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Kamran SC, Otani Y, Qi D, Pompa IR, Dzeng RK, Pittie R, Chung E, Otani K, Wo JY, Zietman AL, Reeves PM, Van Allen EM, Efstathiou JA, Miyamoto DT. PCO24-175: Immune Cell Dynamics After Radiotherapy for Oligometastatic Prostate Cancer. J Natl Compr Canc Netw 2024; 22:PCO24-175. [PMID: 38579846 DOI: 10.6004/jnccn.2023.7170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Affiliation(s)
- Sophia C Kamran
- 1Massachusetts General Hospital, Boston, MA
- 2Harvard Medical School, Boston, MA
- 3Broad Institute of Harvard and MIT, Cambridge, MA
| | | | - David Qi
- 1Massachusetts General Hospital, Boston, MA
| | | | | | - Rea Pittie
- 1Massachusetts General Hospital, Boston, MA
| | - Ella Chung
- 1Massachusetts General Hospital, Boston, MA
| | | | - Jennifer Y Wo
- 1Massachusetts General Hospital, Boston, MA
- 2Harvard Medical School, Boston, MA
| | | | | | - Eliezer M Van Allen
- 2Harvard Medical School, Boston, MA
- 3Broad Institute of Harvard and MIT, Cambridge, MA
- 4Dana-Farber Cancer Institute, Boston, MA
| | - Jason A Efstathiou
- 1Massachusetts General Hospital, Boston, MA
- 2Harvard Medical School, Boston, MA
| | - David T Miyamoto
- 1Massachusetts General Hospital, Boston, MA
- 2Harvard Medical School, Boston, MA
- 3Broad Institute of Harvard and MIT, Cambridge, MA
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Yanagihara TK, Tepper JE, Moon AM, Barry A, Molla M, Seong J, Torres F, Apisarnthanarax S, Buckstein M, Cardenes H, Chang DT, Feng M, Guha C, Hallemeier CL, Hawkins MA, Hoyer M, Iwata H, Jabbour SK, Kachnic L, Kharofa J, Kim TH, Kirichenko A, Koay EJ, Makishima H, Mases J, Meyer JJ, Munoz-Schuffenegger P, Owen D, Park HC, Saez J, Sanford NN, Scorsetti M, Smith GL, Wo JY, Yoon SM, Lawrence TS, Reig M, Dawson LA. Defining Minimum Treatment Parameters of Ablative Radiation Therapy in Patients With Hepatocellular Carcinoma: An Expert Consensus. Pract Radiat Oncol 2024; 14:134-145. [PMID: 38244026 DOI: 10.1016/j.prro.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 08/29/2023] [Accepted: 08/29/2023] [Indexed: 01/22/2024]
Abstract
PURPOSE External beam radiation therapy (EBRT) is a highly effective treatment in select patients with hepatocellular carcinoma (HCC). However, the Barcelona Clinic Liver Cancer system does not recommend the use of EBRT in HCC due to a lack of sufficient evidence and intends to perform an individual patient level meta-analysis of ablative EBRT in this population. However, there are many types of EBRT described in the literature with no formal definition of what constitutes "ablative." Thus, we convened a group of international experts to provide consensus on the parameters that define ablative EBRT in HCC. METHODS AND MATERIALS Fundamental parameters related to dose, fractionation, radiobiology, target identification, and delivery technique were identified by a steering committee to generate 7 Key Criteria (KC) that would define ablative EBRT for HCC. Using a modified Delphi (mDelphi) method, experts in the use of EBRT in the treatment of HCC were surveyed. Respondents were given 30 days to respond in round 1 of the mDelphi and 14 days to respond in round 2. A threshold of ≥70% was used to define consensus for answers to each KC. RESULTS Of 40 invitations extended, 35 (88%) returned responses. In the first round, 3 of 7 KC reached consensus. In the second round, 100% returned responses and consensus was reached in 3 of the remaining 4 KC. The distribution of answers for one KC, which queried the a/b ratio of HCC, was such that consensus was not achieved. Based on this analysis, ablative EBRT for HCC was defined as a BED10 ≥80 Gy with daily imaging and multiphasic contrast used for target delineation. Treatment breaks (eg, for adaptive EBRT) are allowed, but the total treatment time should be ≤6 weeks. Equivalent dose when treating with protons should use a conversion factor of 1.1, but there is no single conversion factor for carbon ions. CONCLUSIONS Using a mDelphi method assessing expert opinion, we provide the first consensus definition of ablative EBRT for HCC. Empirical data are required to define the a/b of HCC.
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Affiliation(s)
- Ted K Yanagihara
- Ablative Radiotherapy Modified Delphi Steering Committee; Department of Radiation Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina.
| | - Joel E Tepper
- Ablative Radiotherapy Modified Delphi Steering Committee; Department of Radiation Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Andrew M Moon
- Ablative Radiotherapy Modified Delphi Steering Committee; Division of Gastroenterology and Hepatology, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Aisling Barry
- Ablative Radiotherapy Modified Delphi Steering Committee; Department of Radiation Oncology, Cork University Hospital, Cork, Ireland
| | - Meritxell Molla
- Ablative Radiotherapy Modified Delphi Steering Committee; Radiation Oncology Department, Hospital Clínic Barcelona, Barcelona, Spain
| | - Jinsil Seong
- Ablative Radiotherapy Modified Delphi Steering Committee; Department of Radiation Oncology, Yonsei University Medical College, Seoul, Republic of Korea
| | - Ferran Torres
- Ablative Radiotherapy Modified Delphi Steering Committee; Biostatistics Unit, Medical School, Universitat Auntònoma de Barcelona, Barcelona, Spain
| | | | - Michael Buckstein
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Higinia Cardenes
- Department of Radiation Oncology, Weill Cornell Medicine, New York, New York
| | - Daniel T Chang
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Mary Feng
- Department of Radiation Oncology, University of California, San Francisco, California
| | - Chandan Guha
- Department of Radiation Oncology, Montefiore Hospital, New York, New York
| | | | - Maria A Hawkins
- Department of Radiation Oncology, University College London, London, England
| | - Morten Hoyer
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Hiromitsu Iwata
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya, Japan
| | - Salma K Jabbour
- Department of Radiation Oncology, Robert Wood Johnson Medical School, Rutgers Cancer Institute, New Brunswick, New Jersey
| | - Lisa Kachnic
- Department of Radiation Oncology, Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York
| | - Jordan Kharofa
- Department of Radiation Oncology, University of Cincinnati Cancer Center, Cincinnati, Ohio
| | - Tae Hyun Kim
- Department of Radiation Oncology, Proton Therapy Center, National Cancer Center, Seoul, Republic of Korea
| | - Alexander Kirichenko
- Department of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, Pennsylvania
| | - Eugene J Koay
- Department of GI Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hirokazu Makishima
- Department of Radiation Oncology, Proton Medical Research Center, University of Tsukuba, Tsukuba, Japan
| | - Joel Mases
- Radiation Oncology Department, Hospital Clínic Barcelona, Barcelona, Spain
| | - Jeffrey J Meyer
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Dawn Owen
- Department of Radiation Oncology, Mayo College of Medicine, Rochester, Minnesota
| | - Hee Chul Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jordi Saez
- Radiation Oncology Department, Hospital Clínic Barcelona, Barcelona, Spain
| | - Nina N Sanford
- Department of Radiation Oncology, University of Texas, Southwestern, Dallas, Texas
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Milan, Italy
| | - Grace L Smith
- Department of GI Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Sang Min Yoon
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Theodore S Lawrence
- Ablative Radiotherapy Modified Delphi Steering Committee; Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Maria Reig
- Ablative Radiotherapy Modified Delphi Steering Committee; Radiation Oncology Department, Hospital Clínic Barcelona, Barcelona, Spain; Liver Cancer Unit, Barcelona Clinic Liver Cancer Group, Barcelona University, Barcelona, Spain.
| | - Laura A Dawson
- Ablative Radiotherapy Modified Delphi Steering Committee; Department of Radiation Oncology, Radiation Medicine Program/University Health Network, University of Toronto, Toronto, Canada
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Smart AC, Niemierko A, Wo JY, Ferrone CR, Tanabe KK, Lillemoe KD, Clark JW, Blaszkowsky LS, Allen JN, Weekes C, Ryan DP, Warshaw AL, Castillo CFD, Hong TS, Keane FK. Portal Vein or Superior Mesenteric Vein Thrombosis with Dose-Escalated Radiation for Borderline or Locally Advanced Pancreatic Cancer. J Gastrointest Surg 2023; 27:2464-2473. [PMID: 37578568 DOI: 10.1007/s11605-023-05796-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 07/29/2023] [Indexed: 08/15/2023]
Abstract
PURPOSE Portal vein and superior mesenteric vein thrombosis (PVT/SMVT) are potentially morbid complications of radiation dose-escalated local therapy for pancreatic cancer. We retrospectively reviewed records for patients treated with and without intraoperative radiation (IORT) to identify risk factors for PVT/SMVT. METHODS Ninety-six patients with locally advanced or borderline resectable pancreatic adenocarcinoma received neoadjuvant therapy followed by surgical exploration from 2009 to 2014. Patients at risk for close or positive surgical margins received IORT boost to a biologically effective dose (BED10) > 100. Prognostic factors for PVT/SMVT were evaluated using competing risks regression. RESULTS Median follow-up was 79 months for surviving patients. Fifty-six patients (58%) received IORT. Twenty-nine patients (30%) developed PVT/SMVT at a median time of 18 months. On univariate competing risks regression, operative blood loss and venous repair with a vascular interposition graft, but not IORT dose escalation or diabetes history, were significantly associated with PVT/SMVT. The development of thrombosis in the absence of recurrence was significantly associated with a longstanding diabetes history, post-neoadjuvant treatment CA19-9, and operative blood loss. All 4 patients who underwent both IORT and vascular repair with a graft developed PVT/SMVT. PVT/SMVT in the absence of recurrence is not associated with significantly worsened overall survival but led to frequent medical interventions. CONCLUSIONS Approximately 30% of patients who underwent neoadjuvant chemoradiation for PDAC developed PVT/SMVT a median of 18 months following surgery. This was significantly associated with venous reconstruction with vascular grafts, but not with escalating radiation dose. PVT/SMVT in the absence of recurrence was associated with significant morbidity.
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Affiliation(s)
- Alicia C Smart
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Andrzej Niemierko
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Kenneth K Tanabe
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Jeffrey W Clark
- Division of Medical Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Lawrence S Blaszkowsky
- Division of Medical Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jill N Allen
- Division of Medical Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Colin Weekes
- Division of Medical Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - David P Ryan
- Division of Medical Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | | | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Florence K Keane
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA.
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Qiao G, Fong ZV, Bolm L, Fernandez Del-Castillo C, Ferrone CR, Servin-Rojas M, Pathak P, Lau-Min K, Allen JN, Blaszkowsky LS, Clark JW, Parikh AR, Ryan DP, Weekes CD, Roberts HM, Wo JY, Hong TS, Lillemoe KD, Qadan M. Feasibility, Safety, and Efficacy of Aggressive Multimodal Management of Elderly Patients with Pancreatic Ductal Adenocarcinoma. Ann Surg 2023:00000658-990000000-00669. [PMID: 37830225 DOI: 10.1097/sla.0000000000006131] [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: 10/14/2023]
Abstract
OBJECTIVE We aimed to evaluate the safety and efficacy of NAT followed by surgical resection in patients with PDAC aged ≥75 years. SUMMARY BACKGROUND DATA Whether administration of neoadjuvant therapy (NAT) followed by surgical resection in elderly patients with pancreatic ductal adenocarcinoma (PDAC) is safe and effective is unknown. METHODS The present study is a three-part comparison of older (≥ 75 years) versus younger (< 75 years) patients in different settings throughout the continuum of PDAC care. The first analysis was a comparison of older versus younger consecutive patients with non-metastatic PDAC who were initiated on FOLFIRINOX. The second was a comparison of older vs. younger patients who underwent NAT followed by surgical resection, and the third and final analysis was a comparison of older patients who underwent either NAT followed by surgical resection vs. upfront surgical resection. Postoperative complications, overall survival (OS), and time to recurrence (TTR), were compared. Propensity-score matching (PSM) analysis was performed to adjust for potential confounders. RESULTS In the first analysis, a lower proportion of older patients (n=40) were able to complete the intended neoadjuvant FOLFIRINOX (8) cycles compared to younger patients (n=214) (65.0% vs. 81.4%, P=0.021). However, older patients were just as likely to undergo surgical exploration as younger patients (77.5% vs 78.5%, P=0.89) as well as surgical resection (57.5% vs 55.6%, P=0.70). In the second analysis, PSM was conducted to compare older (n=54) vs. younger patients (n=54) who underwent NAT followed by surgical resection. There were no significant differences in postoperative complications between the matched groups. While there was a significant difference in overall survival (OS) between older and younger patients (median OS: 16.43 months vs. 30.83 months, P=0.002), importantly, there was no significant difference in time to recurrence (TTR, median: 7.65 months vs. 11.83 months, P=0.215). In the third analysis, older patients who underwent NAT followed by surgical resection (n=48) were compared with similar older patients who underwent upfront surgical resection (n=48). After PSM, there was a significant difference in OS (median OS: 15.78 months vs. 11.51 months, P=0.037) as well as TTR (median TTR: 8.81 months vs. 7.10 months, P=0.046) representing an association with improved outcomes that favored the neoadjuvant approach among older patients alone. CONCLUSIONS This comprehensive three-part study showed that administration of NAT followed by surgical resection appears to be safe and effective among patients ≥ 75 years of age. An aggressive approach should be offered to older adults undergoing multimodal treatment of PDAC.
