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Chuong MD, Lee P, Low DA, Kim J, Mittauer KE, Bassetti MF, Glide-Hurst CK, Raldow AC, Yang Y, Portelance L, Padgett KR, Zaki B, Zhang R, Kim H, Henke LE, Price AT, Mancias JD, Williams CL, Ng J, Pennell R, Raphael Pfeffer M, Levin D, Mueller AC, Mooney KE, Kelly P, Shah AP, Boldrini L, Placidi L, Fuss M, Jitendra Parikh P. Stereotactic MR-guided on-table adaptive radiation therapy (SMART) for borderline resectable and locally advanced pancreatic cancer: A multi-center, open-label phase 2 study. Radiother Oncol 2024; 191:110064. [PMID: 38135187 DOI: 10.1016/j.radonc.2023.110064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 12/03/2023] [Accepted: 12/11/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND AND PURPOSE Radiation dose escalation may improve local control (LC) and overall survival (OS) in select pancreatic ductal adenocarcinoma (PDAC) patients. We prospectively evaluated the safety and efficacy of ablative stereotactic magnetic resonance (MR)-guided adaptive radiation therapy (SMART) for borderline resectable (BRPC) and locally advanced pancreas cancer (LAPC). The primary endpoint of acute grade ≥ 3 gastrointestinal (GI) toxicity definitely related to SMART was previously published with median follow-up (FU) 8.8 months from SMART. We now present more mature outcomes including OS and late toxicity. MATERIALS AND METHODS This prospective, multi-center, single-arm open-label phase 2 trial (NCT03621644) enrolled 136 patients (LAPC 56.6 %; BRPC 43.4 %) after ≥ 3 months of any chemotherapy without distant progression and CA19-9 ≤ 500 U/mL. SMART was delivered on a 0.35 T MR-guided system prescribed to 50 Gy in 5 fractions (biologically effective dose10 [BED10] = 100 Gy). Elective coverage was optional. Surgery and chemotherapy were permitted after SMART. RESULTS Mean age was 65.7 years (range, 36-85), induction FOLFIRINOX was common (81.7 %), most received elective coverage (57.4 %), and 34.6 % had surgery after SMART. Median FU was 22.9 months from diagnosis and 14.2 months from SMART, respectively. 2-year OS from diagnosis and SMART were 53.6 % and 40.5 %, respectively. Late grade ≥ 3 toxicity definitely, probably, or possibly attributed to SMART were observed in 0 %, 4.6 %, and 11.5 % patients, respectively. CONCLUSIONS Long-term outcomes from the phase 2 SMART trial demonstrate encouraging OS and limited severe toxicity. Additional prospective evaluation of this novel strategy is warranted.
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Affiliation(s)
- Michael D Chuong
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL, United States.
| | - Percy Lee
- City of Hope National Medical Center, Los Angeles, CA, United States
| | - Daniel A Low
- UCLA Department of Radiation Oncology, Los Angeles, CA, United States
| | - Joshua Kim
- Henry Ford Health - Cancer, Detroit, MI, United States
| | - Kathryn E Mittauer
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL, United States
| | - Michael F Bassetti
- University of Wisconsin-Madison, Department of Human Oncology, Madison, WI, United States
| | - Carri K Glide-Hurst
- University of Wisconsin-Madison, Department of Human Oncology, Madison, WI, United States
| | - Ann C Raldow
- Department of Radiation Oncology, UCLA David Geffen School of Medicine, Los Angeles, CA, United States
| | - Yingli Yang
- Department of Radiation Oncology, UCLA David Geffen School of Medicine, Los Angeles, CA, United States
| | - Lorraine Portelance
- Sylvester Comprehensive Cancer Center, Miller School of Medicine, Miami, FL, United States
| | - Kyle R Padgett
- Sylvester Comprehensive Cancer Center, Miller School of Medicine, Miami, FL, United States
| | - Bassem Zaki
- Section of Radiation Oncology Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States
| | - Rongxiao Zhang
- Section of Radiation Oncology Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States
| | - Hyun Kim
- Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Lauren E Henke
- Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Alex T Price
- Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Joseph D Mancias
