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Semenkovich NP, Samson P, Badiyan SN, Vlacich GR, Stowe HB, Pellini B, Robinson CG, Chaudhuri AA. Circulating Tumor DNA for Early Risk Stratification of Oligometastatic Lung Cancer. Int J Radiat Oncol Biol Phys 2023; 117:S29-S30. [PMID: 37784469 DOI: 10.1016/j.ijrobp.2023.06.291] [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) Some patients with oligometastatic disease experience prolonged progression-free survival when treated with local consolidative radiotherapy (RT). Precisely identifying these patients remains challenging, however. We hypothesized that pre-RT liquid biopsy circulating tumor DNA (ctDNA) analysis could risk-stratify oligometastatic non-small-cell lung cancer (NSCLC) patients and enable earlier personalized selection for consolidative RT. MATERIALS/METHODS A real-world multi-institutional cohort of 1,487 patients who were diagnosed with oligometastatic NSCLC was analyzed. Each patient underwent liquid biopsy ctDNA analysis using the Tempus xF assay (v2) at least once, for a total of 1,880 ctDNA assays. 20% of the cohort (n = 309) underwent RT after liquid biopsy was obtained and oligometastatic NSCLC was diagnosed by the treating physician. Each patient in the sub-cohort of 309 patients had oligometastatic disease, defined as metastatic disease present in 1-5 organ systems. Outcomes for overall survival (OS) and progression-free survival (PFS) were defined with respect to the initiation time of RT to minimize the risk of guarantee-time bias. ctDNA results were analyzed for variants using VarDict and characterized as pathogenic or likely pathogenic following ACMG/AMP guidelines for variant classification, as determined by SnpEff. Variants considered benign, likely benign, or having conflicting evidence were excluded from consideration. RESULTS Overall survival was significantly worse in oligometastatic NSCLC patients with detectable ctDNA pre-RT, as compared to those without detectable ctDNA pre-RT, with a median OS of 16.8 months versus 25 months (p = 0.030, HR = 1.65, CI = 1.05-2.61). Similar findings were also observed for PFS, which was worse in patents with detectable ctDNA pre-RT, with a median PFS of 5.4 months versus 8.8 months (p = 0.004, HR = 1.57, CI = 1.15-2.13). ctDNA variant allele frequency (VAF) levels demonstrated significant risk correlations, with the maximum pre-RT ctDNA VAF associated with increased risk of both disease progression (p = 0.0084) and death (p = 0.0073). These findings were corroborated by multivariate Cox proportional hazards modeling for PFS (p = 0.02, PFS HR = 4.69, CI = 1.42-13.30) and OS (p = 0.004, HR = 5.66, CI = 1.64-16.85). Notably, multivariate Cox modeling did not show significant impacts of other clinical parameters, including gender, age at diagnosis, smoking status, and squamous histology. Additionally, the ctDNA mutational burden (the number of detectable pathogenic or likely pathogenic variants) was significantly associated with risk for both PFS (p = 0.003, HR = 1.16, CI = 1.06-1.26) and OS (p = 0.003, HR = 1.15, CI = 1.04-1.25) in a multivariate Cox regression model. CONCLUSION These data suggest that liquid biopsy ctDNA detection represents a powerful pre-RT biomarker to risk-stratify oligometastatic NSCLC patients and potentially enable personalized decision-making for local consolidative RT.
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Affiliation(s)
- N P Semenkovich
- Department of Medicine, Division of Endocrinology, Metabolism, and Lipid Research, Washington University School of Medicine, St. Louis, MO
| | - P Samson
- Washington University in St. Louis, St. Louis, MO
| | - S N Badiyan
- Washington University School of Medicine, Department of Radiation Oncology, St. Louis, MO
| | - G R Vlacich
- Washington University School of Medicine, Department of Radiation Oncology, St. Louis, MO
| | - H B Stowe
- Washington University School of Medicine, Department of Radiation Oncology, St. Louis, MO
| | | | - C G Robinson
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - A A Chaudhuri
- Washington University School of Medicine, Department of Radiation Oncology, St. Louis, MO
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Sigmund E, Laugeman E, Schiff JP, Schmidt M, Badiyan S, Robinson CG, Samson P. Temporospatial Feathering of Hot Spots for Computed Tomography-Guided Stereotactic Adaptive Radiotherapy (CT-STAR) for the Ultra-Central Thorax. Int J Radiat Oncol Biol Phys 2023; 117:e718-e719. [PMID: 37786096 DOI: 10.1016/j.ijrobp.2023.06.2224] [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) SBRT to the ultra-central thorax is limited by potential toxicity. It has been demonstrated that exposing proximal bronchial tree or pulmonary arteries to high dose per fraction (fx) treatment may induce bronchopulmonary hemorrhage, amongst other serious complications. Online adaptive radiotherapy is a technique that adjusts a treatment plan to the anatomy-of-the-day and benefits have been demonstrated in ultra-central thoracic disease. In addition, feathering is a treatment planning technique that generates several plans to avoid consistent organ-at-risk (OAR) doses throughout treatment. With daily adaptation, it may be possible to adjust the position of a hot spot (>120% prescription (Rx)) within the tumor each fx (temporospatial feathering) while respecting hard OAR constraints. We investigated the feasibility and plan quality of using CBCT-guided stereotactic adaptive radiotherapy (CT-STAR) for ultra-central lung tumors with hotspot temporospatial feathering. MATERIALS/METHODS Seven patients with ultra-central thoracic disease (6 patients with parenchymal tumors in contact with the trachea, proximal bronchial tree, great vessels, esophagus, or heart; 1 patient with a subcarinal lymph node) receiving standard of care radiotherapy were enrolled on an imaging study. An in-silico planning study first generated an SBRT plan (in silico Rx: 55 Gy in 5fx) that used a GTV_OPT (GTV minus OAR plus a safety margin) to optimize the location of the plan hotspot. Five spherical boost structures were manually created inside of the GTV_OPT structure. The same planning template was used except the boost structures were iteratively used in plan optimization instead of the GTV_OPT structure, to simulate the five CT-STAR fx hotspot temporospatially feathering. The five-plan composite was compared to the initial plan. RESULTS All plans generated met strict OAR constraints. Table 1 shows the mean difference in PTV, GTV, and OARs percent coverage by various isodose levels. Feathering the hotspot had negligible impact on target coverage by 50 Gy and 55 Gy isodose lines as well as OAR doses compared to the base SBRT plan. The feathered plan sum resulted in 14.7% increase in V66 Gy of the GTV. One patient saw a decrease in V66 Gy coverage to all target structures, though V50 Gy and V55 Gy were not affected. CONCLUSION We demonstrated the feasibility and utility of temporospatially adapting the hotspot for central lung SBRT, which safely increases the amount of tumor receiving more than 120% Rx.
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Affiliation(s)
- E Sigmund
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - E Laugeman
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO
| | - J P Schiff
- Washington University in St. Louis, St. Louis, MO
| | - M Schmidt
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - S Badiyan
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - C G Robinson
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - P Samson
- Washington University in St. Louis, St. Louis, MO
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Robinson CG, Contreras C, Moore KMS, Rentschler S, Schwarz JK, Bergom C, Knutson N, Prusator MT, Goddu SM, Hugo GD, Cuculich P, Samson P. Radiotherapy Dose as a Predictor of Outcomes Following Cardiac Radioablation for High-risk Refractory VT. Int J Radiat Oncol Biol Phys 2023; 117:e204. [PMID: 37784859 DOI: 10.1016/j.ijrobp.2023.06.1084] [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) Cardiac radioablation (CRA) is an emerging treatment for high-risk refractory ventricular tachycardia (VT). Despite a fixed prescription dose to the planning target volume (PTV) there is still considerable heterogeneity in the radiotherapy dose distribution due to planning technique, proximity to organs at risk, and radiation oncologist preference. The hypothesis is that plans with an inherently "hotter" internal dose to the PTV may lead to improved VT outcomes. MATERIALS/METHODS Single-center, IRB-approved retrospective case series of patients with refractory VT who had failed at least one prior CA (or were unfit for CA) treated with CRA. All patients were treated with a single fraction of 25 Gy prescribed to the PTV. Maximum dose to PTV was collected from each plan and stratified as high vs low above and below the median. Maximum dose was defined as the highest dose delivered to the "hottest" 0.035 cc of the PTV to avoid known variability in reporting of dose to single voxels within the treatment planning system. Rates of survival (OS), freedom from shock and/or storm (FFSS), and freedom from death, shock, and/or storm (FFDSS) were collected, and stratified by maximum dose to the PTV. Formal statistical comparisons were not performed due to limited patient numbers. RESULTS From 2015-2020, 22 patients were treated with CRA (18 with prior CA, 4 unfit for CA) for high-risk refractory VT. Median age was 64.5 years (range, 49-84), and 90.9% were male. 50% had ICM, with a median NYHA class of 3 (range, 1-4) and median EF of 25% (range, 15-58%). Median follow-up was 31.3 months. 2-year OS was 54.5%, FFSS was 42.4%, and FFDSS was 27.3%. Median maximum dose to the PTV was 42.2 Gy (range, 29.2-45.8 Gy). PTV maximum dose (high vs low) discriminated 2-year OS (63.6% vs 45.5%), FFSS (50% vs 30%) and FFDSS (36.4% vs 18.2%). For all endpoints, Kaplan-Meier curves overlapped for the first 6 months, and then diverged. CONCLUSION In patients with high-risk refractory VT treated with CRA, survival and VT outcomes were similar between both groups out to 6 months, with improved OS and VT control noted after that with higher maximum doses. With a prescription dose of 25 Gy to the PTV, adjusting planning parameters to maintain maximum doses > 42 Gy may improve durable outcomes and requires validation in a larger cohort.