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Affiliation(s)
- Guoliang Qiao
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Zhi Ven Fong
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Louisa Bolm
- Department of Surgery, University Medical Center Schleswig-Holstein, Lubeck, Germany
| | | | | | | | | | - Kelsey Lau-Min
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Jill N Allen
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | | | - Jeffrey W Clark
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Aparna R Parikh
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - David P Ryan
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Colin D Weekes
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Hannah M Roberts
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Boston, MA
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Mora J, Pompa I, Qi D, Gold B, Barbesino N, Benson O, Badusi PO, Bhagwat MS, Wo JY, Zietman AL, Efstathiou JA, Miyamoto DT, Kamran SC. Radiation-Associated Lymphopenia in Advanced Prostate Cancer Treated with Contemporary Radiation Techniques. Int J Radiat Oncol Biol Phys 2023; 117:e419. [PMID: 37785380 DOI: 10.1016/j.ijrobp.2023.06.1573] [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) Lymphocytes play a critical role in the immune system as primary effector cells for cancer control, often depleted by external beam radiation therapy (EBRT). Radiation-associated lymphopenia (RAL) has been shown to be a poor prognostic factor in the management of multiple solid tumors. We hypothesize RAL is similarly observed in advanced prostate cancer (PC) RT with contemporary techniques. MATERIALS/METHODS We identified patients with advanced PC (high-risk or clinical/pathologic node-positive) receiving EBRT including lymph node/prostatic lesion boost on a prospective collection protocol for whom 1 baseline and ≥2 subsequent complete blood count (CBC) with differential samples were available, collected at RT end, 3-, 6-, and 12-months post-RT. Clinicopathological characteristics were retrieved from chart review. Common Terminology Criteria for Adverse Events (CTCAE)v5 was used to grade absolute lymphocyte count (ALC); RAL was defined as CTCAEv5 grade ≥2. As these patients received pelvic nodal irradiation, they were pooled with low/intermediate-risk PC cohort treated with high dose-rate (HDR) brachytherapy or prostate alone EBRT with similar CBC timepoints for univariable analysis to understand RT field size effect on RAL. RESULTS Between 2019 and 2022, among 17 patients in the low/intermediate-risk PC cohort, 6 patients had grade ≥2 lymphopenia. Among 25 patients in the advanced PC cohort, all received androgen deprivation therapy (ADT), 6 received lymph node boost, and 5 received prostatic lesion boost. At RT end, leukopenia was prominently observed (median nadir count 75.1% of baseline), with ALC as major driver (median nadir count 27.3% of baseline). Grade ≥2 lymphopenia was observed in 76% of patients (n = 19) Of 19 advanced PC patients who reached 6 months post-RT follow-up, median ALC was 53.0% of baseline, and Grade ≥2 lymphopenia remained in 37% (n = 7) of patients. Of 8 advanced PC patients who reached 12 months post-RT follow-up, median ALC was 55.6% of baseline. When evaluating whether RT dose or field size contributed to lower nadir ALC counts, combining the low/intermediate-risk and advanced PC cohorts (n = 42), univariable analysis demonstrated Gleason grade group (p = 0.009), RT field size (p = 0.020), ADT use (p = 0.020), baseline ALC (p = 0.037), and baseline hemoglobin (p = 0.009) were independent predictors of Grade ≥2 lymphopenia. Age, prostatic lesion/lymph node boost, and equivalent dose in 2 Gy/fraction (EQD2) were nonsignificant. CONCLUSION Grade ≥2 RAL was observed in patients with advanced PC at end of RT, irrespective of age, RT boost, or EQD2. Lymphocyte recovery from baseline can be prolonged even at 12 months post-RT. Ongoing analyses include expanding data with additional serial CBC, increasing cohort size, and integrating effect of additional systemic therapies. RAL has downstream implications for future chemotherapy/radiopharmaceuticals.
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Affiliation(s)
- J Mora
- Harvard Radiation Oncology Program, Boston, MA
| | - I Pompa
- Massachusetts General Hospital, Boston, MA
| | - D Qi
- Massachusetts General Hospital, Boston, MA
| | - B Gold
- Massachusetts General Hospital, Boston, MA
| | | | - O Benson
- Massachusetts General Hospital, Boston, MA
| | - P O Badusi
- Massachusetts General Hospital, Boston, MA
| | | | - J Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - A L Zietman
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - J A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - D T Miyamoto
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - S C Kamran
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Shiau C, Cao J, Gregory M, Kim Y, He S, Reeves J, Wang S, Lester NA, Su J, Wang PL, Beechem J, Hong TS, Wo JY, Ting D, Hemberg M, Hwang WL. Intercellular Mechanisms of Therapeutic Resistance at the Tumor-Stromal Interface Using Ultra High-Plex Single-Cell Spatial Transcriptomics and Genetically-Engineered Tumoroids. Int J Radiat Oncol Biol Phys 2023; 117:S101-S102. [PMID: 37784270 DOI: 10.1016/j.ijrobp.2023.06.056] [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) There is a major gap in knowledge regarding how intercellular interactions in the tumor microenvironment (TME) mediate therapeutic resistance. Achievement of this goal has been limited by a lack of (1) spatial context in dissociated single-cell methods; (2) single-cell resolution in spatial profiling approaches; (3) high quality data and yield with FFPE patient specimens; and (4) computational methods for ligand-receptor analyses that consider both gene expression and spatial coordinates. MATERIALS/METHODS We developed an innovative spatial biology paradigm that combines cutting-edge experimental and computational methods to enable high-resolution, spatially-guided discovery of critical mediators of therapeutic resistance. We applied this approach to dissect the single-cell spatial transcriptomic landscape of untreated vs. chemoradiotherapy-treated primary human pancreatic ductal adenocarcinoma (PDAC; n = 21) using ultra-high plex spatial molecular imaging (SMI) optimized for high-sensitivity, subcellular detection of up to 6000 gene transcripts in FFPE sections-an order of magnitude greater than contemporary methods. RESULTS We recovered over 1,000,000 high-quality single cells in situ representing more than 20 distinct cell types, including epithelial, immune, endothelial, endocrine, and diverse stromal cells. We developed an optimal transport-based computational method to infer cell-cell communication at the cancer-stromal interface. Treatment with chemoradiotherapy was associated with the largest increase in fibroblast-malignant interactions. Comparing the SMI data with orthogonal single-nucleus RNA-sequencing and digital spatial profiling data, we identified CLCF1-CNTFR as the fibroblast-malignant interaction most associated with resistance to chemoradiotherapy in PDAC. CLCF1 is a gp130-family cytokine that activates Jak-STAT signaling and acts as a potent neurotrophic factor. Notably, the CLCF1-CNTRF (fibroblast-malignant) interaction has prominent pro-oncogenic effects in lung adenocarcinoma and an engineered CNTFR decoy receptor with therapeutic potential has been developed. To functionally validate the role of the CLCF1-CNTFR (fibroblast-malignant) interaction in mediating resistance to cytotoxic therapy, we created CRISPR-engineered cancer-fibroblast tumoroids and modulated expression of this ligand-receptor pair. Pancreatic cancer cell viability in the presence of 5-fluorouracil was better maintained with increased CLCF1-CNTFR signaling. CONCLUSION In this study, we integrated ultra high-plex single-cell spatial transcriptomics, optimal transport ligand-receptor predictions, and genetically-engineered stromal tumoroids to identify and validate CLCF1-CNTFR as an important intercellular mechanism of resistance to chemoradiotherapy in PDAC-pioneering a paradigm for translating single-cell spatial biology to clinical oncology.
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Affiliation(s)
- C Shiau
- Massachusetts General Hospital, Boston, MA
| | - J Cao
- Brigham and Women's Hospital, Boston, MA
| | - M Gregory
- Nanostring Technologies, Seattle, WA
| | - Y Kim
- Nanostring Technologies, Seattle, WA
| | - S He
- Nanostring Technologies, Seattle, WA
| | - J Reeves
- Nanostring Technologies, Seattle, WA
| | - S Wang
- Columbia University, New York, NY
| | - N A Lester
- Massaschusetts General Hospital, Boston, MA
| | - J Su
- Massachusetts General Hospital, BOSTON, MA
| | - P L Wang
- Massaschusetts General Hospital, Boston, MA
| | - J Beechem
- Nanostring Technologies, Seattle, WA
| | - T S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - J Y Wo
- Newton-Wellesley Hospital, Newton, MA
| | - D Ting
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - M Hemberg
- Brigham and Women's Hospital, Boston, MA
| | - W L Hwang
- Broad Institute of MIT and Harvard, Cambridge, MA
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7
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Koenig JL, Pappas L, Yeap BY, Clark JW, Allen JN, Wo JY, Ryan DP, Blaszkowsky LS, Giantonio B, Weekes C, Klempner S, Roberts HJ, Drapek LC, Ly L, Meurer J, Corcoran R, Mehta A, Ting D, Hong TS, Parikh AR. Association between Liver Metastases and Treatment Response in Patients with Metastatic, Microsatellite Stable Colorectal Cancer Treated with Radiation Therapy and Dual Immune Checkpoint Blockade. Int J Radiat Oncol Biol Phys 2023; 117:e308-e309. [PMID: 37785117 DOI: 10.1016/j.ijrobp.2023.06.2333] [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) Most patients with metastatic colorectal cancer (CRC) have microsatellite stable (MSS) disease with a limited response to immune checkpoint inhibitors (ICIs). In our phase 2 trial (NCT03104439), 27 patients with metastatic MSS CRC received ipilimumab, nivolumab, and RT (24 Gy/3 fractions) on C2D1 with a disease control rate (DCR) of 37% (10/27) and overall response rate (ORR) of 15% (4/27). Our follow up phase 2 study with ipilimumab, nivolumab, and RT moved to C1D1 (NCT04361162) showed a DCR of 33% (10/30) and an ORR of 13% (4/30). Clinical and preclinical data suggest liver metastases are less responsive to systemic ICIs and complementary liver-directed RT can potentially overcome this effect. To address this, we investigated the association between liver metastases and response rates among patients treated with and without liver-directed RT in a pooled analysis of our phase 2 studies of nivolumab and ipilimumab with RT. MATERIALS/METHODS In this pooled secondary analysis of two open-label, single-arm, phase 2 studies, eligible patients had metastatic MSS CRC, ECOG PS 0-1, and progressed on at least one line of chemotherapy. Treatment consisted of ipilimumab 1 mg/kg q6weeks for 4 cycles, nivolumab 240 mg q2weeks on a 6-week cycle, and RT (24 Gy/3 fractions) on C1D1 or C2D1 to one site. Responses were defined outside of the RT field by RECIST 1.1 with centrally reviewed imaging q3months. ORR/DCR and PFS/OS were compared between patients with and without liver metastases with the Fisher's exact and log-rank tests, respectively. P-values are two-sided. RESULTS We treated 57 patients (median age 57 years [range, 26-85], 61% male, 88% white, 65% with liver metastases) from 07/2017 to 05/2022. Patients received a median of 3 (range, 1-10) prior lines of systemic therapy. The combined ORR was 14% (8/57; 95% CI, 6-26%) and DCR was 35% (20/57; 95% CI, 23-49%). The ORR was 30% (6/20; 95% CI, 12-54%) in patients without liver metastases and 5% (2/37; 95% CI, 1-18%) in patients with liver metastases (p = 0.017). The DCR was 55% (11/20; 95% CI, 32-77%) in patients without liver metastases and 24% (9/37; 94% CI, 12-41%) in patients with liver metastases (p = 0.040). 76% (28/37) of patients with liver metastases received liver-directed RT including 2/2 (100%) patients with a PR. The ORR was 0% in patients with liver metastases without liver-directed RT. The median PFS was 1.8 months (95% CI, 1.2-2.4 months) and OS was 9.8 months (95% CI, 6.8-12.8). OS was longer in patients without liver metastases (median 13.6 v 6.8 months, p = 0.010) and in patients treated with liver-directed RT among those with liver metastases (median 7.5 months v 4.5 months, p = 0.025). CONCLUSION Among patients with metastatic MSS CRC treated with ICIs and RT in two phase 2 studies, ORR, DCR, and OS are significantly higher in patients without liver metastases. Liver-directed RT may improve ICI efficacy and OS in patients with liver metastases. Further analysis of PFS and prospective study of ICIs with comprehensive liver-directed RT are warranted.