- Brigham and Women's Hospital, Department of Radiation Oncology, Dana-Farber Cancer Institute, Department of Radiation Oncology, Harvard Medical School, Boston, MA, United States
| | - Christopher L Williams
- Brigham and Women's Hospital, Department of Radiation Oncology, Dana-Farber Cancer Institute, Department of Radiation Oncology, Harvard Medical School, Boston, MA, United States
| | - John Ng
- Weill Cornell Medicine Sandra and Edward Meyer Cancer Center, New York, NY, United States
| | - Ryan Pennell
- Weill Cornell Medicine Sandra and Edward Meyer Cancer Center, New York, NY, United States
| | | | - Daphne Levin
- Assuta Medical Center, Tel Aviv, IL, United States
| | - Adam C Mueller
- Department of Radiation Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States
| | - Karen E Mooney
- Department of Radiation Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States
| | - Patrick Kelly
- Orlando Health Cancer Institute, Orlando, FL, United States
| | - Amish P Shah
- Orlando Health Cancer Institute, Orlando, FL, United States
| | - Luca Boldrini
- Department of Radiology, Radiation Oncology and Hematology, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Lorenzo Placidi
- Department of Radiology, Radiation Oncology and Hematology, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
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Parikh PJ, Lee P, Low DA, Kim J, Mittauer KE, Bassetti MF, Glide-Hurst CK, Raldow AC, Yang Y, Portelance L, Padgett KR, Zaki B, Zhang R, Kim H, Henke LE, Price AT, Mancias JD, Williams CL, Ng J, Pennell R, Pfeffer MR, Levin D, Mueller AC, Mooney KE, Kelly P, Shah AP, Boldrini L, Placidi L, Fuss M, Chuong MD. A Multi-Institutional Phase 2 Trial of Ablative 5-Fraction Stereotactic Magnetic Resonance-Guided On-Table Adaptive Radiation Therapy for Borderline Resectable and Locally Advanced Pancreatic Cancer. Int J Radiat Oncol Biol Phys 2023; 117:799-808. [PMID: 37210048 DOI: 10.1016/j.ijrobp.2023.05.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 05/04/2023] [Accepted: 05/13/2023] [Indexed: 05/22/2023]
Abstract
PURPOSE Magnetic resonance (MR) image guidance may facilitate safe ultrahypofractionated radiation dose escalation for inoperable pancreatic ductal adenocarcinoma. We conducted a prospective study evaluating the safety of 5-fraction Stereotactic MR-guided on-table Adaptive Radiation Therapy (SMART) for locally advanced (LAPC) and borderline resectable pancreatic cancer (BRPC). METHODS AND MATERIALS Patients with LAPC or BRPC were eligible for this multi-institutional, single-arm, phase 2 trial after ≥3 months of systemic therapy without evidence of distant progression. Fifty gray in 5 fractions was prescribed on a 0.35T MR-guided radiation delivery system. The primary endpoint was acute grade ≥3 gastrointestinal (GI) toxicity definitely attributed to SMART. RESULTS One hundred thirty-six patients (LAPC 56.6%, BRPC 43.4%) were enrolled between January 2019 and January 2022. Mean age was 65.7 (36-85) years. Head of pancreas lesions were most common (66.9%). Induction chemotherapy mostly consisted of (modified)FOLFIRINOX (65.4%) or gemcitabine/nab-paclitaxel (16.9%). Mean CA19-9 after induction chemotherapy and before SMART was 71.7 U/mL (0-468). On-table adaptive replanning was performed for 93.1% of all delivered fractions. Median follow-up from diagnosis and SMART was 16.4 and 8.8 months, respectively. The incidence of acute grade ≥3 GI toxicity possibly or probably attributed to SMART was 8.8%, including 2 postoperative deaths that were possibly related to SMART in patients who had surgery. There was no acute grade ≥3 GI toxicity definitely related to SMART. One-year overall survival from SMART was 65.0%. CONCLUSIONS The primary endpoint of this study was met with no acute grade ≥3 GI toxicity definitely attributed to ablative 5-fraction SMART. Although it is unclear whether SMART contributed to postoperative toxicity, we recommend caution when pursuing surgery, especially with vascular resection after SMART. Additional follow-up is ongoing to evaluate late toxicity, quality of life, and long-term efficacy.