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Affiliation(s)
- C G Robinson
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - C Contreras
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - K M S Moore
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - S Rentschler
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - J K Schwarz
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - C Bergom
- Washington University in St. Louis, St. Louis, MO
| | - N Knutson
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO
| | - M T Prusator
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - S M Goddu
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - G D Hugo
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - P Cuculich
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - P Samson
- Washington University in St. Louis, St. Louis, MO
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Liu W, Schiff JP, Beckert R, Kiser K, Kim T, Henke LE, Price AT, Kim H, Badiyan SN, Robinson CG, Samson P, Laugeman E. The Impact of Intra-Fraction Bowel Motion on Luminal Gastrointestinal Organ at Risk Dosimetry When Using Stereotactic Adaptive Radiotherapy for Abdominal Malignancies. Int J Radiat Oncol Biol Phys 2023; 117:e690. [PMID: 37786028 DOI: 10.1016/j.ijrobp.2023.06.2162] [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) Daily online adaptive radiotherapy (ART) provides inter-fraction motion management of the luminal gastrointestinal (GI) structures when delivering abdominal SBRT. One potential drawback of ART is the time-consuming process, and intra-fraction GI changes from completion of the ART process to the end of treatment delivery have not been thoroughly evaluated. We explored intra-fraction bowel motion for patients receiving abdominal stereotactic adaptive radiotherapy (sART) MATERIALS/METHODS: Six patients with abdominal malignancies treated with CT-guided sART on a prospective feasibility trial had additional CBCT's acquired post-treatment (pTx-CBCT). All patients were prescribed to 50 Gy/5 fractions (fx), and the constraint for all GI OARs was V33≤0.5 cc. Time from initial CBCT (I-CBCT) used for adaptive planning to pTx-CBCT was collected. The luminal GI OAR (stomach (S), duodenum (D), small bowel (SB), and large bowel (LB)) were retrospectively contoured on pTx-CBCT. The OAR doses were compared between the I-CBCT and pTx-CBCT. The adaptive plan (PA) and initial plan (PI) doses were overlayed on the pTx-CBCT contours. The PA pTx-CBCT OAR doses were then compared to the PI pTx-CBCT OAR doses. A Boolean OAR structure of all GI OARs was evaluated to remove potential differences in structure definitions between providers. The T-test was used to compare differences in instances of D0.5cc ≥ 33 and 50 Gy. Patient charts were reviewed for grades (G) ≥ 3 toxicity. RESULTS Thirty fractions (fx) of sART were delivered and pTx-CBCT were acquired in 26 fx. Mean time from I-CBCT to pTx-CBCT acquisition was 66 min (38-98 min). On average at 0.5 cc the PA overdosed the S by 1.74 Gy based on pTx-CBCT anatomy compared to 2.35 Gy by the PI, the D by 0.47 Gy (PA) vs .84 Gy (PI), the SB by 1.14 Gy (PA) vs 1.43 Gy (PI), and the LB by 0.13 Gy (PA) vs 0.60 Gy (PI). The dose to the Boolean OAR structure was on average 2.51 Gy/fx higher than expected when overlaying the PA on the pTx-CBCT compared to 3.38 Gy/fx higher when overlaying the PI on the pTx-CBCT. There was no significant difference in the instance of the PA exceeding D0.5 cc ≥33 Gy vs the PI (p = 0.083), but the PA significantly reduced the instances of D0.5cc≥50 Gy (p = 0.001) compared to the PI. No patient experienced G≥3 toxicity at a median follow-up of 8 months (3-12). CONCLUSION These data demonstrate sART led to a significant decrease in dose to GI OARs, particularly for prescription dose or greater, even after accounting for intra-fractional bowel motion. While both the PI and the PA violated the V33 luminal GI OAR constraint in approximately ½ of pTx-CBCTs, the fraction of OARs receiving at least 50 Gy was significantly higher when overlaying the PI compared to the PA. While no G3 toxicities were reported in this small cohort, further studies are needed to characterize if the increased dose to GI OARs over the expected dose is clinically significant.
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Affiliation(s)
- W Liu
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO
| | - J P Schiff
- Tulane University School of Medicine, New Orleans, LA
| | - R Beckert
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - K Kiser
- MD Anderson Cancer Center, Houston, TX
| | - T Kim
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO
| | - L E Henke
- University Hospitals, Department of Radiation Oncology, Case Western Reserve University, Cleveland, OH
| | - A T Price
- University Hospitals, Department of Radiation Oncology, Case Western Reserve University, Cleveland, OH
| | - H Kim
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO
| | - S N Badiyan
- Washington University School of Medicine, Department of Radiation Oncology, St. Louis, MO
| | - C G Robinson
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - P Samson
- Washington University in St. Louis, St. Louis, MO
| | - E Laugeman
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO
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Zhang DM, Szymanski J, Bergom C, Cuculich PS, Robinson CG, Schwarz JK, Rentschler SL. Leveraging Radiobiology for Arrhythmia Management: A New Treatment Paradigm? Clin Oncol (R Coll Radiol) 2021; 33:723-734. [PMID: 34535357 DOI: 10.1016/j.clon.2021.09.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 08/04/2021] [Accepted: 09/01/2021] [Indexed: 01/01/2023]
Abstract
Radiation therapy is a well-established approach for safely and non-invasively treating solid tumours and benign diseases with high precision and accuracy. Cardiac radiation therapy has recently emerged as a non-invasive treatment option for the management of refractory ventricular tachycardia. Here we summarise existing clinical and preclinical literature surrounding cardiac radiobiology and discuss how these studies may inform basic and translational research, as well as clinical treatment paradigms in the management of arrhythmias.
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Affiliation(s)
- D M Zhang
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, Missouri, USA
| | - J Szymanski
- Department of Radiation Oncology, Washington University in St. Louis, School of Medicine, Saint Louis, Missouri, USA
| | - C Bergom
- Department of Radiation Oncology, Washington University in St. Louis, School of Medicine, Saint Louis, Missouri, USA
| | - P S Cuculich
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, Missouri, USA; Department of Radiation Oncology, Washington University in St. Louis, School of Medicine, Saint Louis, Missouri, USA
| | - C G Robinson
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, Missouri, USA; Department of Radiation Oncology, Washington University in St. Louis, School of Medicine, Saint Louis, Missouri, USA
| | - J K Schwarz
- Department of Radiation Oncology, Washington University in St. Louis, School of Medicine, Saint Louis, Missouri, USA
| | - S L Rentschler
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, Missouri, USA; Department of Biomedical Engineering, Washington University in St. Louis, School of Medicine, Saint Louis, Missouri, USA; Department of Developmental Biology, Washington University in St. Louis, School of Medicine, Saint Louis, Missouri, USA.
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Vlacich G, Ballard A, Badiyan SN, Spraker M, Henke L, Kim H, Lockhart AC, Park H, Suresh R, Huang Y, Robinson CG, Bradley JD, Samson PP. A single-institution phase I feasibility study of dose-escalated IMRT for non-operative locally advanced esophageal carcinoma. Clin Transl Radiat Oncol 2021; 30:19-25. [PMID: 34278011 PMCID: PMC8267428 DOI: 10.1016/j.ctro.2021.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 06/18/2021] [Accepted: 06/24/2021] [Indexed: 12/29/2022] Open
Abstract
Dose escalation with IMRT to 60 Gy for esophageal cancer is feasible. Dose escalation with cisplatin/5-FU still results in significant toxicity. Improved local control, but comparable survival compared to historical controls. Pretreatment weight loss was found to be an independent predictor of poor survival. Our dose escalation study is one of few with predominant adenocarcinoma histology.
Background and purpose Radiation dose escalation to improve poor outcomes with chemoradiation in locally advanced esophageal carcinoma is limited in part by increased toxicity. This Phase I study investigates the use of IMRT to improve tolerability of dose escalation. Materials and methods A single-institution, prospective study was conducted between 2007 and 2013 for individuals with inoperable esophageal carcinoma. Gross disease received 60 Gy in 30 fractions and at-risk sites received 54 Gy with simultaneous integrated boost. Concurrent chemotherapy primarily consisted of cisplatin/5-FU. The primary objective was to assess feasibility (<15% rate of grade 4–5 toxicity). Secondary objectives included assessment of overall survival (OS), progression free survival (PFS), and locoregional (LRR) and distant recurrence. Results Twenty-six patients were enrolled with median follow up of 17.6 months (range 0.1 to 152.0). The majority were AJCC 7th edition Stage III (54%), distal esophagus primary (81%), and adenocarcinoma histology (85%). Twenty-one patients (81%) completed their course of radiation therapy, while only 55% received 2 cycles of concurrent cisplatin/5-FU. One grade 5 and one grade 4 cardiac event occurred, both during chemoradiation and before receiving 50 Gy. The 3-year OS was 48.6% (95% CI: 32.5 to 72.2%) and PFS was 28.5% (95% CI: 14.6 to 55.5%). Half developed distant failure with LRR occurring in 10 patients (38%), isolated in 5 patients. Conclusion While feasibility was demonstrated, toxicity and compliance remained limiting factors with outcomes similar to historical controls. There remains an uncertain role for dose escalation in definitive management of locally advanced esophageal cancer.
