D. Student in Veterinary Microbiology, Department of Veterinary Microbiology, College of Veterinary Science, Guru Angad Dev Veterinary and Animal Sciences University, Ludhiana-141004, Punjab, India
| | - D. Narang
- Department of Veterinary Microbiology, College of Veterinary Science, Guru Angad Dev Veterinary and Animal Sciences University, Ludhiana-141004, Punjab, India
| | - M. Chandra
- Department of Veterinary Microbiology, College of Veterinary Science, Guru Angad Dev Veterinary and Animal Sciences University, Ludhiana-141004, Punjab, India
| | - A. Sharma
- Department of Veterinary Medicine, College of Veterinary Science, Guru Angad Dev Veterinary and Animal Sciences University, Ludhiana-141004, Punjab, India
| | - A. Narang
- Department of Veterinary Medicine, College of Veterinary Science, Guru Angad Dev Veterinary and Animal Sciences University, Ludhiana-141004, Punjab, India
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Hill C, Han-Oh S, Cheng Z, Meyer J, Herman J, Narang A. Quantifying the Intra-fraction Treatment Variation in the Shift Off Bone in Fiducial-Based IG-SBRT for Pancreatic Adenocarcinoma. Int J Radiat Oncol Biol Phys 2019. [DOI: 10.1016/j.ijrobp.2019.06.800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Rao A, Shin E, Meyer J, Thompson E, Fu W, Hu C, Fishman E, Weiss M, Wolfgang C, Burkhart R, He J, Kerdsirichariat T, Herman J, Ding K, Narang A. Evaluation of a Novel Absorbable Radiopaque Hydrogel in Patients Undergoing Image-Guided Radiotherapy (IGRT) for Borderline Resectable and Locally Advanced Pancreatic Adenocarcinoma. Int J Radiat Oncol Biol Phys 2019. [DOI: 10.1016/j.ijrobp.2019.06.1923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Jia A, Narang A, Safar B, Zaheer A, Murphy A, Azad N, Gearhart S, Fang S, Efron J, Warczynski T, Hacker-Prietz A, Meyer J. Sequential Short-Course Radiation Therapy and Chemotherapy in the Neoadjuvant Treatment of Rectal Cancer. Int J Radiat Oncol Biol Phys 2019. [DOI: 10.1016/j.ijrobp.2019.06.2144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Page B, Hill C, Kiess A, Narang A, Anderson R, Choflet A, Alcorn S, DeWeese T, Viswanathan A, Deville C. Establishing an American Sign Language (ASL) Inclusive Residency Training Program. Int J Radiat Oncol Biol Phys 2019. [DOI: 10.1016/j.ijrobp.2019.06.2214] [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: 11/29/2022]
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40
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Han-Oh S, Nobile L, Laub W, Davies G, Watson A, Stephens D, Meyer J, Narang A. Geometric Reproducibility of Fiducial Markers and Efficacy of a Patient-Specific Margin Design Using Active Breath Hold for Pancreas Stereotactic Body Radiation Therapy. Int J Radiat Oncol Biol Phys 2018. [DOI: 10.1016/j.ijrobp.2018.07.420] [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: 10/28/2022]
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Kim RJ, Simonetti OP, Westwood M, Kramer CM, Narang A, Friedrich MG, Powell AJ, Carr JC, Schulz-Menger J, Nagel E, Chan WS, Bremerich J, Ordovas KG, Rollings RC, Patel AR, Ferrari VA. Guidelines for training in cardiovascular magnetic resonance (CMR). J Cardiovasc Magn Reson 2018; 20:57. [PMID: 30111368 PMCID: PMC6094559 DOI: 10.1186/s12968-018-0481-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 07/19/2018] [Indexed: 11/10/2022] Open
Abstract
These "Guidelines for training in Cardiovascular Magnetic Resonance" were developed by the Certification Committee of the Society for Cardiovascular Magnetic Resonance (SCMR) and approved by the SCMR Board of Trustees.
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Affiliation(s)
- R. J. Kim
- Duke University Medical Center, Durham, USA
| | | | | | - C. M. Kramer
- University of Virginia Health System, Charlottesville, USA
| | - A. Narang
- University of Chicago Medicine, Chicago, USA
| | | | | | | | | | - E. Nagel
- Goethe University Frankfurt, Frankfurt, Germany
| | - W. S. Chan
- Queen Mary Hospital, High West, Hong Kong
| | | | - K. G. Ordovas
- University of California San Francisco, San Francisco, USA
| | | | - A. R. Patel
- University of Chicago Medicine, Chicago, USA
| | - V. A. Ferrari
- Hospital of the University of Pennsylvania, Philadelphia, USA
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Chugh K, Narang A, Kumar L, Sakhuja V, Unni VN, Pirzada R, Singh N, Pereira B, Singhal P. Acute Renal Failure Amongst Children in a Tropical Environment. Int J Artif Organs 2018. [DOI: 10.1177/039139888701000207] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [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
The pathogenetic factors leading to acute renal failure (ARF) in 223 children between the ages of 20 days and 14 years were studied. Diarrhoeal diseases were responsible for ARF in 49.8%, acute glomerulonephritis in 34.1%, drug induced intravascular hemolysis in glucose -6-phosphate dehydrogenase deficiency in 4.5%, snake bite in 4%, hemolytic uremic syndrome in 2.2%, and miscellaneous causes in 5.4%. Dialysis was instituted in 178 children and the others were treated conservatively. Renal histology in 39 out of 76 children who presented with an acute nephritic illness revealed acute endocapillary proliferative glomerulonephritis in 27 and crescentic glomerulonephritis in 12. The histology in 79 out of 147 remaining patients showed acute tubular necrosis in 64, acute cortical necrosis in 13, and acute interstitial nephritis in 2. Overall mortality was 27.4%. This high incidence of ARF due to infective diarrhoeas and dysentery reflects poor socio-economic and hygienic conditions, inadequate facilities in rural areas, delays in seeking medical advice, and lack of knowledge about fluid and electrolyte therapy amongst the staff.