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Affiliation(s)
| | - Percy Lee
- City of Hope National Medical Center, Los Angeles, California
| | - Daniel A Low
- Department of Radiation Oncology, University of California, Los Angeles, California
| | - Joshua Kim
- Henry Ford Health - Cancer, Detroit, Michigan
| | | | - Michael F Bassetti
- Department of Human Oncology, University of Wisconsin-Madison, Madison, Wisconsin
| | - Carri K Glide-Hurst
- Department of Human Oncology, University of Wisconsin-Madison, Madison, Wisconsin
| | - Ann C Raldow
- Department of Radiation Oncology, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Yingli Yang
- Department of Radiation Oncology, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Lorraine Portelance
- Sylvester Comprehensive Cancer Center, Miller School of Medicine, Miami, Florida
| | - Kyle R Padgett
- Sylvester Comprehensive Cancer Center, Miller School of Medicine, Miami, Florida
| | - Bassem Zaki
- Section of Radiation Oncology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Rongxiao Zhang
- Section of Radiation Oncology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Hyun Kim
- Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Lauren E Henke
- Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Alex T Price
- Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Joseph D Mancias
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Christopher L Williams
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - John Ng
- Weill Cornell Medicine Sandra and Edward Meyer Cancer Center, New York, New York
| | - Ryan Pennell
- Weill Cornell Medicine Sandra and Edward Meyer Cancer Center, New York, New York
| | | | | | - Adam C Mueller
- Department of Radiation Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Karen E Mooney
- Department of Radiation Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Amish P Shah
- Orlando Health Cancer Institute, Orlando, Florida
| | - Luca Boldrini
- Department of Radiology, Radiation Oncology and Hematology, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Lorenzo Placidi
- Department of Radiology, Radiation Oncology and Hematology, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | | | - Michael D Chuong
- Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
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Parikh P, Lee P, Low D, Kim J, Mittauer K, Bassetti M, Glide-Hurst C, Raldow A, Yang Y, Portelance L, Zaki B, Kim H, Mancias J, Ng J, Pfeffer R, Mueller A, Kelly P, Boldrini L, Fuss M, Chuong M. Stereotactic MR-Guided On-Table Adaptive Radiation Therapy (SMART) for Patients with Borderline or Locally Advanced Pancreatic Cancer: Primary Endpoint Outcomes of a Prospective Phase II Multi-Center International Trial. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Gill G, Williams B, Aviles M, Glynn T, Hunt B, Zhang R, Thomas C, Zaki B. Dosimetric Effect of Respiratory Phase in MR-Guided SBRT for Locally Advanced Pancreatic Cancer. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.1105] [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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Hunt B, Gill G, Alexander D, Streeter S, Gladstone D, Russo G, Zaki B, Pogue B, Zhang R. Real-Time Internal Motion Monitoring during Radiation Therapy Using Cine MRI and Deep Learning. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.2221] [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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Hunt B, Zaki B, Russo G, Gill G, Asher G, Prioleau T, Gladstone D, Pogue B, Zhang R. Deep Learning-Based Synthetic CT Generation for MR-Only Adaptive Radiation Therapy on MR-Linacs. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.2258] [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: 11/25/2022]
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Gill G, Hunt B, Rose M, Zhang R, Schaner P, Thomas C, Russo G, Zaki B. Automated Analysis of Treatment Log Files and Videos for MR-Guided Stereotactic Body Radiation Therapy Treatments of Thoracic and Abdominal Tumors. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.876] [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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Zhang R, Bruza P, Duval K, Cao X, Ashraf R, Rahman M, Gill G, Hartford A, Zaki B, Schaner P, Jarvis L, Hoopes P, Pogue B, Gladstone D. LOGISTICS OF A FLASH-RT PROGRAM IN CLINICAL SETTING. Phys Med 2022. [DOI: 10.1016/s1120-1797(22)01673-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Chuong M, Clark M, Henke L, Kishan A, Portelance L, Parikh P, Nagar H, Rosenberg S, Mehta M, Abdelrhman T, Smith A, Seung S, Zaki B, Mak R. Patterns of Utilization and Clinical Adoption of 0.35 MR-Guided Radiation Therapy in the United States — Understanding the Transition to Adaptive, Ultra-Hypofractionated Treatments. Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.1400] [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: 11/25/2022]
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Gadallah M, Zaki B, Rady M, Anwer W, Sallam I. Patient satisfaction with primary health care services in two districts in Lower and Upper Egypt. East Mediterr Health J 2021. [DOI: 10.26719/2003.9.3.422] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Thistudy compares patient satisfaction with primary health care services and identifies factors associated with patient satisfaction in two health districts in Egypt where a project for upgrading primary health care services had been running for three years. An exit interview was conducted for 1108 patients using a structured questionnaire. The results revealed that most clients using primary health care services were females. Patient satisfaction was high for accessibility, waiting area conditions and performance of doctors and nurses. The main complaints centred on the availability of prescribed drugs and laboratory investigations. Additionally, level of privacy in the consultation room was described as unsatisfactory by 33% of patients. There was no association between overall patient satisfaction and age, gender, education level or type of service received
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Chiorean EG, Nandakumar G, Fadelu T, Temin S, Alarcon-Rozas AE, Bejarano S, Croitoru AE, Grover S, Lohar PV, Odhiambo A, Park SH, Garcia ER, Teh C, Rose A, Zaki B, Chamberlin MD. Treatment of Patients With Late-Stage Colorectal Cancer: ASCO Resource-Stratified Guideline. JCO Glob Oncol 2021; 6:414-438. [PMID: 32150483 PMCID: PMC7124947 DOI: 10.1200/jgo.19.00367] [Citation(s) in RCA: 95] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE To provide expert guidance to clinicians and policymakers in resource-constrained settings on the management of patients with late-stage colorectal cancer. METHODS ASCO convened a multidisciplinary, multinational Expert Panel that reviewed existing guidelines, conducted a modified ADAPTE process, and used a formal consensus process with additional experts for two rounds of formal ratings. RESULTS Existing sets of guidelines from four guideline developers were identified and reviewed; adapted recommendations from five guidelines form the evidence base and provided evidence to inform the formal consensus process, which resulted in agreement of ≥ 75% on all recommendations. RECOMMENDATIONS Common elements of symptom management include addressing clinically acute situations. Diagnosis should involve the primary tumor and, in some cases, endoscopy, and staging should involve digital rectal exam and/or imaging, depending on resources available. Most patients receive treatment with chemotherapy, where chemotherapy is available. If, after a period of chemotherapy, patients become candidates for surgical resection with curative intent of both primary tumor and liver or lung metastatic lesions on the basis of evaluation in multidisciplinary tumor boards, the guidelines recommend patients undergo surgery in centers of expertise if possible. On-treatment surveillance includes a combination of taking medical history, performing physical examinations, blood work, and imaging; specifics, including frequency, depend on resource-based setting. Additional information is available at www.asco.org/resource-stratified-guidelines.