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Affiliation(s)
- Gregory Vlacich
- Department of Radiation Oncology, Washington University, St. Louis, MO, United States
| | - Andrew Ballard
- Southern Illinois University-Edwardsville, Edwardsville, IL, United States
| | - Shahed N Badiyan
- Department of Radiation Oncology, Washington University, St. Louis, MO, United States
| | - Matthew Spraker
- Department of Radiation Oncology, Washington University, St. Louis, MO, United States
| | - Lauren Henke
- Department of Radiation Oncology, Washington University, St. Louis, MO, United States
| | - Hyun Kim
- Department of Radiation Oncology, Washington University, St. Louis, MO, United States
| | - A Craig Lockhart
- Department of Medicine, Division of Oncology, Washington University, St. Louis, MO, United States
| | - Haeseong Park
- Department of Medicine, Division of Oncology, Washington University, St. Louis, MO, United States
| | - Rama Suresh
- Department of Medicine, Division of Oncology, Washington University, St. Louis, MO, United States
| | - Yi Huang
- Department of Radiation Oncology, Washington University, St. Louis, MO, United States
| | - Cliff G Robinson
- Department of Radiation Oncology, Washington University, St. Louis, MO, United States
| | - Jeffrey D Bradley
- Department of Radiation Oncology, Washington University, St. Louis, MO, United States
| | - Pamela P Samson
- Department of Radiation Oncology, Washington University, St. Louis, MO, United States
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Timmerman RD, Paulus R, Pass HI, Gore EM, Edelman MJ, Galvin J, Straube WL, Nedzi LA, McGarry RC, Robinson CG, Schiff PB, Chang G, Loo BW, Bradley JD, Choy H. Stereotactic Body Radiation Therapy for Operable Early-Stage Lung Cancer: Findings From the NRG Oncology RTOG 0618 Trial. JAMA Oncol 2019; 4:1263-1266. [PMID: 29852037 DOI: 10.1001/jamaoncol.2018.1251] [Citation(s) in RCA: 226] [Impact Index Per Article: 45.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Stereotactic body radiation therapy (SBRT) has become a standard treatment for patients with medically inoperable early-stage lung cancer. However, its effectiveness in patients medically suitable for surgery is unclear. Objective To evaluate whether noninvasive SBRT delivered on an outpatient basis can safely eradicate lung cancer and cure selected patients with operable lung cancer, obviating the need for surgical resection. Design, Setting, and Participants Single-arm phase 2 NRG Oncology Radiation Therapy Oncology Group 0618 study enrolled patients from December 2007 to May 2010 with median follow-up of 48.1 months (range, 15.4-73.7 months). The setting was a multicenter North American academic and community practice cancer center consortium. Patients had operable biopsy-proven peripheral T1 to T2, N0, M0 non-small cell tumors no more than 5 cm in diameter, forced expiratory volume in 1 second (FEV1) and diffusing capacity greater than 35% predicted, arterial oxygen tension greater than 60 mm Hg, arterial carbon dioxide tension less than 50 mm Hg, and no severe medical problems. The data analysis was performed in October 2014. Interventions The SBRT prescription dose was 54 Gy delivered in 3 18-Gy fractions over 1.5 to 2.0 weeks. Main Outcomes and Measures Primary end point was primary tumor control, with survival, adverse events, and the incidence and outcome of surgical salvage as secondary end points. Results Of 33 patients accrued, 26 were evaluable (23 T1 and 3 T2 tumors; 15 [58%] male; median age, 72.5 [range, 54-88] years). Median FEV1 and diffusing capacity of the lung for carbon monoxide at enrollment were 72.5% (range, 38%-136%) and 68% (range, 22%-96%) of predicted, respectively. Only 1 patient had a primary tumor recurrence. Involved lobe failure, the other component defining local failure, did not occur in any patient, so the estimated 4-year primary tumor control and local control rate were both 96% (95% CI, 83%-100%). As per protocol guidelines, the single patient with local recurrence underwent salvage lobectomy 1.2 years after SBRT, complicated by a grade 4 cardiac arrhythmia. The 4-year estimates of disease-free and overall survival were 57% (95% CI, 36%-74%) and 56% (95% CI, 35%-73%), respectively. Median overall survival was 55.2 months (95% CI, 37.7 months to not reached). Protocol-specified treatment-related grade 3, 4, and 5 adverse events were reported in 2 (8%; 95% CI, 0.1%-25%), 0, and 0 patients, respectively. Conclusions and Relevance As given, SBRT appears to be associated with a high rate of primary tumor control, low treatment-related morbidity, and infrequent need for surgical salvage in patients with operable early-stage lung cancer. Trial Registration ClinicalTrials.gov Identifier: NCT00551369.
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Affiliation(s)
- Robert D Timmerman
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas.,Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas
| | - Rebecca Paulus
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | - Harvey I Pass
- Department of Cardiothoracic Surgery, New York University School of Medicine, New York
| | - Elizabeth M Gore
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee
| | - Martin J Edelman
- Department of Hematology/Oncology, University of Maryland, Marlene and Stewart Greenebaum Cancer Center, Baltimore.,now with Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - James Galvin
- Imaging and Radiation Oncology Core (IROC), Philadelphia, Pennsylvania
| | | | - Lucien A Nedzi
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas
| | - Ronald C McGarry
- Department of Radiation Oncology, University of Kentucky, Lexington
| | - Cliff G Robinson
- Department of Radiation Oncology, Washington University in St Louis, St Louis, Missouri
| | - Peter B Schiff
- Department of Radiation Oncology, New York University School of Medicine, New York
| | - Garrick Chang
- Sutter General Hospital accrual under Mercy San Juan Radiation Oncology Center, Carmichael, California
| | - Billy W Loo
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Jeffrey D Bradley
- Department of Radiation Oncology, Washington University in St Louis, St Louis, Missouri
| | - Hak Choy
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas
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Blumenthal DT, Won M, Mehta MP, Gilbert MR, Brown PD, Bokstein F, Brachman DG, Werner-Wasik M, Hunter GK, Valeinis E, Hopkins K, Souhami L, Howard SP, Lieberman FS, Shrieve DC, Wendland MM, Robinson CG, Zhang P, Corn BW. Short delay in initiation of radiotherapy for patients with glioblastoma-effect of concurrent chemotherapy: a secondary analysis from the NRG Oncology/Radiation Therapy Oncology Group database. Neuro Oncol 2019; 20:966-974. [PMID: 29462493 DOI: 10.1093/neuonc/noy017] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background We previously reported the unexpected finding of significantly improved survival for newly diagnosed glioblastoma in patients when radiation therapy (RT) was initiated later (>4 wk post-op) compared with earlier (≤2 wk post-op). In that analysis, data were analyzed from 2855 patients from 16 NRG Oncology/Radiotherapy Oncology Group (RTOG) trials conducted prior to the era of concurrent temozolomide (TMZ) with RT. We now report on 1395 newly diagnosed glioblastomas from 2 studies, treated with RT and concurrent TMZ followed by adjuvant TMZ. Our hypothesis was that concurrent TMZ has a synergistic/radiosensitizing mechanism, making RT timing less significant. Methods Data from patients treated with TMZ-based chemoradiation from NRG Oncology/RTOG 0525 and 0825 were analyzed. An analysis comparable to our prior study was performed to determine whether there was still an impact on survival by delaying RT. Overall survival (OS) was investigated using the Kaplan-Meier method and Cox proportional hazards model. Early progression (during time of diagnosis to 30 days after RT completion) was analyzed using the chi-square test. Results Given the small number of patients who started RT early following surgery, comparisons were made between >4 and ≤4 weeks delay of radiation from time of operation. There was no statistically significant difference in OS (hazard ratio = 0.93; P = 0.29; 95% CI: 0.80-1.07) after adjusting for known prognostic factors (recursive partitioning analysis and O6-methylguanine-DNA methyltransferase methylation status). Similarly, the rate of early progression did not differ significantly (P = 0.63). Conclusions We did not observe a significant prognostic influence of delaying radiation when given concurrently with TMZ for newly diagnosed glioblastoma. The effects of early (1-3 wk post-op) or late (>5 wk) initiation of radiation tested in our prior study could not be replicated.
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Affiliation(s)
| | - Minhee Won
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania, USA
| | | | - Mark R Gilbert
- National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Paul D Brown
- University of Texas-MD Anderson Cancer Center, Houston, Texas, USA.,Mayo Clinic, Rochester, Minnesota, USA
| | | | - David G Brachman
- Saint Joseph's Hospital and Medical Center ACCRUALS for Arizona Oncology Services Foundation, Phoenix, Arizona, USA
| | | | | | - Egils Valeinis
- Paulus Stradins Clinical University Hospital-EORTC, Riga, Latvia
| | | | | | | | | | - Dennis C Shrieve
- University of Utah Health Science Center, Salt Lake City, Utah, USA
| | | | | | - Peixin Zhang
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania, USA
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9
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Badiyan SN, Robinson CG, Bradley JD. Radiation Toxicity in Lung Cancer Patients: The Heart of the Problem? Int J Radiat Oncol Biol Phys 2019; 104:590-592. [DOI: 10.1016/j.ijrobp.2019.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 03/01/2019] [Accepted: 03/04/2019] [Indexed: 12/25/2022]
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10
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Abstract
Definitive treatment of locally advanced non-small-cell lung cancer with radiation is challenging. During the course of treatment, anatomical changes such as tumor regression, tumor displacement/deformation, pleural effusion, and/or atelectasis can result in a deviation of the administered radiation dose from the intended prescribed treatment and thereby worsen local control and toxicity. Adaptive radiotherapy can help correct for these changes and can be generally categorized into 3 philosophical paradigms: (1) maintenance of prescribed dose to the initially defined target volume; (2) dose reduction to healthy organs while maintaining initial prescribed dose to a regressing tumor volume; or (3) dose escalation to a regressing tumor volume with isotoxicity to healthy organs. Numerous single institution studies have investigated these methods, and results from large prospective clinical trials will hopefully provide consensus on the method, utility, and efficacy of implementing adaptive radiation therapy (ART) in a clinical setting. Additional development into standardization and automation of the ART workflow, specifically in identifying when ART is warranted and in reducing the manual clinical effort needed to produce an adaptive plan, will be paramount to making ART feasible for the broader radiation therapy community.
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Affiliation(s)
- James Kavanaugh
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO
| | - Geoffrey Hugo
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO
| | - Cliff G Robinson
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO
| | - Michael C Roach
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO.