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Affiliation(s)
- K.S. Chugh
- Departments of Nephrology and Paediatrics Postgraduate Institute of Medical Education and Research Chandigarh, India
| | - A. Narang
- Departments of Nephrology and Paediatrics Postgraduate Institute of Medical Education and Research Chandigarh, India
| | - L. Kumar
- Departments of Nephrology and Paediatrics Postgraduate Institute of Medical Education and Research Chandigarh, India
| | - V. Sakhuja
- Departments of Nephrology and Paediatrics Postgraduate Institute of Medical Education and Research Chandigarh, India
| | - V. Narayanan Unni
- Departments of Nephrology and Paediatrics Postgraduate Institute of Medical Education and Research Chandigarh, India
| | - R. Pirzada
- Departments of Nephrology and Paediatrics Postgraduate Institute of Medical Education and Research Chandigarh, India
| | - N. Singh
- Departments of Nephrology and Paediatrics Postgraduate Institute of Medical Education and Research Chandigarh, India
| | - B.J.G. Pereira
- Departments of Nephrology and Paediatrics Postgraduate Institute of Medical Education and Research Chandigarh, India
| | - P.C. Singhal
- Departments of Nephrology and Paediatrics Postgraduate Institute of Medical Education and Research Chandigarh, India
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Conley W, Bae H, Narang A, McNutt T, Greco S, Asrari F, Deville C, Tran P, DeWeese T, Song D. End-of-Treatment PSA Is Frequently Elevated Compared to Baseline PSA Following Hypofractionated Radiation Therapy. Int J Radiat Oncol Biol Phys 2017. [DOI: 10.1016/j.ijrobp.2017.06.1139] [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: 10/18/2022]
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Cao Y, Chen L, Narang A, Guss Z, Moore J, Robertson S, Rosati L, Cheng Z, Mian O, Hacker-Prietz A, McNutt T, Herman J. Stereotactic Body Radiation Therapy in Pancreas Adenocarcinoma Demonstrates Minimal Acute and Late Toxicity. Int J Radiat Oncol Biol Phys 2017. [DOI: 10.1016/j.ijrobp.2017.06.932] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Rao A, Feng Z, Shin E, He J, Waters K, Coquia S, De Jong R, Rosati L, Su L, Li D, Jackson J, Clark S, Schultz J, Hutchings D, Kim S, Hruban R, Wong J, Narang A, Herman J, Ding K. Novel Use of a Hydrogel Spacer to Separate the Head of the Pancreas and Duodenum for Radiation Therapy for Pancreatic Cancer. Int J Radiat Oncol Biol Phys 2017. [DOI: 10.1016/j.ijrobp.2017.06.1034] [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: 10/18/2022]
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46
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Cheng Z, McNutt T, Rosati L, Lakshminarayanan P, Chen L, Moore J, Hacker-Prietz A, Herman J, Narang A. PTV Hot-Spot Volume is Associated With Improved Pathologic Response After Neoadjuvant Stereotactic Body Radiation Therapy for Pancreatic Cancer. Int J Radiat Oncol Biol Phys 2017. [DOI: 10.1016/j.ijrobp.2017.06.477] [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: 10/18/2022]
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Tosoian JJ, Alam R, Gergis C, Narang A, Radwan N, Robertson S, McNutt T, Ross AE, Song DY, DeWeese TL, Tran PT, Walsh PC. Unscreened older men diagnosed with prostate cancer are at increased risk of aggressive disease. Prostate Cancer Prostatic Dis 2017; 20:193-196. [PMID: 28045113 DOI: 10.1038/pcan.2016.64] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 10/17/2016] [Accepted: 11/10/2016] [Indexed: 01/15/2023]
Abstract
BACKGROUND To evaluate the relationship between PSA testing history and high-risk disease among older men diagnosed with prostate cancer. METHODS Records from 1993 to 2014 were reviewed for men who underwent radiotherapy for prostate cancer at age 75 years or older. Patients were classified into one of four groups based on PSA-testing history: (1) no PSA testing; (2) incomplete/ineffective PSA testing; (3) PSA testing; or (4) cannot be determined. Outcomes of interest were National Comprehensive Cancer Network (NCCN) risk group (that is, low, intermediate or high risk) and biopsy grade at diagnosis. Multivariable logistic regression was used to determine the association between PSA testing history and high-risk cancer. RESULTS PSA-testing history was available in 274 (94.5%) of 290 subjects meeting study criteria. In total, 148 men (54.0%) underwent PSA testing with follow-up biopsy, 72 (26.3%) underwent PSA testing without appropriate follow-up, and 54 men (19.7%) did not undergo PSA testing. Patients who underwent PSA testing were significantly less likely to be diagnosed with NCCN high-risk cancer (23.0% vs 51.6%, P<0.001). On multivariable analysis, men with no/incomplete PSA testing had more than three-fold increased odds of high-risk disease at diagnosis (odds ratio 3.39, 95% confidence interval 1.96-5.87, P<0.001) as compared to the tested population. CONCLUSIONS Older men who underwent no PSA testing or incomplete testing were significantly more likely to be diagnosed with high-risk prostate cancer than those who were previously screened. It is reasonable to consider screening in healthy older men likely to benefit from early detection and treatment.