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Affiliation(s)
- E Gabriela Chiorean
- University of Washington, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Govind Nandakumar
- Columbia Asia Hospitals, Bangalore, India.,Weill Cornell Medical College, New York, NY
| | | | - Sarah Temin
- American Society of Clinical Oncology, Alexandria, VA
| | | | - Suyapa Bejarano
- Excelmedica, Liga Contra el Cancer Honduras, San Pedro Sulal, Honduras
| | | | | | | | - Andrew Odhiambo
- University of Nairobi, College of Health Sciences, Nairobi, Kenya
| | | | | | - Catherine Teh
- Philippine Association of HPB Surgeons/Makati Medical Center, Makati City, Philippines
| | - Azmina Rose
- Independent Colorectal Patient Representative, London, United Kingdom
| | - Bassem Zaki
- Dartmouth-Hitchcock Medical Center, Lebanon, NH
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van Assen M, De Cecco CN, Eid M, von Knebel Doeberitz P, Scarabello M, Lavra F, Bauer MJ, Mastrodicasa D, Duguay TM, Zaki B, Lo GG, Choe YH, Wang Y, Sahbaee P, Tesche C, Oudkerk M, Vliegenthart R, Schoepf UJ. Prognostic value of CT myocardial perfusion imaging and CT-derived fractional flow reserve for major adverse cardiac events in patients with coronary artery disease. J Cardiovasc Comput Tomogr 2019; 13:26-33. [PMID: 30796003 DOI: 10.1016/j.jcct.2019.02.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [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: 12/13/2018] [Accepted: 02/11/2019] [Indexed: 01/25/2023]
Abstract
OBJECTIVES The purpose of this study was to analyze the prognostic value of dynamic CT perfusion imaging (CTP) and CT derived fractional flow reserve (CT-FFR) for major adverse cardiac events (MACE). METHODS 81 patients from 4 institutions underwent coronary computed tomography angiography (CCTA) with dynamic CTP imaging and CT-FFR analysis. Patients were followed-up at 6, 12, and 18 months after imaging. MACE were defined as cardiac death, nonfatal myocardial infarction, unstable angina requiring hospitalization, or revascularization. CT-FFR was computed for each major coronary artery using an artificial intelligence-based application. CTP studies were analyzed per vessel territory using an index myocardial blood flow, the ratio between territory and global MBF. The prognostic value of CCTA, CT-FFR, and CTP was investigated with a univariate and multivariate Cox proportional hazards regression model. RESULTS 243 vessels in 81 patients were interrogated by CCTA with CT-FFR and 243 vessel territories (1296 segments) were evaluated with dynamic CTP imaging. Of the 81 patients, 25 (31%) experienced MACE during follow-up. In univariate analysis, a positive index-MBF resulted in the largest risk for MACE (HR 11.4) compared to CCTA (HR 2.6) and CT-FFR (HR 4.6). In multivariate analysis, including clinical factors, CCTA, CT-FFR, and index-MBF, only index-MBF significantly contributed to the risk of MACE (HR 10.1), unlike CCTA (HR 1.2) and CT-FFR (HR 2.2). CONCLUSION Our study provides initial evidence that dynamic CTP alone has the highest prognostic value for MACE compared to CCTA and CT-FFR individually or a combination of the three, independent of clinical risk factors.