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Affiliation(s)
- J L Koenig
- Harvard Radiation Oncology Program, Boston, MA
| | - L Pappas
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - B Y Yeap
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - J W Clark
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - J N Allen
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - J Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - D P Ryan
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - L S Blaszkowsky
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - B Giantonio
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - C Weekes
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - S Klempner
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - H J Roberts
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - L C Drapek
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - L Ly
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - J Meurer
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - R Corcoran
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - A Mehta
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA; The Broad Institute, Cambridge, MA
| | - D Ting
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - T S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - A R Parikh
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Hwang WL, Su J, Shiau C, Wang PL, Guo JA, Lester NA, Barth JL, Hoffman HI, Aguirre A, Hong TS, Wo JY, Ting D, Zheng L, Mino-Kenudson M, Jacks T. Molecular Mechanisms of Intratumoral Nerve Recruitment and Perineural Invasion Elucidated with Spatial Transcriptomics and CRISPR Activation. Int J Radiat Oncol Biol Phys 2023; 117:S21. [PMID: 37784453 DOI: 10.1016/j.ijrobp.2023.06.244] [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) Perineural invasion (PNI) is an aggressive manifestation of tumor-nerve interactions associated with postoperative recurrence, metastasis, pain, and decreased survival. Hence, PNI is included in the staging criteria of several malignancies and often an indication for treatment intensification using adjuvant radiotherapy. However, the diverse molecular mechanisms underlying tumor-nerve crosstalk remain largely unknown-hindering the development of new therapies targeting this key pathological process. Moreover, prior studies were limited by a lack of cell-type information, spatial context, and/or a fragmented focus on a small number of pathways. MATERIALS/METHODS Using pancreatic ductal adenocarcinoma (PDAC) as an exemplar given the exceptionally high frequency of PNI in this malignancy, we performed the first comprehensive, cell-type specific, and spatially resolved whole-transcriptome analysis of human PDAC to identify molecular mediators of tumor-nerve crosstalk and PNI. We constructed 12 custom tissue microarrays (TMAs) derived from matched malignant regions with and without tumor-nerve proximity (n = 288 cores). We performed whole-transcriptome digital spatial profiling (DSP) to independently determine mRNA abundance from the malignant, fibroblast, and nerve compartments through optical sectioning. RESULTS We mapped malignant subtypes we previously identified onto the spatial data and found strong (p<0.0001) positive nerve associations with the mesenchymal, basaloid, and neural-like progenitor subtypes and a negative nerve association with the classical subtype. Numerous genes expressed by malignant cells were enriched (e.g., MMP2, PLXND1, NRP1) or depleted (e.g., SEMA3B) in association with radial distance from nerves, including recapitulation of prior literature. To functionally explore these candidate mediators of tumor-nerve crosstalk, we derived genetically-engineered murine organoids (KrasLSL-G12D/+; Trp53FL/FL; Rosa26-dCas9-VPR) and transduced them with guide RNAs to overexpress subtype-specific transcription factors or candidate genes from the spatial analysis. We quantified (1) cancer cell invasion through extracellular matrix using cultured dorsal root ganglia (DRG) sensory neurons as the chemoattractant, and (2) the role of cancer-intrinsic signaling on nerve recruitment/outgrowth by applying conditioned media or exogenous proteins to cultured DRG sensory neurons and tracking their growth with live imaging. CONCLUSION Our results suggest that the mechanisms enabling cancer cells to recruit nerves into the tumor microenvironment are distinct from those facilitating perineural invasion. This study has transformed our understanding of how cancer cells and the peripheral nervous system collaborate to promote tumor growth, survival, and dissemination, and is now guiding prioritization of therapeutic strategies that synergize with adjuvant radiotherapy in the burgeoning field of cancer neuroscience.
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Affiliation(s)
- W L Hwang
- Harvard Medical School / Massachusetts General Hospital, Boston, MA; Broad Institute of MIT and Harvard, Cambridge, MA
| | - J Su
- Massachusetts General Hospital, BOSTON, MA
| | - C Shiau
- Massachusetts General Hospital, Boston, MA
| | - P L Wang
- Massaschusetts General Hospital, Boston, MA
| | - J A Guo
- Broad Institute of MIT and Harvard, Cambridge, MA
| | - N A Lester
- Massaschusetts General Hospital, Boston, MA
| | - J L Barth
- Massaschusetts General Hospital, Boston, MA
| | | | - A Aguirre
- Dana-Farber Cancer Institute, Boston, MA
| | - T S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - J Y Wo
- Newton-Wellesley Hospital, Newton, MA
| | - D Ting
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - L Zheng
- Department of Medical Oncology, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - T Jacks
- Massachusetts Institute of Technology, Cambridge, MA
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De B, Upadhyay R, Liao K, Kumala T, Shi C, Dodoo G, Abi Jaoude J, Corrigan KL, Manzar GS, Marqueen KE, Bernard V, Lee SS, Raghav KPS, Vauthey JN, Tzeng CWD, Tran Cao HS, Lee G, Wo JY, Hong TS, Crane CH, Minsky BD, Smith GL, Holliday EB, Taniguchi CM, Koong AC, Das P, Javle M, Ludmir EB, Koay EJ. Definitive Liver Radiotherapy for Intrahepatic Cholangiocarcinoma with Extrahepatic Metastases. Liver Cancer 2023; 12:198-208. [PMID: 37593365 PMCID: PMC10427952 DOI: 10.1159/000530134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 03/06/2023] [Indexed: 08/19/2023] Open
Abstract
Introduction Tumor-related liver failure (TRLF) is the most common cause of death in patients with intrahepatic cholangiocarcinoma (ICC). Though we previously showed that liver radiotherapy (L-RT) for locally advanced ICC is associated with less frequent TRLF and longer overall survival (OS), the role of L-RT for patients with extrahepatic metastatic disease (M1) remains undefined. We sought to compare outcomes for M1 ICC patients treated with and without L-RT. Methods We reviewed ICC patients that found to have M1 disease at initial diagnosis at a single institution between 2010 and 2021 who received L-RT, matching them with an institutional cohort by propensity score and a National Cancer Database (NCDB) cohort by frequency technique. The median biologically effective dose was 97.5 Gy (interquartile range 80.5-97.9 Gy) for L-RT. Patients treated with other local therapies or supportive care alone were excluded. We analyzed survival with Cox proportional hazard modeling. Results We identified 61 patients who received L-RT and 220 who received chemotherapy alone. At median follow-up of 11 months after diagnosis, median OS was 9 months (95% confidence interval [CI] 8-11) and 21 months (CI: 17-26) for patients receiving chemotherapy alone and L-RT, respectively. TRLF was the cause of death more often in the patients who received chemotherapy alone compared to those who received L-RT (82% vs. 47%; p = 0.001). On multivariable propensity score-matched analysis, associations with lower risk of death included duration of upfront chemotherapy (hazard ratio [HR] 0.82; p = 0.005) and receipt of L-RT (HR: 0.40; p = 0.002). The median OS from diagnosis for NCDB chemotherapy alone cohort was shorter than that of the institutional L-RT cohort (9 vs. 22 months; p < 0.001). Conclusion For M1 ICC, L-RT associated with a lower rate of death due to TRLF and longer OS versus those treated with chemotherapy alone. Prospective studies of L-RT in this setting are warranted.
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Affiliation(s)
- Brian De
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rituraj Upadhyay
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kaiping Liao
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tiffany Kumala
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christopher Shi
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Grace Dodoo
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph Abi Jaoude
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kelsey L Corrigan
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gohar S Manzar
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kathryn E Marqueen
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vincent Bernard
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sunyoung S Lee
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kanwal P S Raghav
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hop S Tran Cao
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Grace Lee
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher H Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Bruce D Minsky
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Grace L Smith
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Emma B Holliday
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cullen M Taniguchi
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Albert C Koong
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Milind Javle
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ethan B Ludmir
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eugene J Koay
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Shiau C, Cao J, Gregory MT, Gong D, Yin X, Cho JW, Wang PL, Su J, Wang S, Reeves JW, Kim TK, Kim Y, Guo JA, Lester NA, Schurman N, Barth JL, Weissleder R, Jacks T, Qadan M, Hong TS, Wo JY, Roberts H, Beechem JM, Castillo CFD, Mino-Kenudson M, Ting DT, Hemberg M, Hwang WL. Therapy-associated remodeling of pancreatic cancer revealed by single-cell spatial transcriptomics and optimal transport analysis. bioRxiv 2023:2023.06.28.546848. [PMID: 37425692 PMCID: PMC10327107 DOI: 10.1101/2023.06.28.546848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
In combination with cell intrinsic properties, interactions in the tumor microenvironment modulate therapeutic response. We leveraged high-plex single-cell spatial transcriptomics to dissect the remodeling of multicellular neighborhoods and cell-cell interactions in human pancreatic cancer associated with specific malignant subtypes and neoadjuvant chemotherapy/radiotherapy. We developed Spatially Constrained Optimal Transport Interaction Analysis (SCOTIA), an optimal transport model with a cost function that includes both spatial distance and ligand-receptor gene expression. Our results uncovered a marked change in ligand-receptor interactions between cancer-associated fibroblasts and malignant cells in response to treatment, which was supported by orthogonal datasets, including an ex vivo tumoroid co-culture system. Overall, this study demonstrates that characterization of the tumor microenvironment using high-plex single-cell spatial transcriptomics allows for identification of molecular interactions that may play a role in the emergence of chemoresistance and establishes a translational spatial biology paradigm that can be broadly applied to other malignancies, diseases, and treatments.
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Affiliation(s)
- Carina Shiau
- Center for Systems Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Center for Cancer Research, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Jingyi Cao
- Evergrande Center for Immunologic Diseases, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Dennis Gong
- Center for Systems Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Center for Cancer Research, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Broad Institute of MIT and Harvard, Cambridge, MA, USA; Harvard-MIT Health Sciences and Technology Program, Cambridge, MA, USA
| | - Xunqin Yin
- Center for Systems Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Center for Cancer Research, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Jae-Won Cho
- Evergrande Center for Immunologic Diseases, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Peter L Wang
- Center for Systems Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Center for Cancer Research, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Broad Institute of MIT and Harvard, Cambridge, MA, USA; Koch Institute for Integrative Cancer Research, Department of Biology, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Jennifer Su
- Center for Systems Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Center for Cancer Research, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Broad Institute of MIT and Harvard, Cambridge, MA, USA; Koch Institute for Integrative Cancer Research, Department of Biology, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Steven Wang
- Center for Systems Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Center for Cancer Research, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Broad Institute of MIT and Harvard, Cambridge, MA, USA; Koch Institute for Integrative Cancer Research, Department of Biology, Massachusetts Institute of Technology, Cambridge, MA, USA
| | | | | | | | - Jimmy A Guo
- Center for Systems Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Center for Cancer Research, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Broad Institute of MIT and Harvard, Cambridge, MA, USA; Biological and Biomedical Sciences Program, Harvard Medical School, Boston, MA, USA
| | - Nicole A Lester
- Center for Systems Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Center for Cancer Research, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Broad Institute of MIT and Harvard, Cambridge, MA, USA; Koch Institute for Integrative Cancer Research, Department of Biology, Massachusetts Institute of Technology, Cambridge, MA, USA
| | | | - Jamie L Barth
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ralph Weissleder
- Center for Systems Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Tyler Jacks
- Koch Institute for Integrative Cancer Research, Department of Biology, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Hannah Roberts
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - David T Ting
- Center for Cancer Research, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Broad Institute of MIT and Harvard, Cambridge, MA, USA; Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Martin Hemberg
- Broad Institute of MIT and Harvard, Cambridge, MA, USA; Evergrande Center for Immunologic Diseases, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - William L Hwang
- Center for Systems Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Center for Cancer Research, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Broad Institute of MIT and Harvard, Cambridge, MA, USA; Koch Institute for Integrative Cancer Research, Department of Biology, Massachusetts Institute of Technology, Cambridge, MA, USA
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11
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Fong ZV, Verdugo FL, Fernandez-Del Castillo C, Ferrone CR, Allen JN, Blaszkowsky LS, Clark JW, Parikh AR, Ryan DP, Weekes CD, Hong TS, Wo JY, Lillemoe KD, Qadan M. Tolerability, Attrition Rates, and Survival Outcomes of Neoadjuvant FOLFIRINOX for Nonmetastatic Pancreatic Adenocarcinoma: Intent-to-Treat Analysis. J Am Coll Surg 2023; 236:1126-1136. [PMID: 36729817 DOI: 10.1097/xcs.0000000000000499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND FOLFIRINOX is increasingly used in the management of pancreatic ductal adenocarcinoma (PDAC). However, neoadjuvant therapy is associated with toxicity, possible disease progression, and biopsy-related and biliary complications that may preclude operative exploration. Data on the true attrition rate outside of clinical trials or resected surgical series are lacking. STUDY DESIGN Patients with nonmetastatic PDAC who initiated FOLFIRINOX from 2015 to 2020 were identified from our institution's pharmacy records. Multivariable regression and Cox proportional hazard models were used for adjusted analyses of categorical and survival outcomes, respectively. RESULTS Of 254 patients who initiated first-line neoadjuvant FOLFIRINOX, 199 (78.3%) underwent exploration, and 54 (21.3%) did not complete their chemotherapy cycles due to poor tolerability (46.3%), poor response (31.5%), or disease progression (14.8%), among other causes (7.4%). A total of 109 (42.9%) patients experienced grade 3/4 FOLFIRINOX-related toxicity, of whom 73 (28.7%) and 100 (39.4%) required an emergency department visit or inpatient admission, respectively. Finally, not undergoing surgical exploration was associated with impaired overall survival (hazard ratio 7.0; 95% CI 3.8 to 12.8; p < 0.001). Independent predictors of not undergoing exploration were remote history of chemotherapy receipt (odds ratio [OR] 0.06; p = 0.02), inability to complete FOLFIRINOX cycles (OR 0.2, p = 0.003), increase in ECOG score (OR 0.2, p < 0.001), and being single or divorced (OR 0.3, p = 0.018). CONCLUSIONS Among 254 patients with nonmetastatic PDAC initiated on FOLFIRINOX, of whom 52% were locally advanced, a total of 199 (78.3%) were explored, 142 (71.4%) underwent successful resection, and 129 (90.8%) were resected with negative margins. Despite 109 (42.9)% of patients experiencing significant toxicity, most patients could be managed through treatment-related complications to complete planned neoadjuvant chemotherapy and undergo planned surgical exploration.