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11
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Henke LE, Contreras JA, Green OL, Cai B, Kim H, Roach MC, Olsen JR, Fischer-Valuck B, Mullen DF, Kashani R, Thomas MA, Huang J, Zoberi I, Yang D, Rodriguez V, Bradley JD, Robinson CG, Parikh P, Mutic S, Michalski J. Magnetic Resonance Image-Guided Radiotherapy (MRIgRT): A 4.5-Year Clinical Experience. Clin Oncol (R Coll Radiol) 2018; 30:720-727. [PMID: 30197095 PMCID: PMC6177300 DOI: 10.1016/j.clon.2018.08.010] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 07/19/2018] [Accepted: 08/21/2018] [Indexed: 10/28/2022]
Abstract
AIMS Magnetic resonance image-guided radiotherapy (MRIgRT) has been clinically implemented since 2014. This technology offers improved soft-tissue visualisation, daily imaging, and intra-fraction real-time imaging without added radiation exposure, and the opportunity for adaptive radiotherapy (ART) to adjust for anatomical changes. Here we share the longest single-institution experience with MRIgRT, focusing on trends and changes in use over the past 4.5 years. MATERIALS AND METHODS We analysed clinical information, including patient demographics, treatment dates, disease sites, dose/fractionation, and clinical trial enrolment for all patients treated at our institution using MRIgRT on a commercially available, integrated 0.35 T MRI, tri-cobalt-60 device from 2014 to 2018. For each patient, factors including disease site, clinical rationale for MRIgRT use, use of ART, and proportion of fractions adapted were summated and compared between individual years of use (2014-2018) to identify shifts in institutional practice patterns. RESULTS Six hundred and forty-two patients were treated with 666 unique treatment courses using MRIgRT at our institution between 2014 and 2018. Breast cancer was the most common disease, with use of cine MRI gating being a particularly important indication, followed by abdominal sites, where the need for cine gating and use of ART drove MRIgRT use. One hundred and ninety patients were treated using ART in 1550 fractions, 67.6% (1050) of which were adapted. ART was primarily used in cancers of the abdomen. Over time, breast and gastrointestinal cancers became increasingly dominant for MRIgRT use, hypofractionated treatment courses became more popular, and gastrointestinal cancers became the principal focus of ART. DISCUSSION MRIgRT is widely applicable within the field of radiation oncology and new clinical uses continue to emerge. At our institution to date, applications such as ART for gastrointestinal cancers and accelerated partial breast irradiation (APBI) for breast cancer have become dominant indications, although this is likely to continue to evolve.
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Affiliation(s)
- L E Henke
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - J A Contreras
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - O L Green
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - B Cai
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - H Kim
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - M C Roach
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - J R Olsen
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - B Fischer-Valuck
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - D F Mullen
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - R Kashani
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - M A Thomas
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - J Huang
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - I Zoberi
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - D Yang
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - V Rodriguez
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - J D Bradley
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - C G Robinson
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - P Parikh
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - S Mutic
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - J Michalski
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA.
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12
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DeWees TA, Nikitas J, Rehman S, Bradley JD, Robinson CG, Roach MC. Defining Optimal Comorbidity Measures for Patients With Early-Stage Non-small cell lung cancer Treated With Stereotactic Body Radiation Therapy. Pract Radiat Oncol 2018; 9:e83-e89. [PMID: 30244094 DOI: 10.1016/j.prro.2018.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 08/21/2018] [Accepted: 09/11/2018] [Indexed: 12/11/2022]
Abstract
PURPOSE Comparison of overall survival (OS) between stereotactic body radiation therapy (SBRT) and other treatments for early-stage non-small cell lung cancer is confounded by differences in age, performance status, and medical comorbidity. We sought to define the most robust measurement for this population among 5 indices: age, Eastern Cooperative Oncology Group performance status, Adult Comorbidity Evaluation 27, Charlson Comorbidity Index (CCI), and age-adjusted CCI (CCIa). METHODS AND MATERIALS A total of 548 patients with stage I non-small cell lung cancer treated with SBRT were analyzed. Patients were divided into high- and low-risk groups for OS for each index using the log-rank test. Continuous and dichotomized models were compared via Akaike information criterion and the Vuong test. Multivariate Cox regression modeling was used with demographic information to determine the independent prognostic value of the continuous and dichotomized versions of the indices. The best was used to stratify the patients into as many significantly different cohorts as possible. RESULTS Optimal cut-points between high-risk and low-risk OS groups for age, Eastern Cooperative Oncology Group status, Adult Comorbidity Evaluation 27, CCI, and CCIa were ≥75 years, ≥1, ≥3, ≥3, and ≥6 with hazard ratios for death of 1.23 (95% confidence interval, 1.00-1.50), 1.66 (1.28-2.15), 1.37 (1.12-1.67), 1.43 (1.17-1.76), and 1.47 (1.20-1.80), respectively. Dichotomizing did not result in a significant loss of prognostic power. Although there was no significant difference in prognostic power among the indices, CCIa best predicted OS. CCIa divided the patients into 3 cohorts with median OS of 42 months, 33 months, and 23 months for scores of ≤5, 6 to 7, and ≥8, respectively. CONCLUSIONS CCIa was the best indicator of OS in every model employed with no loss of prognostic power with dichotomization. Dichotomization of CCIa (≥6) could be implemented in future comparisons of SBRT with OS. No cohort could be identified with a median survival of less than a year, for which treatment could be deemed futile.
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Affiliation(s)
- Todd A DeWees
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Scottsdale, Arizona
| | - John Nikitas
- Department of Radiation Oncology, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Sana Rehman
- Department of Radiation Oncology, Summa Akron City Hospital, Akron, Ohio
| | - Jeffrey D Bradley
- Department of Radiation Oncology, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Cliff G Robinson
- Department of Radiation Oncology, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Michael C Roach
- Department of Radiation Oncology, Washington University in St Louis School of Medicine, St Louis, Missouri.
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13
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Roach MC, Bradley JD, Robinson CG. Optimizing radiation dose and fractionation for the definitive treatment of locally advanced non-small cell lung cancer. J Thorac Dis 2018; 10:S2465-S2473. [PMID: 30206492 DOI: 10.21037/jtd.2018.01.153] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Radiation therapy is the foundation for treatment of locally advanced non-small cell lung cancer (NSCLC), a disease that is often inoperable and has limited long term survival. Local control of disease is strongly linked to patient survival and continues to be problematic despite continued attempts at changing the dose and fractionation of radiation delivered. Technological advancements such as 4-dimensional computed tomography (CT) based planning, positron emission tomography (PET) based target delineation, and daily image guidance have allowed for ever more accurate and conformal treatments. A limit to dose escalation with conventional fractions of 2 Gy once per day appears to have been reached at 60 Gy in the randomized trial Radiation Therapy Oncology Group (RTOG) 0617. Higher doses were surprisingly associated with worse overall survival. Approaches other than conventional dose escalation have been explored to better control disease including accelerating treatment to limit tumor repopulation both with hyperfractionation and its multiple small (<2 Gy) fractions each day and with hypofractionation and its single larger (>2 Gy) fraction each day. These accelerated regimens are increasingly being used with concurrent chemotherapy, and multiple institutions have reported it as tolerable. Tailoring treatment to individual patient disease and normal anatomic characteristics has been explored with isotoxic dose escalation up to the tolerance of organs at risk, with both hyperfractionation and hypofractionation. Metabolic imaging during and after treatment is increasingly being used to boost doses to residual disease. Boost doses have included moderate hypofractionation of 2-4 Gy, and more recently extreme hypofractionation with stereotactic body radiation therapy (SBRT). In spite of all these changes in dose and fractionation, lung and cardiovascular toxicity remain obstacles that limit disease control and patient survival.
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Affiliation(s)
- Michael C Roach
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Jeffrey D Bradley
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Cliff G Robinson
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO, USA
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14
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Waqar SN, Samson PP, Robinson CG, Bradley J, Devarakonda S, Du L, Govindan R, Gao F, Puri V, Morgensztern D. Non-small-cell Lung Cancer With Brain Metastasis at Presentation. Clin Lung Cancer 2018; 19:e373-e379. [PMID: 29526531 PMCID: PMC6990432 DOI: 10.1016/j.cllc.2018.01.007] [Citation(s) in RCA: 128] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 01/15/2018] [Accepted: 01/24/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Data on the prevalence of brain metastases at presentation in patients with non-small-cell lung cancer (NSCLC) are limited. We queried the National Cancer Data Base to determine prevalence, clinical risk factors, and outcomes of patients with NSCLC presenting with brain metastases. PATIENTS AND METHODS Patients with NSCLC diagnosed between 2010 and 2012 were identified using the National Cancer Data Base. The risk of brain metastases for individual variables was summarized by odds ratios and calculated using logistic regression analysis. The Kaplan-Meier product limit method was used to calculate the median and 1-, 2-, and 3-year overall survival (OS). RESULTS Brain metastases were observed in 47,546 (10.4%) of the 457,481 patients with NSCLC overall. The prevalence of brain metastases was much higher (26%) in patients with stage IV disease at presentation. On multivariate analysis, younger age, adenocarcinoma or large cell histology, tumor size > 3 cm, tumor grade ≥ II, and node-positive disease were associated with brain metastases. The prevalence of brain metastases ranged from as low as 0.57% in patients with only 1 risk factor to as high as 22% in patients with all 5 risk factors. The median and 1-, 2-, and 3-year OS for patients with brain metastases were 6 months and 29.9%, 14.3%, and 8.4%, respectively, with the 3-year OS increasing to 36.2% in those with T1/2 and N0/1 undergoing surgery for the primary site. CONCLUSIONS In patients with NSCLC, the risk of brain metastases at presentation may be calculated based on 5 clinical variables. Selected patients with brain metastases at presentation may achieve prolonged benefit.
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Affiliation(s)
- Saiama N Waqar
- Division of Medical Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Pamela P Samson
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Cliff G Robinson
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Jeffrey Bradley
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Siddhartha Devarakonda
- Division of Medical Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Lingling Du
- Division of Medical Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Ramaswamy Govindan
- Division of Medical Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Feng Gao
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Varun Puri
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Daniel Morgensztern
- Division of Medical Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO.