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Affiliation(s)
- M van Assen
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA; University of Groningen, University Medical Center Groningen, Center for Medical Imaging - North East Netherlands, Groningen, the Netherlands.
| | - C N De Cecco
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA; Department of Radiology, Emory University, Atlanta, Georgia, USA.
| | - M Eid
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA.
| | - P von Knebel Doeberitz
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA.
| | - M Scarabello
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA.
| | - F Lavra
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA.
| | - M J Bauer
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA.
| | - D Mastrodicasa
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA.
| | - T M Duguay
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA.
| | - B Zaki
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA.
| | - G G Lo
- Department of Diagnostic and Interventional Radiology, Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong, China.
| | - Y H Choe
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Y Wang
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China.
| | | | - Christian Tesche
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA; Department of Cardiology and Intensive Care Medicine, Heart Center Munich-Bogenhausen, Munich, Germany.
| | - M Oudkerk
- University of Groningen, University Medical Center Groningen, Center for Medical Imaging - North East Netherlands, Groningen, the Netherlands.
| | - R Vliegenthart
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA; University of Groningen, University Medical Center Groningen, Center for Medical Imaging - North East Netherlands, Groningen, the Netherlands; University of Groningen, University Medical Center Groningen, Departments of Radiology, Groningen, the Netherlands.
| | - U J Schoepf
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA.
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Zhong H, van Soest J, Wang J, Valentini V, Geng H, Huang M, Cheng C, Garofalo M, Hong T, Lerma F, Keech J, Anne P, Perera F, Oldenburg N, Parikh P, DeNittis A, Zaki B, Nowlan A, Zhang B, Dekker A, Zhang Z, Xiao Y. External Validation of the European Rectal Cancer Prognosis Model Using NRG Oncology RTOG 0822 Clinical Trial Data. Int J Radiat Oncol Biol Phys 2017. [DOI: 10.1016/j.ijrobp.2017.06.1094] [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: 11/26/2022]
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14
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Bakhoum S, Kabeche L, Wood M, Suriawinata A, Louie R, Chan D, Petritsch C, Murnane J, Compton D, Zaki B. A Mitotic Pathway for Radiation-Induced Genome Damage. Int J Radiat Oncol Biol Phys 2013. [DOI: 10.1016/j.ijrobp.2013.06.1684] [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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15
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Zaki B, Suriawinata A, Bakhoum S. Chromosome Segregation Errors Predict Pathological Response of Rectal Adenocarcinoma to Chemoradiation. Int J Radiat Oncol Biol Phys 2013. [DOI: 10.1016/j.ijrobp.2013.06.486] [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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Hoffer EK, Krohmer S, Gemery J, Zaki B, Pipas JM. Endovascular recanalization of symptomatic portomesenteric venous obstruction after pancreaticoduodenectomy and radiation. J Vasc Interv Radiol 2009; 20:1633-7. [PMID: 19854066 DOI: 10.1016/j.jvir.2009.09.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2009] [Revised: 08/24/2009] [Accepted: 09/01/2009] [Indexed: 01/21/2023] Open
Abstract
Intraoperative radiation therapy (RT) may improve outcomes after pancreaticoduodenectomy for periampullary cancer; however, there is a 20% risk of late portomesenteric venous obstruction. This retrospective study evaluated the percutaneous treatment of portomesenteric venous obstruction that occurred a mean of 10 months after pancreaticoduodenectomy and intraoperative RT. Five patients with medically refractory ascites and portomesenteric obstruction on computed tomographic angiography had successful recanalization with elimination of the pressure gradient and no procedural complications. One patient showed no improvement clinically. Recurrent ascites after stent occlusion was successfully treated in two patients. Percutaneous transhepatic recanalization appears to be a safe and effective therapy in this population.
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Affiliation(s)
- Eric K Hoffer
- Section of Vascular and Interventional Radiology, Dartmouth-Hitchcock Medical Center and Norris Cotton Cancer Center, One Medical Center Drive, Lebanon, NH 03756, USA.
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Ashamalla H, Zaki B, Mokhtar B, Lewis L, Lavaf A, Nasr H, Colella F, Dosik D, Krishnamurthy M, Saad N, Guriguis A. Fractionated stereotactic radiotherapy boost and weekly paclitaxel in malignant gliomas clinical and pharmacokinetics results. Technol Cancer Res Treat 2007; 6:169-76. [PMID: 17535024 DOI: 10.1177/153303460700600303] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Management of Malignant Gliomas continues to be a challenge. We prospectively studied the role of adding weekly Paclitaxel to Fractionated Stereotactic Radiation Therapy (FSRT) in the treatment of Malignant Gliomas. Twenty-three Glioblastoma Multiforme and two Anaplastic Astrocytoma were studied. Patients received 46 Gy at 2 Gy/fraction followed by a boost utilizing FSRT at a fraction of 2.5 Gy for 8 fractions. Paclitaxel is delivered concomitantly at 150 mg/m(2) weekly for six cycles. Eighteen patients had pharmacokinetic assays of Paclitaxel levels. All patients were followed until death or for a maximum of 36 months. The overall survival of the whole group was 14 months. The median survival for RPA prognostic classes III, IV, V, and VI were 20, 14, 12, and 11 months. Higher survival (14 months) was noted in the subtherapeutic phenytoin level group compared to 10 months in the therapeutic group (P=0.271). No grade 4 CTCAE (version 3.0) toxicities were observed. Enhanced survival was demonstrated with gross tumor resection (20.8 months), KPS > or =80 (18.7 months) and age < or =60 years (27 months) as compared to subtotal resection or biopsy (12.1 months, P< 0.005), KPS < or =70 (10.8 months, P=0. 005) and older age > 60 (10.46 months, P=0.006), respectively. Our study suggests that: i) the use of weekly Paclitaxel and FSRT in Gliomas is well tolerated with a survival of 14 months; ii) the regimen resulted in improvement of survival of RPA classes IV, V, VI; and iii) the use of FSRT boost may be studied with other chemotherapeutic agents to see if superior results can be attained.