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Affiliation(s)
- Zhi Ven Fong
- From the Department of Surgery, Massachusetts General Hospital, Boston, MA (Fong, Verdugo, Fernandez-del Castillo, Ferrone, Qadan)
| | - Fidel Lopez Verdugo
- From the Department of Surgery, Massachusetts General Hospital, Boston, MA (Fong, Verdugo, Fernandez-del Castillo, Ferrone, Qadan)
| | - Carlos Fernandez-Del Castillo
- From the Department of Surgery, Massachusetts General Hospital, Boston, MA (Fong, Verdugo, Fernandez-del Castillo, Ferrone, Qadan)
| | - Cristina R Ferrone
- From the Department of Surgery, Massachusetts General Hospital, Boston, MA (Fong, Verdugo, Fernandez-del Castillo, Ferrone, Qadan)
| | - Jill N Allen
- the Department of Medicine, Massachusetts General Hospital, Boston, MA (Allen, Blaszkowsky, Clark, Parikh, Ryan, Weekes)
| | - Lawrence S Blaszkowsky
- the Department of Medicine, Massachusetts General Hospital, Boston, MA (Allen, Blaszkowsky, Clark, Parikh, Ryan, Weekes)
| | - Jeffrey W Clark
- the Department of Medicine, Massachusetts General Hospital, Boston, MA (Allen, Blaszkowsky, Clark, Parikh, Ryan, Weekes)
| | - Aparna R Parikh
- the Department of Medicine, Massachusetts General Hospital, Boston, MA (Allen, Blaszkowsky, Clark, Parikh, Ryan, Weekes)
| | - David P Ryan
- the Department of Medicine, Massachusetts General Hospital, Boston, MA (Allen, Blaszkowsky, Clark, Parikh, Ryan, Weekes)
| | - Colin D Weekes
- the Department of Medicine, Massachusetts General Hospital, Boston, MA (Allen, Blaszkowsky, Clark, Parikh, Ryan, Weekes)
| | - Theodore S Hong
- the Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA (Hong, Wo)
| | - Jennifer Y Wo
- the Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA (Hong, Wo)
| | - Keith D Lillemoe
- From the Department of Surgery, Massachusetts General Hospital, Boston, MA (Fong, Verdugo, Fernandez-del Castillo, Ferrone, Qadan)
- the Department of Medicine, Massachusetts General Hospital, Boston, MA (Allen, Blaszkowsky, Clark, Parikh, Ryan, Weekes)
- the Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA (Hong, Wo)
| | - Motaz Qadan
- From the Department of Surgery, Massachusetts General Hospital, Boston, MA (Fong, Verdugo, Fernandez-del Castillo, Ferrone, Qadan)
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12
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Lopez-Verdugo F, Fong ZV, Lillemoe KD, Blaszkowsky LS, Parikh AR, Wo JY, Hong TS, Ferrone CR, Fernandez-Del Castillo C, Qadan M. Underlying Bias in the Treatment of Pancreatic Cancer: Minorities Treated at the Same Facilities are Less Likely to Receive Neoadjuvant Therapy. Ann Surg 2023; 277:829-834. [PMID: 34954756 DOI: 10.1097/sla.0000000000005354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To identify disparities in access to NAT for PDAC at the prehospital and intrahospital phases of care. SUMMARY OF BACKGROUND DATA Delivery of NAT in PDAC is susceptible to disparities in access. There are limited data that accurately locate the etiology of disparities at the prehospital and intrahospital phases of care. METHODS Retrospective cohort of patients ≥18 years old with clinical stage I-II PDAC from the 2010-2016 National Cancer Database. Multiple logistic regression was used to assess 2 sequential outcomes: (1) access to an NAT facility (prehospital phase) and (2) receipt of NAT at an NAT facility (intrahospital phase). RESULTS A total of 36,208 patients were included for analysis in the prehospital phase of care. Higher education, longer travel distances, being treated at academic/research or integrated network cancer programs, and more recent year of diagnosis were independently associated with receipt of treatment at an NAT facility. All patients treated at NAT facilities (31,099) were included for the second analysis. Higher education level and receiving care at an academic/research facility were independently associated with increased receipt of NAT. NonBlack racial minorities (including American Indian, Asian, Pacific Islanders), being Hispanic, being uninsured, and having Medicaid insurance were associated with decreased receipt of NAT at NAT facilities. CONCLUSIONS Non-Black racial minorities and Hispanic patients were less likely to receive NAT at NAT facilities compared to White and non-Hispanic patients, respectively. Discrepancies in administration of NAT while being treated at NAT facilities exist and warrant urgent further investigation.
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Affiliation(s)
| | - Zhi Ven Fong
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | | | - Aparna R Parikh
- Department of Medicine, Massachusetts General Hospital, Boston, MA; and
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
| | | | | | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Boston, MA
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13
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Boucher Y, Posada JM, Subudhi S, Kumar AS, Rosario SR, Gu L, Kumra H, Mino-Kenudson M, Talele NP, Duda DG, Fukumura D, Wo JY, Clark JW, Ryan DP, Fernandez-Del Castillo C, Hong TS, Pittet MJ, Jain RK. Addition of Losartan to FOLFIRINOX and Chemoradiation Reduces Immunosuppression-Associated Genes, Tregs, and FOXP3+ Cancer Cells in Locally Advanced Pancreatic Cancer. Clin Cancer Res 2023; 29:1605-1619. [PMID: 36749873 PMCID: PMC10106451 DOI: 10.1158/1078-0432.ccr-22-1630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 12/31/2022] [Accepted: 02/03/2023] [Indexed: 02/09/2023]
Abstract
PURPOSE Adding losartan (LOS) to FOLFIRINOX (FFX) chemotherapy followed by chemoradiation (CRT) resulted in 61% R0 surgical resection in our phase II trial in patients with locally advanced pancreatic cancer (LAPC). Here we identify potential mechanisms of benefit by assessing the effects of neoadjuvant LOS on the tumor microenvironment. EXPERIMENTAL DESIGN We performed a gene expression and immunofluorescence (IF) analysis using archived surgical samples from patients treated with LOS+FFX+CRT (NCT01821729), FFX+CRT (NCT01591733), or surgery upfront, without any neoadjuvant therapy. We also conducted a longitudinal analysis of multiple biomarkers in the plasma of treated patients. RESULTS In comparison with FFX+CRT, LOS+FFX+CRT downregulated immunosuppression and pro-invasion genes. Overall survival (OS) was associated with dendritic cell (DC) and antigen presentation genes for patients treated with FFX+CRT, and with immunosuppression and invasion genes or DC- and blood vessel-related genes for those treated with LOS+FFX+CRT. Furthermore, LOS induced specific changes in circulating levels of IL-8, sTie2, and TGF-β. IF revealed significantly less residual disease in lesions treated with LOS+FFX+CRT. Finally, patients with a complete/near complete pathologic response in the LOS+FFX+CRT-treated group had reduced CD4+FOXP3+ regulatory T cells (Tregs), fewer immunosuppressive FOXP3+ cancer cells (C-FOXP3), and increased CD8+ T cells in pancreatic ductal adenocarcinoma lesions. CONCLUSIONS Adding LOS to FFX+CRT reduced pro-invasion and immunosuppression-related genes, which were associated with improved OS in patients with LAPC. Lesions from responders in the LOS+FFX+CRT-treated group had reduced Tregs, decreased C-FOXP3 and increased CD8+ T cells. These findings suggest that LOS may potentiate the benefit of FFX+CRT by reducing immunosuppression.
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Affiliation(s)
- Yves Boucher
- Steele Laboratories of Tumor Biology, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Jessica M. Posada
- Steele Laboratories of Tumor Biology, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston
- Department of Pathology, Brigham and Women’s Hospital, Boston, University of Geneva, CH-1211 Geneva, Switzerland
| | - Sonu Subudhi
- Steele Laboratories of Tumor Biology, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Ashwin S. Kumar
- Steele Laboratories of Tumor Biology, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston
- Harvard–MIT Division of Health Sciences and Technology, Cambridge, University of Geneva, CH-1211 Geneva, Switzerland
| | - Spencer R. Rosario
- Department of Biostatistics and Bioinformatics, University of Geneva, CH-1211 Geneva, Switzerland
- Department of Pharmacology and Therapeutics, Roswell Park Comprehensive Cancer Center, Buffalo, University of Geneva, CH-1211 Geneva, Switzerland
| | - Liqun Gu
- Steele Laboratories of Tumor Biology, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Heena Kumra
- Steele Laboratories of Tumor Biology, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Mari Mino-Kenudson
- Department of Pathology, University of Geneva, CH-1211 Geneva, Switzerland
| | - Nilesh P. Talele
- Steele Laboratories of Tumor Biology, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Dan G. Duda
- Steele Laboratories of Tumor Biology, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Dai Fukumura
- Steele Laboratories of Tumor Biology, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Jennifer Y. Wo
- Department of Radiation Oncology, University of Geneva, CH-1211 Geneva, Switzerland
| | - Jeffrey W. Clark
- Department of Medicine, University of Geneva, CH-1211 Geneva, Switzerland
| | - David P. Ryan
- Department of Medicine, University of Geneva, CH-1211 Geneva, Switzerland
| | | | - Theodore S. Hong
- Department of Radiation Oncology, University of Geneva, CH-1211 Geneva, Switzerland
| | - Mikael J. Pittet
- Department of Pathology and Immunology, University of Geneva, CH-1211 Geneva, Switzerland
- Ludwig Institute for Cancer Research, 1005 Lausanne, Switzerland
- Agora Cancer Research Center, Lausanne, Switzerland
| | - Rakesh K. Jain
- Steele Laboratories of Tumor Biology, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston
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14
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Furtado FS, Wu MZ, Esfahani SA, Ferrone CR, Blaszkowsky LS, Clark JW, Ryan DP, Goyal L, Franses JW, Wo JY, Hong TS, Qadan M, Tanabe KK, Weekes CD, Cusack JC, Crafa F, Mahmood U, Anderson MA, Mojtahed A, Hahn PF, Caravan P, Kilcoyne A, Vangel M, Striar RM, Rosen BR, Catalano OA. Positron Emission Tomography/Magnetic Resonance Imaging (PET/MRI) Versus the Standard of Care Imaging in the Diagnosis of Peritoneal Carcinomatosis. Ann Surg 2023; 277:e893-e899. [PMID: 35185121 DOI: 10.1097/sla.0000000000005418] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To compare positron emission tomography (PET)/magnetic resonance imaging (MRI) to the standard of care imaging (SCI) for the diagnosis of peritoneal carcinomatosis (PC) in primary abdominopelvic malignancies. SUMMARY BACKGROUND DATA Identifying PC impacts prognosis and management of multiple cancer types. METHODS Adult subjects were prospectively and consecutively enrolled from April 2019 to January 2021. Inclusion criteria were: 1) acquisition of whole-body contrast-enhanced (CE) 18F-fluorodeoxyglucose PET/MRI, 2) pathologically confirmed primary abdominopelvic malignancies. Exclusion criteria were: 1) greater than 4 weeks interval between SCI and PET/MRI, 2) unavailable follow-up. SCI consisted of whole-body CE PET/computed tomography (CT) with diagnostic quality CT, and/or CE-CT of the abdomen and pelvis, and/or CE-MRI of the abdomen±pelvis. If available, pathology or surgical findings served as the reference standard, otherwise, imaging followup was used. When SCI and PET/MRI results disagreed, medical records were checked for management changes. Follow-up data were collected until August 2021. RESULTS One hundred sixty-four subjects were included, 85 (52%) were female, and the median age was 60 years (interquartile range 50-69). At a subject level, PET/MRI had higher sensitivity (0.97, 95% CI 0.86-1.00) than SCI (0.54, 95% CI 0.37-0.71), P < 0.001, without a difference in specificity, of 0.95 (95% CI 0.90-0.98) for PET/MRI and 0.98 (95% CI 0.93-1.00) for SCI, P ¼ 0.250. PET/MRI and SCI results disagreed in 19 cases. In 5/19 (26%) of the discordant cases, PET/MRI findings consistent with PC missed on SCI led to management changes. CONCLUSION PET/MRI improves detection of PC compared with SCI which frequently changes management.