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15
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Vlacich G, Samson PP, Perkins SM, Roach MC, Parikh PJ, Bradley JD, Lockhart AC, Puri V, Meyers BF, Kozower B, Robinson CG. Treatment utilization and outcomes in elderly patients with locally advanced esophageal carcinoma: a review of the National Cancer Database. Cancer Med 2017; 6:2886-2896. [PMID: 29139215 PMCID: PMC5727236 DOI: 10.1002/cam4.1250] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 10/06/2017] [Accepted: 10/09/2017] [Indexed: 11/30/2022] Open
Abstract
For elderly patients with locally advanced esophageal cancer, therapeutic approaches and outcomes in a modern cohort are not well characterized. Patients ≥70 years old with clinical stage II and III esophageal cancer diagnosed between 1998 and 2012 were identified from the National Cancer Database and stratified based on treatment type. Variables associated with treatment utilization were evaluated using logistic regression and survival evaluated using Cox proportional hazards analysis. Propensity matching (1:1) was performed to help account for selection bias. A total of 21,593 patients were identified. Median and maximum ages were 77 and 90, respectively. Treatment included palliative therapy (24.3%), chemoradiation (37.1%), trimodality therapy (10.0%), esophagectomy alone (5.6%), or no therapy (12.9%). Age ≥80 (OR 0.73), female gender (OR 0.81), Charlson–Deyo comorbidity score ≥2 (OR 0.82), and high‐volume centers (OR 0.83) were associated with a decreased likelihood of palliative therapy versus no treatment. Age ≥80 (OR 0.79) and Clinical Stage III (OR 0.33) were associated with a decreased likelihood, while adenocarcinoma histology (OR 1.33) and nonacademic cancer centers (OR 3.9), an increased likelihood of esophagectomy alone compared to definitive chemoradiation. Age ≥80 (OR 0.15), female gender (OR 0.80), and non‐Caucasian race (OR 0.63) were associated with a decreased likelihood, while adenocarcinoma histology (OR 2.10) and high‐volume centers (OR 2.34), an increased likelihood of trimodality therapy compared to definitive chemoradiation. Each treatment type demonstrated improved survival compared to no therapy: palliative treatment (HR 0.49) to trimodality therapy (HR 0.25) with significance between all groups. Any therapy, including palliative care, was associated with improved survival; however, subsets of elderly patients with locally advanced esophageal cancer are less likely to receive aggressive therapy. Care should be taken to not unnecessarily deprive these individuals of treatment that may improve survival.
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Affiliation(s)
- Gregory Vlacich
- Department of Radiation Oncology, Washington University, St. Louis, Missouri
| | - Pamela P Samson
- Department of Radiation Oncology, Washington University, St. Louis, Missouri
| | - Stephanie M Perkins
- Department of Radiation Oncology, Washington University, St. Louis, Missouri
| | - Michael C Roach
- Department of Radiation Oncology, Washington University, St. Louis, Missouri
| | - Parag J Parikh
- Department of Radiation Oncology, Washington University, St. Louis, Missouri
| | - Jeffrey D Bradley
- Department of Radiation Oncology, Washington University, St. Louis, Missouri
| | - A Craig Lockhart
- Department of Medicine, Division of Oncology, Washington University, St. Louis, Missouri
| | - Varun Puri
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
| | - Bryan F Meyers
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
| | - Benjamin Kozower
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
| | - Cliff G Robinson
- Department of Radiation Oncology, Washington University, St. Louis, Missouri
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16
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Ahmad U, Crabtree TD, Patel AP, Morgensztern D, Robinson CG, Krupnick AS, Kreisel D, Jones DR, Patterson GA, Meyers BF, Puri V. Adjuvant Chemotherapy Is Associated With Improved Survival in Locally Invasive Node Negative Non-Small Cell Lung Cancer. Ann Thorac Surg 2017; 104:303-307. [PMID: 28433225 DOI: 10.1016/j.athoracsur.2017.01.069] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [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] [Received: 08/28/2016] [Revised: 01/10/2017] [Accepted: 01/15/2017] [Indexed: 01/16/2023]
Abstract
BACKGROUND The objectives of this study are to explore factors that are associated with use of adjuvant chemotherapy and to evaluate its impact on overall survival in node-negative patients who undergo lung and chest wall resection for non-small cell lung cancer (NSCLC). METHODS Patients who underwent concomitant lung and chest wall resection for NSCLC were abstracted from the National Cancer Database. Clinical, pathologic, treatment, and follow-up data were obtained. Patients with pathologic nodal metastases or patients who received any radiation treatment were excluded, and the cohort was dichotomized based on administration of adjuvant postoperative chemotherapy. RESULTS Between 1998 and 2010, 824 patients met the inclusion criteria. This cohort exclusively consisted of pT3 N0 patients who did not receive any induction treatment or adjuvant radiation treatment. Adjuvant chemotherapy was administered to 255 patients (31%). Patients in the chemotherapy group were younger and had shorter inpatient length of stay. Both groups had similar comorbidities, tumor size, unplanned readmission rate, and incomplete resection rate. In multivariable analysis, younger age and shorter length of stay were associated with a greater likelihood of receiving adjuvant chemotherapy. Adjuvant chemotherapy was associated with improved survival (hazard ratio 0.74, 95% CI: 0.6 to 0.9), whereas increasing age, white race, length of inpatient stay, tumor size, and residual tumor were independently associated with greater risk of death. CONCLUSIONS Patients who undergo lobectomy with chest wall resection for locally advanced NSCLC should be strongly considered for postoperative adjuvant chemotherapy even in the absence of nodal disease. Actual selection of patients for adjuvant chemotherapy is affected by perioperative factors.
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Affiliation(s)
- Usman Ahmad
- Thoracic Surgery, Heart and Vascular Institute, Cleveland Clinic, Ohio
| | - Traves D Crabtree
- Department of Thoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Aalok P Patel
- Department of Thoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Daniel Morgensztern
- Department of Medical Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Cliff G Robinson
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - A Sasha Krupnick
- Department of Thoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Daniel Kreisel
- Department of Thoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - David R Jones
- Thoracic Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - G Alexander Patterson
- Department of Thoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Bryan F Meyers
- Department of Thoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Varun Puri
- Department of Thoracic Surgery, Washington University School of Medicine, St. Louis, Missouri.
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17
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McMillan MT, Ojerholm E, Verma V, Higgins KA, Singhal S, Predina JD, Berman AT, Grover S, Robinson CG, Simone CB. Radiation Treatment Time and Overall Survival in Locally Advanced Non-small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2017; 98:1142-1152. [PMID: 28721898 DOI: 10.1016/j.ijrobp.2017.04.004] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 02/06/2017] [Accepted: 04/03/2017] [Indexed: 12/25/2022]
Abstract
PURPOSE Prolonged radiation treatment (RT) time (RTT) has been associated with worse survival in several malignancies. The present study investigated whether delays during RT are associated with overall survival (OS) in non-small cell lung cancer (NSCLC). METHODS AND MATERIALS The National Cancer Database was queried for patients with stage III NSCLC who had received definitive concurrent chemotherapy and fractionated RT to standard doses (59.4-70.0 Gy) and fractionation from 2004 to 2013. The RTT was classified as standard or prolonged for each treatment regimen according to the radiation dose and number of fractions. Cox proportional hazards models were used to evaluate the association between the following factors and OS: RTT, RT fractionation, demographic and pathologic factors, and chemotherapeutic agents. RESULTS Of 14,154 patients, the RTT was prolonged in 6262 (44.2%). Factors associated with prolonged RTT included female sex (odds ratio [OR] 1.21, P<.0001), black race (OR 1.20, P=.001), nonprivate health insurance (OR 1.30, P<.0001), and lower income (<$63,000 annually, OR 1.20, P<.0001). The median OS was significantly worse for patients with prolonged RTT than that for those with standard RTT (18.6 vs 22.7 months, P<.0001). Furthermore, the OS worsened with each cumulative interval of delay (standard RTT vs prolonged 1-2 days, 20.5 months, P=.009; prolonged 3-5 days, 17.9 months, P<.0001; prolonged 6-9 days, 17.7 months, P<.0001; prolonged >9 days, 17.1 months, P<.0001). On multivariable analysis, prolonged RTT was independently associated with inferior OS (hazard ratio 1.21, P<.0001). Prolonged RTT as a continuous variable was also significantly associated with worse OS (hazard ratio 1.001, P=.0007). CONCLUSIONS Delays during RT appear to negatively affect survival for patients with locally advanced NSCLC. We have detailed the demographic and socioeconomic barriers influencing prolonged RTT as a method to address the health disparities in this regard. Cumulative interruptions of RT should be minimized.
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Affiliation(s)
- Matthew T McMillan
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Eric Ojerholm
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Vivek Verma
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Kristin A Higgins
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Sunil Singhal
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jarrod D Predina
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Abigail T Berman
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Surbhi Grover
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Cliff G Robinson
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Charles B Simone
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland.
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Samson P, Crabtree TD, Robinson CG, Morgensztern D, Broderick S, Krupnick AS, Kreisel D, Patterson GA, Meyers B, Puri V. Defining the Ideal Time Interval Between Planned Induction Therapy and Surgery for Stage IIIA Non-Small Cell Lung Cancer. Ann Thorac Surg 2017; 103:1070-1075. [PMID: 28110809 PMCID: PMC5444908 DOI: 10.1016/j.athoracsur.2016.09.053] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 09/03/2016] [Accepted: 09/12/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Induction therapy leads to significant improvement in survival for selected patients with stage IIIA non-small cell lung cancer. The ideal time interval between induction therapy and surgery remains unknown. METHODS Clinical stage IIIA non-small cell lung cancer patients receiving induction therapy and surgery were identified in the National Cancer Database. Delayed surgery was defined as greater than or equal to 3 months after starting induction therapy. A logistic regression model identified variables associated with delayed surgery. Cox proportional hazards modeling and Kaplan-Meier analysis were performed to evaluate variables independently associated with overall survival. RESULTS From 2006 to 2010, 1,529 of 2,380 (64.2%) received delayed surgery. Delayed surgery patients were older (61.2 ± 10.0 years versus 60.3 ± 9.2; p = 0.03), more likely to be non-white (12.4% versus 9.7%; p = 0.046), and less likely to have private insurance (50% versus 58.2%; p = 0.002). Delayed surgery patients were also more likely to have a sublobar resection (6.3% versus 2.9%). On multivariate analysis, age greater than 68 years (odds ratio [OR], 1.37; 95% confidence interval [CI], 1.1 to 1.7) was associated with delayed surgery, whereas white race (OR, 0.75; 95% CI, 0.57 to 0.99) and private insurance status (OR, 0.82; 95% CI, 0.68 to 0.99) were associated with early surgery. Delayed surgery was associated with higher risk of long-term mortality (hazard ratio, 1.25; 95% CI, 1.07 to 1.47). CONCLUSIONS Delayed surgery after induction therapy for stage IIIA lung cancer is associated with shorter survival, and is influenced by both social and physiologic factors. Prospective work is needed to further characterize the relationship between patient comorbidities and functional status with receipt of timely surgery.