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Affiliation(s)
- H Ashamalla
- Radiation Oncology, New York Methodist Hospital, Weill Medical College of Cornell University, 506 6th Street, Brooklyn, NY 11215, USA.
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Pipas JM, Zaki B, Suriawinata AA, Tsapakos MJ, Ripple GH, Colacchio TA, Sutton JE, Gordon SR, Kasibhatla MS, Barth RJ. Cetuximab, intensity-modulated radiotherapy (IMRT), and twice-weekly gemcitabine for pancreatic adenocarcinoma. J Clin Oncol 2006. [DOI: 10.1200/jco.2006.24.18_suppl.14056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
14056 Background: Epidermal growth factor receptor (EGFR) is over expressed in pancreatic cancer. Cetuximab is an EGFR-antagonist which has synergy with gemcitabine (gem) and radiation. Gem is a potent radiosensitizer. We are conducting a Phase II trial of cetuximab with IMRT and twice-weekly gem. Eligibility includes stage I-III adenocarcinoma, with EGFR staining by immunohistochemistry. Pretreatment evaluation includes chest/abdomen CT scan and laparoscopy. Methods: Cetuximab 400 mg/m2 IV load was given over two hours. One week later, treatment continued with weekly cetuximab 250mg/m2 IV over one hour, and gem 50mg/m2 IV twice-weekly for twelve doses, concurrent with IMRT given in 28 daily fractions to 54Gy. Cetuximab/gem was given prior to that day’s IMRT. GI prophylaxis was with a proton pump inhibitor. Patients were considered for resection 4–8 weeks following therapy. Results: Ten patients enrolled to date, median age 70 years (range 54–83). Ninety percent of tumors were EGFR positive (range 1+ to 3+). At presentation, three tumors were unresectable, three borderline resectable and four resectable. One patient was removed from study following cetuximab anaphylaxis. Eight patients experienced grade III-IV hematotoxicity. Two patients had ischemic stroke in the backdrop of infection, one from stent obstruction/cholangitis, the other during neutropenic fever. One of these patients (age 81) died. Autopsy revealed severe atherosclerotic disease and evidence of prior strokes. Eight patients were evaluable for response. No patient had local progression. One patient had liver metastases post treatment. Two patients (25%) exhibited partial response. All others had stable disease. EGFR over expression did not predict response. Six patients went on to margin (−) resection, including one patient each with borderline resectable and unresectable disease prior to therapy. At median follow up of 8.5 months, there were no recurrences. Conclusions: Therapy yields modest efficacy and high resectability rates in patients with pancreatic cancer. Downstaging of tumor can occur in some patients. Toxicity may in part reflect the elderly patient demographic. Planned accrual is 48 patients. [Table: see text]
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Affiliation(s)
- J. M. Pipas
- Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - B. Zaki
- Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | | | | | | | | | | | | | | | - R. J. Barth
- Dartmouth-Hitchcock Medical Center, Lebanon, NH
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Pipas JM, Barth RJ, Zaki B, Tsapakos MJ, Suriawinata AA, Bettmann MA, Cates JM, Ripple GH, Sutton JE, Gordon SR, McDonnell CE, Perez RP, Redfield N, Meyer LP, Marshall JF, Cole BF, Colacchio TA. Docetaxel/Gemcitabine Followed by Gemcitabine and External Beam Radiotherapy in Patients With Pancreatic Adenocarcinoma. Ann Surg Oncol 2005; 12:995-1004. [PMID: 16252135 DOI: 10.1245/aso.2005.04.503] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2005] [Accepted: 07/27/2005] [Indexed: 11/18/2022]
Abstract
BACKGROUND Pancreatic cancer remains highly lethal. Previous attempts with neoadjuvant therapy in this disease have been inconclusive, but a potential for benefit exists. We conducted a phase II trial of dose-intense docetaxel and gemcitabine followed by twice-weekly gemcitabine and external beam radiotherapy in patients with pancreatic adenocarcinoma. METHODS Patients with stage I to III disease were eligible. Docetaxel 65 mg/m(2) intravenously over 1 hour and gemcitabine 4000 mg/m(2) given intravenously over 30 minutes were given on days 1, 15, and 29. On day 43, radiotherapy was begun at 50.4 Gy with gemcitabine 50 mg/m(2) intravenously over 30 minutes twice weekly for 12 doses. After treatment, patients were considered for resection. RESULTS Twenty-four assessable patients were recruited onto the trial. All but one patient completed a full 12 weeks of therapy. Grade 3 and 4 hematological and nonhematological toxicities were common but manageable, and neutropenic fever did not occur. No patient had local tumor progression. Twelve patients (50%) responded by