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Affiliation(s)
- Felipe S Furtado
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Athinoula A Martinos Center for Biomedical Imaging, Harvard Medical School, Charlestown, MA
| | - Mark Z Wu
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Shadi A Esfahani
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Athinoula A Martinos Center for Biomedical Imaging, Harvard Medical School, Charlestown, MA
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Lawrence S Blaszkowsky
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Jeffrey W Clark
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - David P Ryan
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Lipika Goyal
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Joseph W Franses
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Kenneth K Tanabe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Colin D Weekes
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - James C Cusack
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Umar Mahmood
- Athinoula A Martinos Center for Biomedical Imaging, Harvard Medical School, Charlestown, MA
| | - Mark A Anderson
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Amirkasra Mojtahed
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Peter F Hahn
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Peter Caravan
- Athinoula A Martinos Center for Biomedical Imaging, Harvard Medical School, Charlestown, MA
| | - Aoife Kilcoyne
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Mark Vangel
- Biostatistics Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Robin M Striar
- Athinoula A Martinos Center for Biomedical Imaging, Harvard Medical School, Charlestown, MA
| | - Bruce R Rosen
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Athinoula A Martinos Center for Biomedical Imaging, Harvard Medical School, Charlestown, MA
| | - Onofrio A Catalano
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Athinoula A Martinos Center for Biomedical Imaging, Harvard Medical School, Charlestown, MA
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Chamseddine I, Kim Y, De B, Naqa IE, Duda DG, Wolfgang JA, Pursley J, Wo JY, Hong TS, Paganetti H, Koay EJ, Grassberger C. Predictive Model of Liver Toxicity to Aid the Personalized Selection of Proton Versus Photon Therapy in Hepatocellular Carcinoma. Int J Radiat Oncol Biol Phys 2023:S0360-3016(23)00104-9. [PMID: 36739920 DOI: 10.1016/j.ijrobp.2023.01.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 12/23/2022] [Accepted: 01/27/2023] [Indexed: 02/05/2023]
Abstract
PURPOSE Our objective was to develop an externally validated model for predicting liver toxicity after radiation therapy in patients with hepatocellular carcinoma (HCC) that can integrate both photon and proton dose distributions with patient-specific characteristics. METHODS AND MATERIALS Training data consisted of all patients with HCC treated between 2008 and 2019 at our institution (n = 117, 60%/40% photon/proton). We developed a shallow convolutional neural network (CNN) to predict posttreatment liver dysfunction from the differential dose-volume histogram (DVH) and baseline liver metrics. To reduce bias and improve robustness, we used ensemble learning (CNNE). After a preregistered study analysis plan, we evaluated stability using internal bootstrap resampling and generalizability using a data set from a different institution (n = 88). Finally, we implemented a class activation map method to characterize the critical DVH subregions and benchmarked the model against logistic regression and XGBoost. The models were evaluated using the area under the receiver operating characteristic curve and area under the precision-recall curve. RESULTS The CNNE model showed similar internal performance and robustness compared with the benchmarks. CNNE exceeded the benchmark models in external validation, with an area under the receiver operating characteristic curve of 0.78 versus 0.55 to 0.70, and an area under the precision-recall curve of 0.6 versus 0.43 to 0.52. The model showed improved predictive power in the photon group, excellent specificity in both modalities, and high sensitivity in the photon high-risk group. Models built solely on DVHs confirm outperformance of the CNNE and indicate that the proposed structure efficiently abstracts features from both proton and photon dose distributions. The activation map method demonstrates the importance of the low-dose bath and its interaction with low liver function at baseline. CONCLUSIONS We developed and externally validated a patient-specific prediction model for hepatic toxicity based on the entire DVH and clinical factors that can integrate both photon and proton therapy cohorts. This model complements the new American Society for Radiation Oncology clinical practice guidelines and could support value-driven integration of proton therapy into the management of HCC.
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Affiliation(s)
- Ibrahim Chamseddine
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Yejin Kim
- Korean Advanced Institute of Science and Technology, Daejeon, South Korea
| | - Brian De
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Issam El Naqa
- Department of Machine Learning, Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Dan G Duda
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - John A Wolfgang
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jennifer Pursley
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Harald Paganetti
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Eugene J Koay
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Clemens Grassberger
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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16
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Wu TC, Sanford NN, Anand S, Chu FI, Wo JY, Raldow AC. Current Practice Patterns in Locally Advanced Rectal Cancer at Academic Institutions: A National Survey Among Radiation Oncologists, Medical Oncologists, and Colorectal Surgeons. Clin Colorectal Cancer 2022; 21:309-314. [PMID: 36216758 DOI: 10.1016/j.clcc.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/18/2022] [Accepted: 06/07/2022] [Indexed: 01/26/2023]
Abstract
PURPOSE To assess the current treatment patterns in locally advanced rectal cancer (LARC) among radiation oncologists (RO), medical oncologists (MO), and colorectal surgeons (SR) specializing in gastrointestinal (GI) malignancies at academic institutions. MATERIALS AND METHODS An online survey consisting of 7 LARC clinical vignettes was distributed to GI specialists practicing at ACGME accredited academic institutions. Treatment paradigms consisted of long-course chemoradiation (LC-CRT) and short-course (SCRT) radiotherapy, chemotherapy (CHT), and surgery. The survey was open from January to April 2021. RESULTS Thirty-six RO, 14 MO and 21 SR (71/508 physicians) replied resulting in a response rate of 14.0%. For low rectal node positive tumors, 88.7% of primary recommendations incorporated TNT (73.1% LC-CRT, 26.9% SCRT). NOM was preferred by 41.3% if a clinical complete response (cCR) was achieved. The presence of high-risk features led 95.8% of physicians to employ TNT (79.4% LC-CRT, 20.6% SCRT). For a cT3N1-2 mid-rectal tumor without high-risk features, 85.9% would primarily recommend TNT (56.6% LC-CRT, 43.4% SCRT). For a cT4bN2a mid-rectal tumor without high-risk features, 97.2% of primary recommendations included TNT (76.9% LC-CRT, 23.1% SCRT). CONCLUSION Among academic RO, MO, and SR, the traditional regimen of LC-CRT, surgery, and adjuvant CHT is now infrequently recommended for LARC. TNT has been widely adopted for locally advanced node positive rectal tumors with variable patterns of care with respect to sequencing of CHT and RT. Fractionation with LC-CRT remained the majority. Non-operative management after a cCR in low rectal tumors has gained traction transforming LARC from a once classically perceived surgical disease.
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Affiliation(s)
- Trudy C Wu
- Department of Radiation Oncology, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA.
| | - Nina N Sanford
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, TX
| | - Sidharth Anand
- Department of Medical Oncology, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA
| | - Fang-I Chu
- Department of Radiation Oncology, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA
| | - Jennifer Y Wo
- Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, MA
| | - Ann C Raldow
- Department of Radiation Oncology, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA
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17
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Boucher Y, Posada JM, Subudhi S, Rosario SR, Gu L, Kumar AS, Kumra H, Mino-Kenudson M, Talele NP, Duda DG, Fukumura D, Wo JY, Clark JW, Ryan DP, Castillo CFD, Hong TS, Pittet MJ, Jain RK. Abstract C043: Addition of losartan to FOLFORINOX and chemoradiation downregulates pro-invasion and immunosuppression-associated genes in locally advanced pancreatic cancer. Cancer Res 2022. [DOI: 10.1158/1538-7445.panca22-c043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Abstract
Purpose: Adding losartan to FOLFIRINOX (FFX) chemotherapy followed by chemoradiation (CRT) resulted in 61% R0 surgical resection in our phase II trial in patients with locally advanced pancreatic cancer. Here we identify potential mechanisms of benefit by assessing the effects of neoadjuvant losartan+FFX+CRT versus FFX+CRT on the stromal tumor microenvironment. Experimental Design: We performed a gene expression analysis of RNA extracted from pancreatic cancer tissue sections and immunofluorescence for cancer cells and immune cells using archived surgical samples from patients treated with losartan+FFX+CRT (NCT01591733), FFX+CRT (NCT01591733) or surgery upfront, without any neoadjuvant therapy. We then assessed whether certain gene sets could stratify the overall survival of patients. Results: Neoadjuvant losartan+FFX+CRT and FFX+CRT increased the expression of genes linked to vascular normalization, transendothelial migration of leukocytes, T cell activation and cytolytic activity, and dendritic cell related genes versus no neoadjuvant treatment. In comparison to FFX+CRT, losartan+FFX+CRT downregulated pro-invasion, immunosuppression, and M2 macrophages related genes, and upregulated genes associated with tumor suppression, including the p53 pathway. Furthermore, immunostaining revealed significantly less residual disease in lesions treated with losartan+FFX+CRT versus FFX+CRT. Losartan+FFX+CRT also reduced CD4+FOXP3+ regulatory T cells in pancreatic cancer lesions with a complete/near complete response. Overall survival was associated with dendritic cell and antigen presentation genes for patients treated with FFX+CRT, and with immunosuppression and invasion genes or dendritic cell- and blood vessel-related genes for those treated with losartan+FFX+CRT. Conclusions: Adding losartan to FFX+CRT reduced pro-invasion and immunosuppression related genes, which were associated with improved treatment outcomes in patients with locally advanced pancreatic cancer.
Citation Format: Yves Boucher, Jessica M. Posada, Sonu Subudhi, Spencer R. Rosario, Liqun Gu, Ashwin S. Kumar, Heena Kumra, Mari Mino-Kenudson, Nilesh P. Talele, Dan G. Duda, Dai Fukumura, Jennifer Y. Wo, Jeffrey W. Clark, David P. Ryan, Carlos Fernandez-Del Castillo, Theodore S. Hong, Mikael J. Pittet, Rakesh K. Jain. Addition of losartan to FOLFORINOX and chemoradiation downregulates pro-invasion and immunosuppression-associated genes in locally advanced pancreatic cancer [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer; 2022 Sep 13-16; Boston, MA. Philadelphia (PA): AACR; Cancer Res 2022;82(22 Suppl):Abstract nr C043.
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Affiliation(s)
| | | | | | | | - Liqun Gu
- 1Massachusetts General Hospital, Boston, MA,
| | | | - Heena Kumra
- 1Massachusetts General Hospital, Boston, MA,
| | | | | | - Dan G. Duda
- 1Massachusetts General Hospital, Boston, MA,
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18
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Hwang WL, Su J, Guo JA, Shiau C, Barth JL, Hoffman HI, Divakar P, Reeves JW, Miller E, Cervantes-Jaramillo G, Freed-Pastor W, Funes V, Wo JY, Hong TS, Castillo CFD, Zheng L, Aguirre AJ, Ting DT, Mino-Kenudson M, Jacks T. Abstract C052: Identifying mediators of perineural invasion in pancreatic cancer using spatial transcriptomics. Cancer Res 2022. [DOI: 10.1158/1538-7445.panca22-c052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Abstract
Intratumoral nerves play important and versatile roles in cancer initiation, progression, recurrence, treatment-resistance, metastasis, morbidity, and mortality for many malignancies but the diverse molecular mechanisms underlying tumor-nerve crosstalk remain largely unknown. One of the differentiating hallmarks of pancreatic ductal adenocarcinoma (PDAC) is an exceptionally high frequency of perineural invasion (PNI), a histopathologic manifestation of tumor-nerve crosstalk whereby cancer cells recruit, migrate towards, and envelop or invade peripheral nerves. Evidence for some neurochemicals/neurotrophins involved in PNI have been uncovered, but most of the underlying work was limited by a lack of cell-type specificity, spatial context, and fragmented focus on individual pathways. To address these shortcomings, we set out to comprehensively identify cell-type specific genes spatially linked to PNI in patient tumors and then dissect the functional roles of these genes through live imaging of dorsal root ganglia (DRG) sensory neurons incubated in conditioned media from cancer cell organoids overexpressing candidate genes via CRISPR activation (CRISPRa). First, we performed whole transcriptome digital spatial profiling (NanoString GeoMx) on twelve custom tissue microarrays (n=288 cores) derived from intratumorally-matched malignant regions with and without PNI in primary resected PDAC specimens (n=31 patients). Differential gene expression (DE) analysis (FDR < 0.001) for PNI demonstrated that for malignant cells there were 271 enriched and 65 depleted genes, and for fibroblasts there were 16 enriched and 27 depleted genes. We further evaluated associations between PNI and expression of malignant subtypes previously identified from single-nucleus RNA-seq applied to 43 primary resected PDAC specimens. We found that malignant cells engaged in PNI were enriched in the mesenchymal, basaloid and neural-like progenitor (NRP) subtypes and depleted in the classical subtype. To test these associations functionally, we generated isogenic murine organoid lines (KrasG12D/+;Trp53FL/FL;R26-dCas9-VPR) overexpressing subtype-driving transcription factors and collected conditioned media. DRG sensory neurons demonstrate enhanced and suppressed growth kinetics when grown in NRP and classical conditioned media, respectively; mesenchymal and basal-like conditioned media do not appear to influence growth kinetics. These results suggest that while mesenchymal, basaloid, and NRP cells likely all play a role in cancer cell invasion of nerves, NRP cells may have an additional role in tumor-nerve tropism. Additional experiments exploring the functional effects of the top enriched and depleted genes from the DE analysis are ongoing. We anticipate that this study will provide a high-resolution understanding of critical intercellular interactions in the PDAC tumor microenvironment that facilitate PNI and tumor-nerve crosstalk more broadly to guide novel therapeutic strategies.