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Affiliation(s)
- Pamela Samson
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Traves D Crabtree
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Cliff G Robinson
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Daniel Morgensztern
- Division of Medical Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Stephen Broderick
- Division of Cardiothoracic Surgery, St. Luke's Hospital, Chesterfield, Missouri
| | - A Sasha Krupnick
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Bryan Meyers
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri.
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Speirs CK, DeWees TA, Rehman S, Molotievschi A, Velez MA, Mullen D, Fergus S, Trovo M, Bradley JD, Robinson CG. Heart Dose Is an Independent Dosimetric Predictor of Overall Survival in Locally Advanced Non-Small Cell Lung Cancer. J Thorac Oncol 2016; 12:293-301. [PMID: 27743888 DOI: 10.1016/j.jtho.2016.09.134] [Citation(s) in RCA: 182] [Impact Index Per Article: 22.8] [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: 07/10/2016] [Revised: 09/15/2016] [Accepted: 09/22/2016] [Indexed: 02/06/2023]
Abstract
INTRODUCTION In the randomized trial of standard- versus high-dose chemoradiotherapy for locally advanced (LA) NSCLC (Radiation Therapy Oncology Group 0617), overall survival (OS) was worse in the high-dose arm. Although heart dose was suggested as a contributing factor, actionable parameters have not been established. We present an analysis of clinical and dosimetric parameters affecting OS in this patient population, focusing on heart dose. METHODS Clinical data were collected on 416 patients with LA NSCLC treated at a single institution, with a subset of 333 available treatment plans recontoured using Radiation Therapy Oncology Group 0617 normal tissue guidelines. Toxicity and dosimetry data were analyzed for 322 patients; multivariate analysis was performed on 251 patients. Dosimetric parameters of radiation to tumor and organs at risk were analyzed with clinical data pertaining to OS, disease-free survival, and toxicity. RESULTS Patients were treated with radiation therapy to prescribed doses of 50.0 to 84.9 Gy (median 66.0 Gy). Median follow-up was 14.5 months. Median OS was 16.8 months. The 1- and 2-year OS rates were 61.4% and 38.8%, respectively. On multivariate analysis, factors independently associated with worse OS were increasing heart V50 (volume receiving ≥50 Gy), heart volume, lung V5 (proportion of the lung structure [excluding the target volume]) receiving at least 5 Gy), bilateral mediastinal lymph node involvement, and lack of concurrent chemotherapy. When stratified by heart V50 less than 25% versus 25% or greater, the 1-year OS rates were 70.2% versus 46.8% and the 2-year OS rates were 45.9% versus 26.7% (p < 0.0001). Median heart V50 was significantly higher (20.8% versus 13.9%, p < 0.0001) for patients with cardiac toxicity with a Common Terminology Criteria for Adverse Events grade of 1 or higher. CONCLUSIONS Heart dose is associated with OS and cardiac toxicity for patients with LA NSCLC treated with chemoradiotherapy.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Carcinoma, Non-Small-Cell Lung/mortality
- Carcinoma, Non-Small-Cell Lung/pathology
- Carcinoma, Non-Small-Cell Lung/therapy
- Carcinoma, Squamous Cell/mortality
- Carcinoma, Squamous Cell/pathology
- Carcinoma, Squamous Cell/therapy
- Chemoradiotherapy/mortality
- Female
- Follow-Up Studies
- Heart/physiopathology
- Heart/radiation effects
- Humans
- Lung Neoplasms/mortality
- Lung Neoplasms/pathology
- Lung Neoplasms/therapy
- Male
- Middle Aged
- Neoplasm Recurrence, Local/mortality
- Neoplasm Recurrence, Local/pathology
- Neoplasm Recurrence, Local/therapy
- Neoplasm Staging
- Organs at Risk/physiopathology
- Organs at Risk/radiation effects
- Prognosis
- Radiometry
- Radiotherapy Dosage
- Radiotherapy, Intensity-Modulated/methods
- Retrospective Studies
- Survival Rate
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Affiliation(s)
- Christina K Speirs
- Department of Radiation Oncology, Siteman Cancer Center, Washington University/Barnes Jewish Hospital, Saint Louis, Missouri
| | - Todd A DeWees
- Department of Radiation Oncology, Siteman Cancer Center, Washington University/Barnes Jewish Hospital, Saint Louis, Missouri
| | - Sana Rehman
- Department of Radiation Oncology, Siteman Cancer Center, Washington University/Barnes Jewish Hospital, Saint Louis, Missouri
| | | | - Maria A Velez
- Department of Radiation Oncology, Siteman Cancer Center, Washington University/Barnes Jewish Hospital, Saint Louis, Missouri
| | - Daniel Mullen
- Department of Radiation Oncology, Siteman Cancer Center, Washington University/Barnes Jewish Hospital, Saint Louis, Missouri
| | - Sandra Fergus
- Department of Radiation Oncology, Siteman Cancer Center, Washington University/Barnes Jewish Hospital, Saint Louis, Missouri
| | - Marco Trovo
- Department of Radiation Oncology, Centro di Referimento Oncologico Aviano, Aviano, Italy
| | - Jeffrey D Bradley
- Department of Radiation Oncology, Siteman Cancer Center, Washington University/Barnes Jewish Hospital, Saint Louis, Missouri
| | - Cliff G Robinson
- Department of Radiation Oncology, Siteman Cancer Center, Washington University/Barnes Jewish Hospital, Saint Louis, Missouri.
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Morgensztern D, Du L, Waqar SN, Patel A, Samson P, Devarakonda S, Gao F, Robinson CG, Bradley J, Baggstrom M, Masood A, Govindan R, Puri V. Adjuvant Chemotherapy for Patients with T2N0M0 NSCLC. J Thorac Oncol 2016; 11:1729-35. [PMID: 27287414 DOI: 10.1016/j.jtho.2016.05.022] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [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: 03/09/2016] [Revised: 05/10/2016] [Accepted: 05/26/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Adjuvant chemotherapy improves survival in patients with completely resected stage II and III NSCLC. However, its role in patients with stage IB NSCLC disease remains unclear. We evaluated the role of adjuvant chemotherapy in a large data set of patients with completely resected T2N0M0 NSCLC. METHODS Patients with pathologic stage T2N0M0 NSCLC who underwent complete (R0) resection between 2004 and 2011 were identified from the National Cancer Data Base and classified into four groups based on tumor size: 3.1 to 3.9 cm, 4 to 4.9 cm, 5 to 5.9 cm, and 6 to 7 cm. Patients who died within 1 month after their operation were excluded. Survival curves were estimated by the Kaplan-Meier product-limit method and compared by log-rank test. RESULTS Among the 25,267 patients who met the inclusion criteria, there were 4996 (19.7%) who received adjuvant chemotherapy. Adjuvant chemotherapy was associated with improved median and 5-year overall survival compared with observation for all tumor size groups. In patients with T2 tumors smaller than 4 cm, adjuvant chemotherapy was associated with improved median and 5-year overall survival in univariate (101.6 versus 68.2 months [67% versus 55%], hazard ratio [HR] = 0.66, 95% confidence interval [CI]: 0.61-0.72, p < 0.0001) and multivariable analysis (HR = 0.77, 95% CI: 0.70-0.83, p < 0.001) as well as propensity-matched score (101.6 versus 78.9 months [68% versus 60%], HR = 0.75, 95% CI: 0.70-0.86; p < 0.0001). CONCLUSIONS In patients with completely resected T2N0M0, adjuvant chemotherapy is associated with improved survival in all tumor size groups. The benefit in patients with tumors smaller than 4 cm strongly suggests a role for chemotherapy in this patient population and counters its current status as an exclusion criteria for adjuvant trials.
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Affiliation(s)
- Daniel Morgensztern
- Department of Medicine, Division of Medical Oncology, Washington University School of Medicine, St. Louis, Missouri.