Response Evaluation Criteria in Solid Tumors Group (RECIST) criteria, including one radiographic complete response. Seventeen patients underwent resection after therapy. Margin-negative resections were performed in 13 patients, including 9 patients whose disease was borderline or unresectable before treatment. A treatment effect was seen in all resection specimens. There have been no local recurrences of tumor, and several patients remain alive without evidence of disease. CONCLUSIONS Docetaxel/gemcitabine followed by gemcitabine/radiotherapy is active in the treatment of pancreatic adenocarcinoma, with manageable toxicity. Tumor downstaging occurs in some patients to allow complete resection. Further investigation of this regimen is warranted.
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Affiliation(s)
- J Marc Pipas
- Gastrointestinal Oncology Program, Dartmouth-Hitchcock Medical Center/Norris Cotton Cancer Center, One Medical Center Drive, Lebanon, NH 03756, USA.
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Pipas JM, Barth RJ, Zaki B, Colacchio TA, Gordon SR, Sutton JE, Ripple GH, Tsapakos MJ, Cates JM, Perez RP. Docetaxel/gemcitabine followed by gemcitabine and radiotherapy in patients with pancreatic adenocarcinoma. J Clin Oncol 2004. [DOI: 10.1200/jco.2004.22.90140.4109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- J. M. Pipas
- Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - R. J. Barth
- Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - B. Zaki
- Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | | | | | | | | | | | - J. M. Cates
- Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - R. P. Perez
- Dartmouth-Hitchcock Medical Center, Lebanon, NH
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Ashamalla H, Rafla S, Zaki B, Ikoro NC, Ross P. Radioactive gold grain implants in recurrent and locally advanced head-and-neck cancers. Brachytherapy 2004; 1:161-6. [PMID: 15090280 DOI: 10.1016/s1538-4721(02)00054-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2002] [Revised: 08/09/2002] [Accepted: 08/09/2002] [Indexed: 10/27/2022]
Abstract
PURPOSE The radioactive gold grain applicator and seeds offer the flexibility necessary for effective use in the treatment of difficult sites of head-and-neck cancers. This study reviews our experience with gold grain (198Au) implants in locally advanced head-and-neck cancer to demonstrate their efficacy and feasibility. METHODS AND MATERIALS This study reviewed the charts of 94 patients who were treated with gold grain implants (1970-1995) and who were treated with radioactive 198Au implants. Thirty-seven of the subjects had implants located in the head-and-neck region, and these form the basis for this report. Of these, eight of the cases were located in the supraglottic larynx, five in the nasopharynx, four in the retromolar trigone, two in the oral cavity, four in the base of the tongue, four in the maxillary antrum, four in the palate, two in metastatic cervical lymph nodes (of unknown primary tumor), two in the tonsillar fossa, one in the pyriform fossa, and one in the posterior pharyngeal wall. Twenty-eight were recurrent cases after prior surgeries and radiation. Six were residual locally advanced cases, and 3 patients had their implants for a second primary tumor in an area that had been irradiated before. The gold grains were inserted with a Royal Marsden gun and 198Au, 130-180 MBq per seed. The median number of seeds implanted was 34. The total radiation dose, delivered at a margin of 0.5 cm around the target volume, ranged from 40 to 120 Gy, with a median of 80 Gy. RESULTS Complete local control was achieved in 33% and was contingent on two factors: (1) the size of the lesion implanted and (2) the histology and possible primary tumor site. In 19 tumors with a diameter greater than 2.5 cm, only 2 (11%) had complete tumor control. Conversely, 9 of 14 patients (64%) who had lesions smaller than 2.5 cm experienced successful local control (p = 0.002). Palatal-adenoid-cystic tumors had an average progression-free survival of 52 months, compared with 13, 9, and 4 months, respectively, in nasopharyngeal, oropharyngeal, and supraglottic squamous cell carcinoma. Palliation was successfully accomplished in 76% of the cases. Cessation of bleeding occurred in 50% of the subjects, pain control was achieved in 88%, and 60% experienced relief of dysphagia. CONCLUSIONS Gold grain implants have a role in the palliation of recurrent head-and-neck tumors, particularly for sites difficult to reach via other techniques, such as the supraglottic larynx, base of the tongue, hypopharynx, and the nasopharynx. Local control is best achieved in lesions less than 2.5 cm in dimension and is most successful in slow-growing tumors.