Citation Format: William L. Hwang, Jennifer Su, Jimmy A. Guo, Carina Shiau, Jaimie L. Barth, Hannah I. Hoffman, Prajan Divakar, Jason W. Reeves, Eric Miller, Grissel Cervantes-Jaramillo, William Freed-Pastor, Vanessa Funes, Jennifer Y. Wo, Theodore S. Hong, Carlos Fernandez-del Castillo, Lei Zheng, Andrew J. Aguirre, David T. Ting, Mari Mino-Kenudson, Tyler Jacks. Identifying mediators of perineural invasion in pancreatic cancer using spatial transcriptomics [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer; 2022 Sep 13-16; Boston, MA. Philadelphia (PA): AACR; Cancer Res 2022;82(22 Suppl):Abstract nr C052.
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Affiliation(s)
| | - Jennifer Su
- 2Massachusetts Institute of Technology, Cambridge, MA,
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Lei Zheng
- 6Johns Hopkins University, Baltimore, MD,
| | | | | | | | - Tyler Jacks
- 2Massachusetts Institute of Technology, Cambridge, MA,
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Chawla A, Qadan M, Castillo CFD, Wo JY, Allen JN, Clark JW, Murphy JE, Catalano OA, Ryan DP, Ting DT, Deshpande V, Weekes CD, Parikh A, Lillemoe KD, Hong TS, Ferrone CR. Prospective Phase II Trials Validate the Effect of Neoadjuvant Chemotherapy on Pattern of Recurrence in Pancreatic Adenocarcinoma. Ann Surg 2022; 276:e502-e509. [PMID: 33086310 DOI: 10.1097/sla.0000000000004585] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to characterize the patterns of first recurrence after curative-intent resection for pancreatic adenocarcinoma (PDAC). SUMMARY OF BACKGROUND DATA We evaluated the first site of recurrence after neoadjuvant treatment as locoregional (LR) or distant metastasis (DM). To validate our findings, we evaluated the pattern from 2 phase II clinical trials evaluating neoadjuvant chemotherapy (NAC) in PDAC. METHODS We identified site of first recurrence from a retrospective cohort of patients from 2011 to 2017 treated with NAC followed by chemoradiation and then an operation or an operation first followed by adjuvant therapy, and 2 separate prospective cohorts of patients derived from 2 phase II clinical trials evaluating patients treated with NAC in borderline-resectable and locally advanced PDAC. RESULTS In the retrospective cohorts, 160 out of 285 patients (56.1%) recurred after a median disease-free survival (mDFS) of 17.2 months. The pattern of recurrence was DM in 81.9% of patients, versus LR in 11.1%. This pattern was consistent in patients treated with upfront resection and adjuvant chemotherapy (DM 83.0%, LR 16.9%) regardless of margin-involvement (DM 80.1%, LR 19.4%). The use of NAC did not alter pattern of recurrence; 81.7% had DM and 18.3% had LR. This pattern also remained consistent regardless of margin-involvement (DM 94.1%, LR 5.9%). In the Phase II borderline-resectable trial (NCI# 01591733) cohort of 32 patients, the mDFS was 34.2 months. Pattern of recurrence remained predominantly DM (88.9%) versus LR (11.1%). In the Phase II locally-advanced trial (NCI# 01821729) cohort of 34 patients, the mDFS was 30.7 months. Although there was a higher rate of local recurrence in this cohort, pattern of first recurrence remained predominantly DM (66.6%) versus LR (33.3%) and remained consistent independent of margin-status. CONCLUSIONS The pattern of recurrence in PDAC is predominantly DM rather than LR, and is consistent regardless of the use of NAC and margin involvement.
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Affiliation(s)
- Akhil Chawla
- Division of Surgical Oncology, Department of Surgery, Northwestern Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jill N Allen
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jeffrey W Clark
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Janet E Murphy
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Onofrio A Catalano
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - David P Ryan
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - David T Ting
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Vikram Deshpande
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Colin D Weekes
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Aparna Parikh
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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20
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Nipp RD, Gaufberg E, Vyas C, Azoba C, Qian CL, Jaggers J, Weekes CD, Allen JN, Roeland EJ, Parikh AR, Miller L, Wo JY, Smith MH, Brown PMC, Shulman E, Fernandez-Del Castillo C, Kimmelman AC, Ting D, Hong TS, Greer JA, Ryan DP, Temel JS, El-Jawahri A. Supportive Oncology Care at Home Intervention for Patients With Pancreatic Cancer. JCO Oncol Pract 2022; 18:e1587-e1593. [PMID: 35830625 DOI: 10.1200/op.22.00088] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 03/22/2022] [Accepted: 06/07/2022] [Indexed: 12/17/2023] Open
Abstract
PURPOSE We sought to determine the feasibility of delivering a Supportive Oncology Care at Home intervention among patients with pancreatic cancer. METHODS We prospectively enrolled patients with pancreatic cancer from a parent trial of neoadjuvant fluorouracil, leucovorin, oxaliplatin, and irinotecan (FOLFIRINOX). The intervention entailed (1) remote monitoring of patient-reported symptoms, vital signs, and body weight; (2) a hospital-at-home care model; and (3) structured communication with the oncology team. We defined the intervention as feasible if ≥ 60% of patients enrolled in the study and ≥ 60% completed the daily assessments within the first 2-weeks of enrollment. We determined rates of treatment delays, urgent clinic visits, emergency department visits, and hospitalizations among those who did (n = 20) and did not (n = 24) receive Supportive Oncology Care at Home from the parent trial. RESULTS From January 2019 to September 2020, we enrolled 80.8% (21/26) of potentially eligible patients. One patient became ineligible following consent because of moving out of state, resulting in 20 participants (median age = 67 years). In the first 2 weeks of enrollment, 65.0% of participants completed all daily assessments. Overall, patients reported 96.1% of daily symptoms, 96.1% of daily vital signs, and 92.5% of weekly body weights. Patients receiving the intervention had lower rates of treatment delays (55.0% v 75.0%), urgent clinic visits (10.0% v 25.0%), and emergency department visits/hospitalizations (45.0% v 62.5%) compared with those not receiving the intervention from the same parent trial. CONCLUSION Findings demonstrate the feasibility and acceptability of a Supportive Oncology Care at Home intervention. Future work will investigate the efficacy of this intervention for decreasing health care use and improving patient outcomes.
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Affiliation(s)
- Ryan D Nipp
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA
| | - Eva Gaufberg
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA
| | - Charu Vyas
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA
| | - Chinenye Azoba
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA
| | - Carolyn L Qian
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA
| | - Jordon Jaggers
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA
| | - Colin D Weekes
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA
| | - Jill N Allen
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA
| | - Eric J Roeland
- Division of Hematology/Medical Oncology, School of Medicine, Oregon Health and Science University, Portland, OR
| | - Aparna R Parikh
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA
| | - Laurie Miller
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | | | | | | | | | - Alec C Kimmelman
- Department of Radiation Oncology, Perlmutter Cancer Center NYU Langone Medical Center, New York, NY
| | - David Ting
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Joseph A Greer
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - David P Ryan
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA
| | - Jennifer S Temel
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA
| | - Areej El-Jawahri
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA
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21
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Saraf A, Roberts HJ, Wo JY, Parikh AR. Optimal Neoadjuvant Strategies for Locally Advanced Rectal Cancer by Risk Assessment and Tumor Location. J Natl Compr Canc Netw 2022; 20:1177-1184. [DOI: 10.6004/jnccn.2022.7061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 08/08/2022] [Indexed: 03/28/2023]
Abstract
Neoadjuvant therapy is standard of care for locally advanced rectal cancer (LARC). Advancements in multimodality therapy options and sequencing of radiation therapy (RT), surgery, and chemotherapy make decision-making challenging. Traditional treatment of patients with LARC involves neoadjuvant chemoradiation followed by total mesorectal excision and consideration of adjuvant chemotherapy. Advancement in RT has led to trials offering both short-course and long-course RT with good long-term clinical outcomes. Intensification of therapy in high-risk patients has led to studies of total neoadjuvant therapy with chemotherapy and chemoradiation, now standard management for most LARC. De-escalation of therapy in patients with favorable prognosis has led to several considerations, including non–total mesorectal excision management or neoadjuvant chemotherapy only. Several considerations of patient and disease factors can help inform the optimal chemotherapy regimens in different sequencing of neoadjuvant strategies. Finally, novel biomarkers, such as microsatellite instability, has led to utilization of novel therapies, including neoadjuvant immunotherapy, with substantial response. This review attempts to frame the rapidly growing data in LARC in context of disease and patient risk factors, to inform optimal, personalized treatment of patients with LARC.
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22
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Shiau C, Su J, Guo JA, Hong TS, Wo JY, Jagadeesh KA, Hwang WL. Treatment-associated remodeling of the pancreatic cancer endothelium at single-cell resolution. Front Oncol 2022; 12:929950. [PMID: 36185212 PMCID: PMC9524152 DOI: 10.3389/fonc.2022.929950] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 08/19/2022] [Indexed: 11/14/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is one of the most treatment refractory and lethal malignancies. The diversity of endothelial cell (EC) lineages in the tumor microenvironment (TME) impacts the efficacy of antineoplastic therapies, which in turn remodel EC states and distributions. Here, we present a single-cell resolution framework of diverse EC lineages in the PDAC TME in the context of neoadjuvant chemotherapy, radiotherapy, and losartan. We analyzed a custom single-nucleus RNA-seq dataset derived from 37 primary PDAC specimens (18 untreated, 14 neoadjuvant FOLFIRINOX + chemoradiotherapy, 5 neoadjuvant FOLFIRINOX + chemoradiotherapy + losartan). A single-nucleus transcriptome analysis of 15,185 EC profiles revealed two state programs (ribosomal, cycling), four lineage programs (capillary, arterial, venous, lymphatic), and one program that did not overlap significantly with prior signatures but was enriched in pathways involved in vasculogenesis, stem-like state, response to wounding and hypoxia, and endothelial-to-mesenchymal transition (reactive EndMT). A bulk transcriptome analysis of two independent cohorts (n = 269 patients) revealed that the lymphatic and reactive EndMT lineage programs were significantly associated with poor clinical outcomes. While losartan and proton therapy were associated with reduced lymphatic ECs, these therapies also correlated with an increase in reactive EndMT. Thus, the development and inclusion of EndMT-inhibiting drugs (e.g., nintedanib) to a neoadjuvant chemoradiotherapy regimen featuring losartan and/or proton therapy may be most effective in depleting both lymphatic and reactive EndMT populations and potentially improving patient outcomes.
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Affiliation(s)
- Carina Shiau
- Center for Systems Biology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Center for Cancer Research, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Broad Institute of Massachusetts Institute of Technology (MIT) and Harvard, Cambridge, MA, United States
| | - Jennifer Su
- Center for Systems Biology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Center for Cancer Research, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Broad Institute of Massachusetts Institute of Technology (MIT) and Harvard, Cambridge, MA, United States
| | - Jimmy A. Guo
- Center for Systems Biology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Center for Cancer Research, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Broad Institute of Massachusetts Institute of Technology (MIT) and Harvard, Cambridge, MA, United States
- Biological and Biomedical Sciences Program, Harvard Medical School, Boston, MA, United States
| | - Theodore S. Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Jennifer Y. Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Karthik A. Jagadeesh
- Broad Institute of Massachusetts Institute of Technology (MIT) and Harvard, Cambridge, MA, United States
- *Correspondence: William L. Hwang, ; Karthik A. Jagadeesh,
| | - William L. Hwang
- Center for Systems Biology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Center for Cancer Research, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Broad Institute of Massachusetts Institute of Technology (MIT) and Harvard, Cambridge, MA, United States
- *Correspondence: William L. Hwang, ; Karthik A. Jagadeesh,
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23
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Solidum JGN, Rojo RD, Wo JY, Dee EC. Proton Beam Therapy for Esophageal Cancer. Cancers (Basel) 2022; 14:cancers14164045. [PMID: 36011037 PMCID: PMC9407004 DOI: 10.3390/cancers14164045] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/09/2022] [Accepted: 08/12/2022] [Indexed: 12/05/2022] Open
Abstract
Simple Summary Early-stage esophageal cancer is managed surgically, with the addition of radiotherapy for locally advanced disease. Current photon-based radiotherapy results in a high treatment-related complications, due to proximal organ involvement. The anatomic location of the esophagus raises challenges due to the anatomical changes associated with diaphragmatic motion, weight loss, tumor changes, and set-up variability. These propelled the interest in proton beam therapy (PBT), which theoretically offers a reduction in the radiation exposure to healthy neighboring tissues with improvements in the therapeutic ratio. In this review, we present the role of PBT for esophageal cancer, including treatment planning, early clinical comparisons with photon-based techniques, ongoing trials, current challenges, toxicities, and issues of equity and health services. Abstract Early-stage esophageal cancer is often primarily managed surgically, with the addition of radiotherapy for locally advanced disease. However, current photon-based radiotherapy regimens and surgery results in a high incidence of treatment-related cardiac and pulmonary complications due to the involvement of proximal organs at risk. In addition, the anatomic location of the esophagus raises challenges for radiotherapy due to the anatomical changes associated with diaphragmatic motion, weight loss, tumor changes, and set-up variability. These challenges propelled the interest in proton beam therapy (PBT), which theoretically offers a reduction in the radiation exposure to healthy neighboring tissues with improvements in the therapeutic ratio. Several dosimetric studies support the potential advantages of PBT for esophageal cancer treatment however, translation of these results to improved clinical outcomes remains unclear with limited clinical data, especially in large populations. Studies on the effect on quality of life are likewise lacking. Here, we review the existing and emerging role of PBT for esophageal cancer, including treatment planning, early clinical comparisons of PBT with photon-based techniques, recently concluded and ongoing clinical trials, challenges and toxicities, effects on quality of life, and global inequities in the treatment of esophageal cancer.