| | - Lingling Du
- Department of Medicine, Division of Medical Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Saiama N Waqar
- Department of Medicine, Division of Medical Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Aalok Patel
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Pamela Samson
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Siddhartha Devarakonda
- Department of Medicine, Division of Medical Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Feng Gao
- Division of Biostatistics, Washington University School of Medicine, St. Louis, Missouri
| | - Cliff G Robinson
- Division of Radiation Therapy, Washington University School of Medicine, St. Louis, Missouri
| | - Jeffrey Bradley
- Division of Radiation Therapy, Washington University School of Medicine, St. Louis, Missouri
| | - Maria Baggstrom
- Department of Medicine, Division of Medical Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Ashiq Masood
- Department of Medicine, Division of Medical Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Ramaswamy Govindan
- Department of Medicine, Division of Medical Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Varun Puri
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
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Robinson CG, Patel AP, DeWees T, Morgensztern D, Bradley JD, Puri V. Response to "Is post-operative radiotherapy of any benefit after R0 resection for N2 disease?". Transl Lung Cancer Res 2015; 4:667. [PMID: 26629444 DOI: 10.3978/j.issn.2218-6751.2015.08.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Cliff G Robinson
- 1 Department of Radiation Oncology, 2 Department of Surgery, Division of Cardiothoracic Surgery, 3 Department of Medicine, Division of Medical Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Aalok P Patel
- 1 Department of Radiation Oncology, 2 Department of Surgery, Division of Cardiothoracic Surgery, 3 Department of Medicine, Division of Medical Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Todd DeWees
- 1 Department of Radiation Oncology, 2 Department of Surgery, Division of Cardiothoracic Surgery, 3 Department of Medicine, Division of Medical Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Daniel Morgensztern
- 1 Department of Radiation Oncology, 2 Department of Surgery, Division of Cardiothoracic Surgery, 3 Department of Medicine, Division of Medical Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jeffrey D Bradley
- 1 Department of Radiation Oncology, 2 Department of Surgery, Division of Cardiothoracic Surgery, 3 Department of Medicine, Division of Medical Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Varun Puri
- 1 Department of Radiation Oncology, 2 Department of Surgery, Division of Cardiothoracic Surgery, 3 Department of Medicine, Division of Medical Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
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Roach MC, Rehman S, DeWees TA, Abraham CD, Bradley JD, Robinson CG. It's never too late: Smoking cessation after stereotactic body radiation therapy for non-small cell lung carcinoma improves overall survival. Pract Radiat Oncol 2015; 6:12-8. [PMID: 26598909 DOI: 10.1016/j.prro.2015.09.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 09/09/2015] [Accepted: 09/11/2015] [Indexed: 12/23/2022]
Abstract
PURPOSE As stereotactic body radiation therapy (SBRT) has emerged as a quick, effective, and well-tolerated treatment for early stage non-small cell lung carcinoma (NSCLC), it can be difficult to convince patients to quit smoking in follow-up. We evaluated whether there was a survival benefit to smoking cessation after SBRT. METHODS AND MATERIALS Patients with early-stage NSCLC treated from 2004 to 2013 who were still smoking tobacco at the time of SBRT were identified from a prospective institutional review board-approved registry. Peripheral tumors were treated to 54 Gy in 3 fractions and central tumors to 50 Gy in 5 fractions. Patients were reviewed for overall survival (OS) and disease progression. The log-rank and Cox regression tests were used to identify factors predictive of OS. RESULTS Thirty-two patients (27%) quit smoking after SBRT, and 87 (73%) continued smoking. Median follow-up was 22 months (range, 2-87). On multivariate analysis, smoking status (hazard ratio, 2.1; 95% confidence interval, 1.02-4.2; P = .045), increasing age-adjusted Charlson comorbidity score and larger tumor size were predictive of worse OS. The prior number of cigarette pack-years was not significant (P = .62). In a Kaplan-Meier comparison, smoking cessation after SBRT was associated with improved 2-year OS, 78% versus 69% (P = .014). There was no significant difference in 2-year progression-free survival (75% vs 55%, P = .23) or local control (97% vs 88%, P = .63). CONCLUSION OS is significantly improved in patients who stop smoking after SBRT for early-stage NSCLC, no matter their previous smoking history. Encouraging smoking cessation should be an important part of every posttreatment visit.
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Affiliation(s)
- Michael C Roach
- Department of Radiation Oncology, Siteman Cancer Center, Washington University in Saint Louis, St. Louis, Missouri
| | - Sana Rehman
- Department of Radiation Oncology, Siteman Cancer Center, Washington University in Saint Louis, St. Louis, Missouri
| | - Todd A DeWees
- Department of Radiation Oncology, Siteman Cancer Center, Washington University in Saint Louis, St. Louis, Missouri
| | - Christopher D Abraham
- Department of Radiation Oncology, Siteman Cancer Center, Washington University in Saint Louis, St. Louis, Missouri
| | - Jeffrey D Bradley
- Department of Radiation Oncology, Siteman Cancer Center, Washington University in Saint Louis, St. Louis, Missouri
| | - Cliff G Robinson
- Department of Radiation Oncology, Siteman Cancer Center, Washington University in Saint Louis, St. Louis, Missouri.
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23
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Affiliation(s)
| | | | - Todd DeWees
- Washington University in St Louis, St Louis, MO
| | | | | | - Varun Puri
- Washington University in St Louis, St Louis, MO
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24
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Rehman S, Roach MC, Bradley JD, Robinson CG. Lung Stereotactic Body Radiation Therapy. Mo Med 2015; 112:361-5. [PMID: 26606817 PMCID: PMC6167240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Lung stereotactic body radiation therapy (SBRT) is a novel and effective modality for treatment of early stage non-sail cell lung cancer (NSCLC), with expanding indications in locally advanced and metastatic disease. Herein, we will review current treatment recommendations for early stage NSCLC, detail treatment planning of SBRT, and discuss future directions.
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25
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Samson P, Patel A, Crabtree TD, Morgensztern D, Robinson CG, Colditz GA, Waqar S, Kreisel D, Krupnick AS, Patterson GA, Broderick S, Meyers BF, Puri V. Multidisciplinary Treatment for Stage IIIA Non-Small Cell Lung Cancer: Does Institution Type Matter? Ann Thorac Surg 2015; 100:1773-9. [PMID: 26228601 DOI: 10.1016/j.athoracsur.2015.04.144] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 04/15/2015] [Accepted: 04/17/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Improved survival of patients with early-stage non-small cell lung cancer (NSCLC) undergoing resection at high-volume centers has been reported. However, the effect of institution is unclear in stage IIIA NSCLC, where a variety of neoadjuvant and adjuvant therapies are used. METHODS Treatment and outcomes data of clinical stage IIIA NSCLC patients undergoing resection as part of multimodality therapy was obtained from the National Cancer Database. Multivariable regression models were fitted to evaluate variables influencing 30-day mortality and overall survival. RESULTS From 1998 to 2010, 11,492 clinical stage IIIA patients underwent resection at community centers, and 7,743 patients received resection at academic centers. Academic center patients were more likely to be younger, female, non-Caucasian, have a lower Charlson-Deyo comorbidity score, and to receive neoadjuvant chemotherapy (49.6% vs 40.6%; all p < 0.001). Higher 30-day mortality was associated with increasing age, male gender, preoperative radiotherapy, and pneumonectomy. Patients undergoing operations at academic centers experienced lower 30-day mortality (3.3% vs 4.5%; odds ratio, 0.75; 95% confidence interval [CI], 0.60 to 0.93; p < 0.001). Decreased long-term survival was associated with increasing age, male gender, higher Charlson-Deyo comorbidity score, and larger tumors. Neoadjuvant chemotherapy (hazard ratio, 0.66; 95% CI, 0.62 to 0.70), surgical intervention at an academic center (hazard ratio, 0.92; 95% CI, 0.88 to 0.97), and lobectomy (hazard ratio, 0.72; 95% CI, 0.67 to 0.77) were associated with improved overall survival. CONCLUSIONS Stage IIIA NSCLC patients undergoing resection at academic centers had lower 30-day mortality and increased overall survival compared with patients treated at community centers, possibly due to higher patient volume and an increased rate of neoadjuvant chemotherapy.
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Affiliation(s)
- Pamela Samson
- Division of Cardiothoracic Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Aalok Patel
- Division of Cardiothoracic Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Traves D Crabtree
- Division of Cardiothoracic Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Daniel Morgensztern
- Division of Medical Oncology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Cliff G Robinson
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Graham A Colditz
- Institute for Public Health, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Saiama Waqar
- Division of Medical Oncology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - A Sasha Krupnick
- Division of Cardiothoracic Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Stephen Broderick
- Division of Cardiothoracic Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri.
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Robinson CG, Patel AP, Bradley JD, DeWees T, Waqar SN, Morgensztern D, Baggstrom MQ, Govindan R, Bell JM, Guthrie TJ, Colditz GA, Crabtree TD, Kreisel D, Krupnick AS, Patterson GA, Meyers BF, Puri V. Postoperative radiotherapy for pathologic N2 non-small-cell lung cancer treated with adjuvant chemotherapy: a review of the National Cancer Data Base. J Clin Oncol 2015; 33:870-6. [PMID: 25667283 DOI: 10.1200/jco.2014.58.5380] [Citation(s) in RCA: 178] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
PURPOSE To investigate the impact of modern postoperative radiotherapy (PORT) on overall survival (OS) for patients with N2 non-small-cell lung cancer (NSCLC) treated nationally with surgery and adjuvant chemotherapy. PATIENTS AND METHODS Patients with pathologic N2 NSCLC who underwent complete resection and adjuvant chemotherapy from 2006 to 2010 were identified from the National Cancer Data Base and stratified by use of PORT (≥ 45 Gy). A total of 4,483 patients were identified (PORT, n = 1,850; no PORT, n = 2,633). The impact of patient and treatment variables on OS was explored using Cox regression. RESULTS Median follow-up time was 22 months. On univariable analysis, improved OS correlated with younger age, treatment at an academic facility, female sex, urban population, higher income, lower Charlson comorbidity score, smaller tumor size, multiagent chemotherapy, resection with at least a lobectomy, and PORT. On multivariable analysis, improved OS remained independently predicted by younger age, female sex, urban population, lower Charlson score, smaller tumor size, multiagent chemotherapy, resection with at least a lobectomy, and PORT (hazard ratio, 0.886; 95% CI, 0.798 to 0.988). Use of PORT was associated with an increase in median and 5-year OS compared with no PORT (median OS, 45.2 v 40.7 months, respectively; 5-year OS, 39.3% [95% CI, 35.4% to 43.5%] v 34.8% [95% CI, 31.6% to 38.3%], respectively; P = .014). CONCLUSION For patients with N2 NSCLC after complete resection and adjuvant chemotherapy, modern PORT seems to confer an additional OS advantage beyond that achieved with adjuvant chemotherapy alone.
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Affiliation(s)
| | | | | | - Todd DeWees
- All authors: Washington University, St Louis, MO
| | | | | | | | | | | | | | | | | | | | | | | | | | - Varun Puri
- All authors: Washington University, St Louis, MO
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Bell TM, Shaia CI, Bunton TE, Robinson CG, Wilkinson ER, Hensley LE, Cashman KA. Pathology of experimental Machupo virus infection, Chicava strain, in cynomolgus macaques (Macaca fascicularis) by intramuscular and aerosol exposure. Vet Pathol 2014; 52:26-37. [PMID: 24990481 DOI: 10.1177/0300985814540544] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Machupo virus, the causative agent of Bolivian hemorrhagic fever (BHF), is a highly lethal viral hemorrhagic fever of which little is known and for which no Food and Drug Administration-approved vaccines or therapeutics are available. This study evaluated the cynomolgus macaque as an animal model using the Machupo virus, Chicava strain, via intramuscular and aerosol challenge. The incubation period was 6 to 10 days with initial signs of depression, anorexia, diarrhea, mild fever, and a petechial skin rash. These were often followed by neurologic signs and death within an average of 18 days. Complete blood counts revealed leukopenia as well as marked thrombocytopenia. Serum chemistry values identified a decrease in total protein, marked increases in alanine aminotransferase and aspartate aminotransferase, and moderate increases in alkaline phosphatase. Gross pathology findings included a macular rash extending across the axillary and inguinal regions beginning at approximately 10 days postexposure as well as enlarged lymph nodes and spleen, enlarged and friable liver, and sporadic hemorrhages along the gastrointestinal mucosa and serosa. Histologic lesions consisted of foci of degeneration and necrosis/apoptosis in the haired skin, liver, pancreas, adrenal glands, lymph nodes, tongue, esophagus, salivary glands, stomach, small intestine, and large intestine. Lymphohistiocytic interstitial pneumonia was also present. Inflammation within the central nervous system (nonsuppurative encephalitis) was histologically apparent approximately 16 days postexposure and was generally progressive. This study provides insight into the course of Machupo virus infection in cynomolgus macaques and supports the usefulness of cynomolgus macaques as a viable model of human Machupo virus infection.