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Affiliation(s)
- Hani Ashamalla
- Department of Radiation Oncology, New York Methodist Hospital, Weill Cornell Medical College, Brooklyn, NY 11215, USA.
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Ashamalla H, Zaki B, Nasr H, Colella F, Dosik D, Krishnamurthy M, Vance W, Saad N, Guriguis A. Phase I/II fractionated stereotactic radiotherapy and weekly paclitaxel in malignant gliomas. Int J Radiat Oncol Biol Phys 2003. [DOI: 10.1016/s0360-3016(03)01294-x] [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: 10/27/2022]
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Gadallah M, Zaki B, Rady M, Anwer W, Sallam I. Patient satisfaction with primary health care services in two districts in Lower and Upper Egypt. East Mediterr Health J 2003; 9:422-30. [PMID: 15751936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
This study compares patient satisfaction with primary health care services and identifies factors associated with patient satisfaction in two health districts in Egypt where a project for upgrading primary health care services had been running for three years. An exit interview was conducted for 1108 patients using a structured questionnaire. The results revealed that most clients using primary health care services were females. Patient satisfaction was high for accessibility, waiting area conditions and performance of doctors and nurses. The main complaints centred on the availability of prescribed drugs and laboratory investigations. Additionally, level of privacy in the consultation room was described as unsatisfactory by 33% of patients. There was no association between overall patient satisfaction and age, gender, education level or type of service received.
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Affiliation(s)
- M Gadallah
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Ashamalla H, Zaki B, Mokhtar B, Colella F, Selim H, Krishnamurthy M, Ross P. Hyperfractionated radiotherapy and paclitaxel for locally advanced/unresectable pancreatic cancer. Int J Radiat Oncol Biol Phys 2003; 55:679-87. [PMID: 12573755 DOI: 10.1016/s0360-3016(02)03791-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE To determine prospectively the maximal tolerated dose and potential antitumor activity of weekly paclitaxel with concurrent hyperfractionated radiotherapy in patients with locally advanced and/or unresectable pancreatic cancer. METHODS AND MATERIALS We embarked on Phase I-II study of hyperfractionated radiotherapy using a concomitant in-field boost to a total dose of 63.80 Gy in 6 weeks at 1.1 Gy/fraction. Paclitaxel was administered weekly on Days 1, 8, 15, 22, 29, and 36 as a 3-h infusion. Paclitaxel doses were escalated from 20 mg/m(2)/wk to 70 mg/m(2)/wk. Twenty patients were studied, 14 women and 6 men (mean age 64 years). Some patients presented with one or more symptoms. Obstructive jaundice was the main presenting symptom in 10 patients and epigastric pain in 14. All patients had unresectable histologically proven adenocarcinoma of the pancreas (15 head, 4 body, and 1 tail). Reasons for unresectability were involvement of the portal vein, and/or superior mesenteric artery (n = 14), paraaortic nodes (n = 8), and medically inoperable (n = 1). Fourteen patients underwent a biliary bypass procedure before treatment (four endoscopic stenting, five choledochojejunostomy, and five cholecystojejunostomy). The follow-up period ranged from 14 to 66 months (median 44). RESULTS The dose-limiting toxicity was observed at 70 mg/m(2)/wk. Grade IV Radiation Therapy Oncology Group late GI toxicity was seen in 1 patient in the form of duodenal stricture and hemorrhage. Grade II gastrointestinal adverse effects occurred in 13 patients and Grade 3 in 1 patient. No neurologic morbidity was encountered. Eight patients required cytokine support for Grade 2 and 3 neutropenia. The treatment course was delivered within the planned time in 80% of the patients. Complete relief of pain occurred in 10 of 14 patients. The CA 19-9 level was either stable or decreasing in 12 of 15 patients. Of 17 assessable patients, stable disease was seen in 10, regression in 2, a partial response in 3, and a complete response in 2. CONCLUSION The use of hyperfractionated radiotherapy to a dose of 63.80 Gy with concomitant weekly paclitaxel is tolerated. The maximal tolerated dose of paclitaxel for this study was 60 mg/m(2)/wk. The preliminary objective responses denote activity of the regimen. We recommend testing this regimen in larger scale studies.
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Affiliation(s)
- H Ashamalla
- Department of Radiation Oncology, New York Methodist Hospital, Weill Medical College, Brooklyn, NY 11215, USA.
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