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Affiliation(s)
- Jea Giezl N. Solidum
- College of Medicine, University of the Philippines Manila, Manila 1000, Metro Manila, Philippines
| | - Raniv D. Rojo
- College of Medicine, University of the Philippines Manila, Manila 1000, Metro Manila, Philippines
| | - Jennifer Y. Wo
- Department of Radiation Oncology, Massachusetts General Hospital, 100 Blossom St., Boston, MA 02114, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Edward Christopher Dee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
- Correspondence:
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24
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Hwang WL, Jagadeesh KA, Guo JA, Hoffman HI, Yadollahpour P, Reeves JW, Mohan R, Drokhlyansky E, Van Wittenberghe N, Ashenberg O, Farhi SL, Schapiro D, Divakar P, Miller E, Zollinger DR, Eng G, Schenkel JM, Su J, Shiau C, Yu P, Freed-Pastor WA, Abbondanza D, Mehta A, Gould J, Lambden C, Porter CBM, Tsankov A, Dionne D, Waldman J, Cuoco MS, Nguyen L, Delorey T, Phillips D, Barth JL, Kem M, Rodrigues C, Ciprani D, Roldan J, Zelga P, Jorgji V, Chen JH, Ely Z, Zhao D, Fuhrman K, Fropf R, Beechem JM, Loeffler JS, Ryan DP, Weekes CD, Ferrone CR, Qadan M, Aryee MJ, Jain RK, Neuberg DS, Wo JY, Hong TS, Xavier R, Aguirre AJ, Rozenblatt-Rosen O, Mino-Kenudson M, Castillo CFD, Liss AS, Ting DT, Jacks T, Regev A. Single-nucleus and spatial transcriptome profiling of pancreatic cancer identifies multicellular dynamics associated with neoadjuvant treatment. Nat Genet 2022; 54:1178-1191. [PMID: 35902743 DOI: 10.1038/s41588-022-01134-8] [Citation(s) in RCA: 88] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 06/16/2022] [Indexed: 12/24/2022]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is a highly lethal and treatment-refractory cancer. Molecular stratification in pancreatic cancer remains rudimentary and does not yet inform clinical management or therapeutic development. Here, we construct a high-resolution molecular landscape of the cellular subtypes and spatial communities that compose PDAC using single-nucleus RNA sequencing and whole-transcriptome digital spatial profiling (DSP) of 43 primary PDAC tumor specimens that either received neoadjuvant therapy or were treatment naive. We uncovered recurrent expression programs across malignant cells and fibroblasts, including a newly identified neural-like progenitor malignant cell program that was enriched after chemotherapy and radiotherapy and associated with poor prognosis in independent cohorts. Integrating spatial and cellular profiles revealed three multicellular communities with distinct contributions from malignant, fibroblast and immune subtypes: classical, squamoid-basaloid and treatment enriched. Our refined molecular and cellular taxonomy can provide a framework for stratification in clinical trials and serve as a roadmap for therapeutic targeting of specific cellular phenotypes and multicellular interactions.
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Affiliation(s)
- William L Hwang
- Center for Systems Biology and Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Broad Institute of MIT and Harvard, Cambridge, MA, USA.,Koch Institute for Integrative Cancer Research, Department of Biology, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Karthik A Jagadeesh
- Center for Systems Biology and Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Jimmy A Guo
- Center for Systems Biology and Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Broad Institute of MIT and Harvard, Cambridge, MA, USA.,School of Medicine, University of California, San Francisco, San Francisco, CA, USA.,Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA.,Biological and Biomedical Sciences Program, Harvard Medical School, Boston, MA, USA
| | - Hannah I Hoffman
- Center for Systems Biology and Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Broad Institute of MIT and Harvard, Cambridge, MA, USA.,Koch Institute for Integrative Cancer Research, Department of Biology, Massachusetts Institute of Technology, Cambridge, MA, USA.,Harvard-MIT MD/PhD and Health Sciences and Technology Program, Harvard Medical School, Boston, MA, USA
| | - Payman Yadollahpour
- Center for Systems Biology and Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | | | - Rahul Mohan
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | | | | | - Orr Ashenberg
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | | | - Denis Schapiro
- Broad Institute of MIT and Harvard, Cambridge, MA, USA.,Laboratory of Systems Pharmacology, Department of Systems Biology, Harvard Medical School, Boston, MA, USA.,Institute for Computational Biomedicine and Institute of Pathology, Faculty of Medicine, Heidelberg University and Heidelberg University Hospital, Heidelberg, Germany
| | | | | | | | - George Eng
- Koch Institute for Integrative Cancer Research, Department of Biology, Massachusetts Institute of Technology, Cambridge, MA, USA.,Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jason M Schenkel
- Koch Institute for Integrative Cancer Research, Department of Biology, Massachusetts Institute of Technology, Cambridge, MA, USA.,Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jennifer Su
- Center for Systems Biology and Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Broad Institute of MIT and Harvard, Cambridge, MA, USA.,Koch Institute for Integrative Cancer Research, Department of Biology, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Carina Shiau
- Center for Systems Biology and Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Patrick Yu
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - William A Freed-Pastor
- Koch Institute for Integrative Cancer Research, Department of Biology, Massachusetts Institute of Technology, Cambridge, MA, USA.,Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | | | - Arnav Mehta
- Broad Institute of MIT and Harvard, Cambridge, MA, USA.,Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA.,Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joshua Gould
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | | | | | | | | | - Julia Waldman
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | | | - Lan Nguyen
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Toni Delorey
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Devan Phillips
- Broad Institute of MIT and Harvard, Cambridge, MA, USA.,Genentech, South San Francisco, CA, USA
| | - Jaimie L Barth
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marina Kem
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Clifton Rodrigues
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Debora Ciprani
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jorge Roldan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Piotr Zelga
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Vjola Jorgji
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jonathan H Chen
- Broad Institute of MIT and Harvard, Cambridge, MA, USA.,Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Zackery Ely
- Koch Institute for Integrative Cancer Research, Department of Biology, Massachusetts Institute of Technology, Cambridge, MA, USA
| | | | | | | | | | - Jay S Loeffler
- Center for Systems Biology and Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - David P Ryan
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Colin D Weekes
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Martin J Aryee
- Broad Institute of MIT and Harvard, Cambridge, MA, USA.,Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Rakesh K Jain
- Center for Systems Biology and Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Edwin L. Steele Laboratory for Tumor Biology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Donna S Neuberg
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jennifer Y Wo
- Center for Systems Biology and Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Theodore S Hong
- Center for Systems Biology and Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ramnik Xavier
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Andrew J Aguirre
- Broad Institute of MIT and Harvard, Cambridge, MA, USA.,Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Orit Rozenblatt-Rosen
- Broad Institute of MIT and Harvard, Cambridge, MA, USA.,Genentech, South San Francisco, CA, USA
| | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Andrew S Liss
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - David T Ting
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Tyler Jacks
- Koch Institute for Integrative Cancer Research, Department of Biology, Massachusetts Institute of Technology, Cambridge, MA, USA.
| | - Aviv Regev
- Broad Institute of MIT and Harvard, Cambridge, MA, USA. .,Genentech, South San Francisco, CA, USA.
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25
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DuBois JS, Kambadakone A, Wo JY, Zhang ML. Case 19-2022: A 29-Year-Old Woman with Jaundice and Chronic Diarrhea. N Engl J Med 2022; 386:2413-2423. [PMID: 35731657 DOI: 10.1056/nejmcpc2201231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Jon S DuBois
- From the Departments of Medicine (J.S.D.), Radiology (A.K.), Radiation Oncology (J.Y.W.), and Pathology (M.L.Z.), Massachusetts General Hospital, and the Departments of Medicine (J.S.D.), Radiology (A.K.), Radiation Oncology (J.Y.W.), and Pathology (M.L.Z.), Harvard Medical School - both in Boston
| | - Avinash Kambadakone
- From the Departments of Medicine (J.S.D.), Radiology (A.K.), Radiation Oncology (J.Y.W.), and Pathology (M.L.Z.), Massachusetts General Hospital, and the Departments of Medicine (J.S.D.), Radiology (A.K.), Radiation Oncology (J.Y.W.), and Pathology (M.L.Z.), Harvard Medical School - both in Boston
| | - Jennifer Y Wo
- From the Departments of Medicine (J.S.D.), Radiology (A.K.), Radiation Oncology (J.Y.W.), and Pathology (M.L.Z.), Massachusetts General Hospital, and the Departments of Medicine (J.S.D.), Radiology (A.K.), Radiation Oncology (J.Y.W.), and Pathology (M.L.Z.), Harvard Medical School - both in Boston
| | - M Lisa Zhang
- From the Departments of Medicine (J.S.D.), Radiology (A.K.), Radiation Oncology (J.Y.W.), and Pathology (M.L.Z.), Massachusetts General Hospital, and the Departments of Medicine (J.S.D.), Radiology (A.K.), Radiation Oncology (J.Y.W.), and Pathology (M.L.Z.), Harvard Medical School - both in Boston
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Hwang WL, Jagadeesh KA, Guo JA, Hoffman HI, Shiau C, Su J, Yadollahpour P, Reeves JW, Kim Y, Kim S, Gregory M, Divakar P, Miller E, Rhodes M, Warren S, Rueckert E, Fuhrman K, Zollinger DR, Fropf R, Beechem JM, Mehta A, Delorey T, McCabe C, Barth JL, Zelga P, Ferrone CR, Qadan M, Lillemoe KD, Jain RK, Wo JY, Hong TS, Xavier R, Rozenblatt-Rosen O, Aguirre AJ, Castillo CFD, Liss AS, Mino-Kenudson M, Ting DT, Jacks T, Regev A. Abstract SY12-04: Multicellular spatial community featuring a novel neuronal-like malignant phenotype is enriched in pancreatic cancer after neoadjuvant chemotherapy and radiotherapy. Cancer Res 2022. [DOI: 10.1158/1538-7445.am2022-sy12-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is projected to be the second leading cause of cancer mortality in the United States by 2030. Given that resistance to cytotoxic therapy is pervasive, there is a critical need to elucidate salient gene expression programs and spatial relationships among malignant and stromal cells in the tumor microenvironment (TME), particularly in residual disease. We developed and applied a single-nucleus RNA-seq (snRNA-seq) technique to 43 banked frozen primary PDAC specimens that either received neoadjuvant therapy (n=25) or were treatment-naïve (n=18). We discovered expression programs across malignant cell and fibroblast profiles that formed the basis for a refined molecular taxonomy, including a novel neural-like progenitor (NRP) malignant program enriched with neoadjuvant treatment in tumors and organoids, and associated with the worst prognosis in bulk profiles from independent cohorts.
To elucidate how neoadjuvant treatment and cancer cell- and fibroblast-intrinsic programs modulate the composition of multicellular neighborhoods, we performed spatial profiling with the GeoMx[1] platform (NanoString) on 21 formalin-fixed paraffin-embedded sections using the human whole transcriptome atlas (WTA). Each tumor showed intra-tumoral heterogeneity in tissue architecture and regions of interest (ROIs) with diverse patterns of neoplastic cells, cancer-associated fibroblasts (CAFs), and immune cells were selected for profiling. We deconvolved the WTA data with our snRNA-seq cell type signatures and mapped expression programs onto the tumor architecture to reveal three distinct multicellular neighborhoods, which we annotated as classical, squamoid-basaloid, and treatment-enriched. The observed enrichment in post-treatment residual disease of multiple spatially-defined receptor-ligand interactions and a neighborhood featuring the NRP program, neurotropic CAF program, and CD8+ T cells may open new therapeutic opportunities.