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Affiliation(s)
- T M Bell
- US Army Medical Research Institute of Infectious Diseases (USAMRIID), Frederick, MD, USA
| | - C I Shaia
- Joint Pathology Center, Silver Spring, MD, USA
| | | | - C G Robinson
- US Army Medical Research Institute of Infectious Diseases (USAMRIID), Frederick, MD, USA
| | - E R Wilkinson
- US Army Medical Research Institute of Infectious Diseases (USAMRIID), Frederick, MD, USA
| | - L E Hensley
- National Institute of Allergy and Infectious Diseases, Integrated Research Facility, Frederick, MD, USA
| | - K A Cashman
- US Army Medical Research Institute of Infectious Diseases (USAMRIID), Frederick, MD, USA
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Twenhafel NA, Mattix ME, Johnson JC, Robinson CG, Pratt WD, Cashman KA, Wahl-Jensen V, Terry C, Olinger GG, Hensley LE, Honko AN. Pathology of experimental aerosol Zaire ebolavirus infection in rhesus macaques. Vet Pathol 2012; 50:514-29. [PMID: 23262834 DOI: 10.1177/0300985812469636] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
There is limited knowledge of the pathogenesis of human ebolavirus infections and no reported human cases acquired by the aerosol route. There is a threat of ebolavirus as an aerosolized biological weapon, and this study evaluated the pathogenesis of aerosol infection in 18 rhesus macaques. Important and unique findings include early infection of the respiratory lymphoid tissues, early fibrin deposition in the splenic white pulp, and perivasculitis and vasculitis in superficial dermal blood vessels of haired skin with rash. Initial infection occurred in the respiratory lymphoid tissues, fibroblastic reticular cells, dendritic cells, alveolar macrophages, and blood monocytes. Virus spread to regional lymph nodes, where significant viral replication occurred. Virus secondarily infected many additional blood monocytes and spread from the respiratory tissues to multiple organs, including the liver and spleen. Viremia, increased temperature, lymphocytopenia, neutrophilia, thrombocytopenia, and increased alanine aminotransferase, aspartate aminotransferase, γ-glutamyl transpeptidase, total bilirubin, serum urea nitrogen, creatinine, and hypoalbuminemia were measurable mid to late infection. Infection progressed rapidly with whole-body destruction of lymphoid tissues, hepatic necrosis, vasculitis, hemorrhage, and extravascular fibrin accumulation. Hypothermia and thrombocytopenia were noted in late stages with the development of disseminated intravascular coagulation and shock. This study provides unprecedented insight into pathogenesis of human aerosol Zaire ebolavirus infection and suggests development of a medical countermeasure to aerosol infection will be a great challenge due to massive early infection of respiratory lymphoid tissues. Rhesus macaques may be used as a model of aerosol infection that will allow the development of lifesaving medical countermeasures under the Food and Drug Administration's animal rule.
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Affiliation(s)
- N A Twenhafel
- Pathology Division, US Army Medical Research Institute of Infectious Diseases, 1425 Porter St, Fort Detrick, MD 21702-5011, USA.
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Stephans KL, Djemil T, Tendulkar RD, Robinson CG, Reddy CA, Videtic GM. Prediction of Chest Wall Toxicity From Lung Stereotactic Body Radiotherapy (SBRT). Int J Radiat Oncol Biol Phys 2012; 82:974-80. [DOI: 10.1016/j.ijrobp.2010.12.002] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2010] [Revised: 11/28/2010] [Accepted: 12/07/2010] [Indexed: 12/26/2022]
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Robinson CG, Palomo JM, Rahmathulla G, McGraw M, Donze J, Liu L, Vogelbaum MA. Effect of alternative temozolomide schedules on glioblastoma O(6)-methylguanine-DNA methyltransferase activity and survival. Br J Cancer 2010; 103:498-504. [PMID: 20628383 PMCID: PMC2939788 DOI: 10.1038/sj.bjc.6605792] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: O6-methylguanine-DNA methyltransferase (MGMT) expression in glioblastoma correlates with temozolomide resistance. Dose-intense temozolomide schedules deplete MGMT activity in peripheral blood mononuclear cells; however, no published data exist evaluating the effect of temozolomide schedules on intracranial tumour MGMT activity. Methods: Human glioblastoma cells (GBM43) with an unmethylated MGMT promoter were implanted intracranially in immunodeficient rodents. Three weeks later, animals received temozolomide 200 mg m−2 for 5 days (schedule A, standard dose) or 100 mg m−2 for 21 days (schedule B, dose intense). Results: Tumour MGMT activity was depleted by day 6 in both treatment groups compared with baseline. O6-methylguanine-DNA methyltransferase activity returned to baseline by day 22 in the schedule A group, but remained suppressed in the schedule B group. By day 29, MGMT activity had returned to baseline in both groups. Mean tumour volume was significantly decreased compared with untreated controls with either schedule (P<0.01), although neither schedule was superior (P=0.60). Median survival was 64, 42, and 28 days for schedule A, schedule B, and no drug, respectively (P<0.001 A or B vs control, P=NS A vs B). Conclusions: Dose-intense temozolomide prolongs tumour MGMT activity depletion compared with standard dosing, however, survival was not improved in this model.
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Affiliation(s)
- C G Robinson
- Department of Radiation Oncology, Washington University in St Louis, 4921 Parkview Place, St Louis, MO 63110, USA
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Tilney LG, Harb OS, Connelly PS, Robinson CG, Roy CR. How the parasitic bacterium Legionella pneumophila modifies its phagosome and transforms it into rough ER: implications for conversion of plasma membrane to the ER membrane. J Cell Sci 2001; 114:4637-50. [PMID: 11792828 DOI: 10.1242/jcs.114.24.4637] [Citation(s) in RCA: 242] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Within five minutes of macrophage infection by Legionella pneumophila, the bacterium responsible for Legionnaires’ disease, elements of the rough endoplasmic reticulum (RER) and mitochondria attach to the surface of the bacteria-enclosed phagosome. Connecting these abutting membranes are tiny hairs, which are frequently periodic like the rungs of a ladder. These connections are stable and of high affinity - phagosomes from infected macrophages remain connected to the ER and mitochondria (as they were in situ) even after infected macrophages are homogenized. Thin sections through the plasma and phagosomal membranes show that the phagosomal membrane is thicker (72±2 Å) than the ER and mitochondrial membranes (60±2 Å), presumably owing to the lack of cholesterol, sphingolipids and glycolipids in the ER. Interestingly, within 15 minutes of infection, the phagosomal membrane changes thickness to resemble that of the attached ER vesicles. Only later (e.g. after six hours) does the ER-phagosome association become less frequent. Instead ribosomes stud the former phagosomal membrane and L. pneumophila reside directly in the rough ER. Examination of phagosomes of various L. pneumophila mutants suggests that this membrane conversion is a four-stage process used by L. pneumophila to establish itself in the RER and to survive intracellularly. But what is particularly interesting is that L. pneumophila is exploiting a poorly characterized naturally occuring cellular process.
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Affiliation(s)
- L G Tilney
- Department of Biology, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Abstract
The allocation of medical resources is often a great concern in the United States. This article discusses a case concerning utility of resources in a patient with a terminal disease. We assert that the goals of treatment tailored to an individual patient should be made at the bedside by a fiduciary (physician) in conjunction with the patient's preferences and values. There is great responsibility in making these decisions and it is critical that they be made at the bedside with the patient and family clearly aware of the goals of treatments and informed of treatment limitations.
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Affiliation(s)
- S P Douglas
- G. V. "Sonny" Montgomery VA Medical Center, Jackson, Mississippi 39216, USA.
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Abstract
The SV40 T antigen database (http://www.pitt.edu/pipaslab/) lists viruses and plasmids expressing mutant forms of large T antigen. Each entry contains information regarding the mutant designation, mutant type, virus strain, nucleotide change, amino acid change and pertinent references. The database is now available as an internet searchable index.
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Affiliation(s)
- C G Robinson
- Department of Biological Sciences, University of Pittsburgh, Pittsburgh, PA 15260, USA
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Abstract
Tight neoprene 'warm pants' are increasingly utilised by sportsmen to prevent muscular injury. However, they may impede venous flow from the legs. We describe a case of extensive proximal deep vein thrombosis with subsequent pulmonary embolism in a fit young man with previous hip trauma.
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Affiliation(s)
- N I Jowett
- Department of Medicine, Pembrokeshire Health Trust, Wales, UK
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Abstract
Evidence for oral shedding of herpes simplex virus Type I (HSV) indicating endogenous viral reactivation as a measure of depressed host defense was sought in 44 critically ill surgical patients. Eighteen (41%) of these showed persistent HSV shedding. None of 50 controls showed HSV shedding, but 4 (10%) of 42 patients undergoing elective surgery showed transient postoperative viral reactivation. In the critically ill surgical patients, oral HSV shedding was not related to outcome. However, failure to develop a rise in specific HSV antibody, in the presence of viral shedding, was associated with a high mortality. This is further evidence for impairment of both cell-mediated and humoral immunity in critically ill surgical patients.
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Robinson CG, Gladstone JL, Goodman S, Schulman BD. Outbreak of viral hepatitis in a municipal hospital. Arch Intern Med 1968; 122:318-21. [PMID: 4175536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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