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Affiliation(s)
- J J Tosoian
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - R Alam
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - C Gergis
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - A Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - N Radwan
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - S Robertson
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - T McNutt
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - A E Ross
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - D Y Song
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - T L DeWeese
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - P T Tran
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - P C Walsh
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Leung D, Narang A, Minard C, Hiremath G, Goss J, Shepherd R. A 10-Year united network for organ sharing review of mortality and risk factors in young children awaiting liver transplantation. Liver Transpl 2016; 22:1584-1592. [PMID: 27541809 PMCID: PMC5083224 DOI: 10.1002/lt.24605] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 08/04/2016] [Indexed: 12/21/2022]
Abstract
Young children < 2 years of age with chronic end-stage liver disease (YC2) are a uniquely vulnerable group listed for liver transplantation, characterized by a predominance of biliary atresia (BA). To investigate wait-list mortality, associated risk factors, and outcomes of YC2, we evaluated United Network for Organ Sharing registry data from April 2003 to March 2013 for YC2 listed for deceased donor transplant (BA = 994; other chronic liver disease [CLD] = 221). Overall, wait-list mortality among YC2 was 12.4% and posttransplant mortality was 8%, accounting for an overall postlisting mortality of 19.6%. YC2 demonstrated 12.2%, 18.7%, and 20.6% wait-list mortality by 90, 180, and 270 days, respectively. YC2 with CLD demonstrated significantly higher wait-list mortality compared with BA among YC2 (23.9% versus 9.8%; P < 0.05). Multivariate analyses revealed that listing Pediatric End-Stage Liver Disease [PELD] > 21 (hazard ratio [HR], 3.2; 95% confidence interval [CI], 1.6-6.5), lack of exception (HR, 5.8; 95% CI, 2.8-11.8), listing height < 60.6 cm (HR, 2.1; 95% CI, 1.4-3.1), listing weight > 10 kg (HR, 3.8; 95% CI, 1.5-9.2), and initial creatinine > 0.5 (HR, 6.8; 95% CI, 3.4-13.5) were independent risk factors for YC2 wait-list mortality (P < 0.005 for all). Adjusting for all variables, the risk of death among CLD patients was 2 (95% CI, 1.3-3.1) times greater than patients with BA + surgery (presumed Kasai). Furthermore, the risk of death in BA without surgery was 1.9 (95% CI, 1‐3.4) times greater than BA with presumed Kasai. Our data highlight unacceptably high wait-list and early post-liver transplant mortality in YC2 not predicted by PELD and suggest key risk factors deserving of further study in this age group. Liver Transplantation 22 1584-1592 2016 AASLD.
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Affiliation(s)
- D.H. Leung
- Department of Pediatrics, Baylor College of Medicine, Houston, TX,Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Texas Children's Hospital, Houston, TX
| | - A. Narang
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - C.G. Minard
- Dan L. Duncan Institute for Clinical and Translational Research, Houston, TX
| | - G. Hiremath
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - J.A. Goss
- Division of Abdominal Transplant Surgery, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, United States
| | - R. Shepherd
- Department of Pediatrics, Baylor College of Medicine, Houston, TX,Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Texas Children's Hospital, Houston, TX
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Peng L, Cheng Z, Rosati L, Narang A, Chen L, Moore J, Hooker T, Jackson J, Herman J, McNutt T. Dosimetric Constraints in Stereotactic Body Radiation Therapy for Locally Advanced Pancreatic Cancer: Capacity for Dose Escalation. Int J Radiat Oncol Biol Phys 2016. [DOI: 10.1016/j.ijrobp.2016.06.2189] [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: 10/20/2022]
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Chen L, Cao Y, Narang A, Cheng Z, Rosati L, Mian O, Robertson S, McNutt T, Hacker-Prietz A, Herman J. Neoadjuvant Stereotactic Body Radiation Therapy Dosimetric Parameters Predict for Pathologic Outcomes and Survival in Pancreas Adenocarcinoma. Int J Radiat Oncol Biol Phys 2016. [DOI: 10.1016/j.ijrobp.2016.06.1127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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