Next, we mapped malignant/CAF programs and immune cell subsets at single-cell spatial resolution by performing spatial molecular imaging (SMI[2]; NanoString CosMx) using a panel of 960 RNA targets on a subset of seven tumors (2 untreated, 5 treated) and captured over 200,000 cells with an average of more than 450 transcripts detected per cell. Correlating ROIs from whole-transcriptome DSP to matched fields of view in kiloplex SMI enabled further dissection of PDAC architecture and treatment-associated remodeling of cell type distributions and receptor-ligand interactions.
Ongoing functional studies have begun to elucidate the key regulatory elements underlying the distinct treatment-associated NRP malignant program and its interactions with the TME. Overall, the complementary combination of snRNA-seq, whole-transcriptome DSP, and kiloplex SMI provides a high-resolution molecular framework that can be harnessed to augment precision oncology efforts in pancreatic cancer.
[1] GeoMx DSP is for Research Use Only and not for use in diagnostic procedures. [2] CosMx SMI is for Research Use Only and not for use in diagnostic procedures.
Citation Format: William L. Hwang, Karthik A. Jagadeesh, Jimmy A. Guo, Hannah I. Hoffman, Carina Shiau, Jennifer Su, Payman Yadollahpour, Jason W. Reeves, Youngmi Kim, Sean Kim, Mark Gregory, Prajan Divakar, Eric Miller, Michael Rhodes, Sarah Warren, Erroll Rueckert, Kit Fuhrman, Daniel R. Zollinger, Robin Fropf, Joseph M. Beechem, Arnav Mehta, Toni Delorey, Cristin McCabe, Jaimie L. Barth, Piotr Zelga, Cristina R. Ferrone, Motaz Qadan, Keith D. Lillemoe, Rakesh K. Jain, Jennifer Y. Wo, Theodore S. Hong, Ramnik Xavier, Orit Rozenblatt-Rosen, Andrew J. Aguirre, Carlos Fernandez-Del Castillo, Andrew S. Liss, Mari Mino-Kenudson, David T. Ting, Tyler Jacks, Aviv Regev. Multicellular spatial community featuring a novel neuronal-like malignant phenotype is enriched in pancreatic cancer after neoadjuvant chemotherapy and radiotherapy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr SY12-04.
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Affiliation(s)
| | | | | | | | | | - Jennifer Su
- 4Massachusetts Institute of Technology, Cambridge, MA
| | | | | | | | - Sean Kim
- 5NanoString Technologies, Seattle, WA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Tyler Jacks
- 4Massachusetts Institute of Technology, Cambridge, MA
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Park J, Venkatesulu BP, Kujundzic K, Katsoulakis E, Solanki AA, Puckett LL, Kapoor R, Chapman CH, Hagan M, Kelly MD, Palta J, Ashman JB, Jacqmin D, Kachnic LA, Minsky BD, Olsen J, Raldow AC, Wo JY, Dawes S, Wilson E, Kudner R, Das P. Consensus Quality Measures and Dose Constraints for Rectal Cancer From the Veterans Affairs Radiation Oncology Quality Surveillance Program and American Society for Radiation Oncology (ASTRO) Expert Panel. Pract Radiat Oncol 2022; 12:424-436. [PMID: 35907764 DOI: 10.1016/j.prro.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 05/12/2022] [Accepted: 05/13/2022] [Indexed: 12/01/2022]
Abstract
PURPOSE Ensuring high quality, evidence-based radiation therapy for patients with cancer is of the upmost importance. To address this need, the Veterans Affairs (VA) Radiation Oncology Program partnered with the American Society for Radiation Oncology and established the VA Radiation Oncology Quality Surveillance program. As part of this ongoing effort to provide the highest quality of care for patients with rectal cancer, a blue-ribbon panel comprised of rectal cancer experts was formed to develop clinical quality measures. METHODS AND MATERIALS The Rectal Cancer Blue Ribbon panel developed quality, surveillance, and aspirational measures for (a) initial consultation and workup, (b) simulation, treatment planning, and treatment, and (c) follow-up. Twenty-two rectal cancer specific measures were developed (19 quality, 1 aspirational, and 2 surveillance). In addition, dose-volume histogram constraints for conventional and hypofractionated radiation therapy were created. CONCLUSIONS The quality measures and dose-volume histogram for rectal cancer serves as a guideline to assess the quality of care for patients with rectal cancer receiving radiation therapy. These quality measures will be used for quality surveillance for veterans receiving care both inside and outside the VA system to improve the quality of care for these patients.
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Affiliation(s)
- John Park
- Department of Radiation Oncology, Kansas City VA Medical Center, Kansas City, Missouri; Department of Radiology, University of Missouri Kansas City School of Medicine, Kansas City, Missouri.
| | - Bhanu Prasad Venkatesulu
- Department of Radiation Oncology, Strich School of Medicine, Loyola University, Chicago, Illinois
| | | | - Evangelia Katsoulakis
- Department of Radiation Oncology, James A. Haley Veterans Affairs Healthcare System, Tampa, Florida
| | - Abhishek A Solanki
- Department of Radiation Oncology, Strich School of Medicine, Loyola University, Chicago, Illinois; Department of Radiation Oncology, Edward Hines, Jr. VA Hospital, Chicago, Illinois
| | - Lindsay L Puckett
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Radiation Oncology, Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin
| | - Rishabh Kapoor
- Department of Radiation Oncology, Virginia Commonwealth University School of Medicine, Richmond, Virginia; Department of Radiation Oncology, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia
| | - Christina H Chapman
- Department of Radiation Oncology, University of Michigan Medical School, Ann Arbor, Michigan; Department of Radiation Oncology, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Michael Hagan
- Department of Radiation Oncology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Maria D Kelly
- VHA National Radiation Oncology Program, Richmond, Virginia
| | - Jatinder Palta
- Department of Radiation Oncology, Virginia Commonwealth University School of Medicine, Richmond, Virginia; VHA National Radiation Oncology Program, Richmond, Virginia
| | | | - Dustin Jacqmin
- Department of Radiation Oncology, University of Wisconsin, Madison, Wisconsin
| | - Lisa A Kachnic
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
| | - Bruce D Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jeffrey Olsen
- Department of Radiation Oncology, University of Colorado, Aurora, Colorado
| | - Ann C Raldow
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Samantha Dawes
- American Society for Radiation Oncology, Arlington, Virginia
| | - Emily Wilson
- American Society for Radiation Oncology, Arlington, Virginia
| | - Randi Kudner
- American Society for Radiation Oncology, Arlington, Virginia
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Park J, Puckett LL, Katsoulakis E, Venkatesulu BP, Kujundzic K, Solanki AA, Movsas B, Simone CB, Sandler H, Lawton CA, Das P, Wo JY, Buchholz TA, Fisher CM, Harrison LB, Sher DJ, Kapoor R, Chapman CH, Dawes S, Kudner R, Wilson E, Hagan M, Palta J, Kelly MD. Veterans Affairs Radiation Oncology Quality Surveillance Program and American Society for Radiation Oncology Quality Measures Initiative. Pract Radiat Oncol 2022; 12:468-474. [PMID: 35690354 DOI: 10.1016/j.prro.2022.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 05/27/2022] [Accepted: 05/31/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Ensuring high quality, evidence-based radiation therapy for patients is of the upmost importance. As a part of the largest integrated health system in America, the Department of Veterans Affairs National Radiation Oncology Program (VA-NROP) established a quality surveillance initiative to address the challenge and necessity of providing the highest quality of care for veterans treated for cancer. METHODS As part of this initiative, the VA-NROP contracted with the American Society for Radiation Oncology (ASTRO) to commission five Blue-Ribbon Panels for lung, prostate, rectal, breast, and head & neck cancers experts. This group worked collaboratively with the VA-NROP to develop consensus quality measures. In addition to the site-specific measures, an additional Blue-Ribbon Panel comprised of the chairs and other members of the disease sites was formed to create 18 harmonized quality measures for all five sites (13 quality, 4 surveillance, and 1 aspirational). CONCLUSION The VA-NROP and ASTRO collaboration have created quality measures spanning five disease sites to help improve patient outcomes. These will be used for the ongoing quality surveillance of veterans receiving radiation therapy through the VA and its community partners. ETHICS BOARD APPROVAL N/A - No human subjects were required.
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Affiliation(s)
- John Park
- Department of Radiation Oncology, Kansas City VA Medical Center, Kansas City, MO; Department of Radiology, Univ. of Missouri Kansas City School of Medicine, Kansas City, MO.
| | - Lindsay L Puckett
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI; Department of Radiation Oncology, Clement J. Zablocki VA Medical Center, Milwaukee, WI
| | - Evangelia Katsoulakis
- Department of Radiation Oncology, James A. Haley Veterans Affairs Healthcare System, Tampa, FL
| | | | | | - Abhishek A Solanki
- Department of Radiation Oncology, Strich School of Medicine, Loyola University, Chicago, IL; Department of Radiation Oncology, Edward Hines, Jr. VA Hospital, Chicago, IL
| | - Benjamin Movsas
- Department of Radiation Oncology, Henry Ford Cancer Institute, Detroit, MI
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Howard Sandler
- Department of Radiation Oncology, Cedar-Sinai Medical Center, Los Angeles, CA
| | - Colleen A Lawton
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
| | - Thomas A Buchholz
- Department of Radiation Oncology, Scripps MD Anderson Cancer Center, San Diego, CA
| | | | - Louis B Harrison
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL
| | - David J Sher
- Department of Radiation Oncology, UT Southwestern Dallas, TX
| | - Rishabh Kapoor
- Department of Radiation Oncology, Virginia Commonwealth University School of Medicine, Richmond, VA; Department of Radiation Oncology, Hunter Holmes McGuire VA Medical Center, Richmond, VA
| | - Christina H Chapman
- Department of Radiation Oncology, University of Michigan Medical School, Ann Arbor, MI; Department of Radiation Oncology, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | | | - Randi Kudner
- American Society for Radiation Oncology, Arlington, VA
| | - Emily Wilson
- American Society for Radiation Oncology, Arlington, VA
| | - Michael Hagan
- Department of Radiation Oncology, Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Jatinder Palta
- Department of Radiation Oncology, Virginia Commonwealth University School of Medicine, Richmond, VA; VHA National Radiation Oncology Program, Richmond, VA
| | - Maria D Kelly
- VHA National Radiation Oncology Program, Richmond, VA
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Rajurkar M, Parikh AR, Solovyov A, You E, Kulkarni AS, Chu C, Xu KH, Jaicks C, Taylor MS, Wu C, Alexander KA, Good CR, Szabolcs A, Gerstberger S, Tran AV, Xu N, Ebright RY, Van Seventer EE, Vo KD, Tai EC, Lu C, Joseph-Chazan J, Raabe MJ, Nieman LT, Desai N, Arora KS, Ligorio M, Thapar V, Cohen L, Garden PM, Senussi Y, Zheng H, Allen JN, Blaszkowsky LS, Clark JW, Goyal L, Wo JY, Ryan DP, Corcoran RB, Deshpande V, Rivera MN, Aryee MJ, Hong TS, Berger SL, Walt DR, Burns KH, Park PJ, Greenbaum BD, Ting DT. Reverse Transcriptase Inhibition Disrupts Repeat Element Life Cycle in Colorectal Cancer. Cancer Discov 2022; 12:1462-1481. [PMID: 35320348 PMCID: PMC9167735 DOI: 10.1158/2159-8290.cd-21-1117] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [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: 08/17/2021] [Revised: 01/27/2022] [Accepted: 03/08/2022] [Indexed: 11/16/2022]
Abstract
Altered RNA expression of repetitive sequences and retrotransposition are frequently seen in colorectal cancer, implicating a functional importance of repeat activity in cancer progression. We show the nucleoside reverse transcriptase inhibitor 3TC targets activities of these repeat elements in colorectal cancer preclinical models with a preferential effect in p53-mutant cell lines linked with direct binding of p53 to repeat elements. We translate these findings to a human phase II trial of single-agent 3TC treatment in metastatic colorectal cancer with demonstration of clinical benefit in 9 of 32 patients. Analysis of 3TC effects on colorectal cancer tumorspheres demonstrates accumulation of immunogenic RNA:DNA hybrids linked with induction of interferon response genes and DNA damage response. Epigenetic and DNA-damaging agents induce repeat RNAs and have enhanced cytotoxicity with 3TC. These findings identify a vulnerability in colorectal cancer by targeting the viral mimicry of repeat elements. SIGNIFICANCE Colorectal cancers express abundant repeat elements that have a viral-like life cycle that can be therapeutically targeted with nucleoside reverse transcriptase inhibitors (NRTI) commonly used for viral diseases. NRTIs induce DNA damage and interferon response that provide a new anticancer therapeutic strategy. This article is highlighted in the In This Issue feature, p. 1397.
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Affiliation(s)
- Mihir Rajurkar
- Mass General Cancer Center, Harvard Medical School; Charlestown, MA, USA
| | - Aparna R. Parikh
- Mass General Cancer Center, Harvard Medical School; Charlestown, MA, USA
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School; Boston, MA, USA
| | - Alexander Solovyov
- Computational Oncology, Department of Epidemiology and Biostatistics; Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Eunae You
- Mass General Cancer Center, Harvard Medical School; Charlestown, MA, USA
| | | | - Chong Chu
- Department of Biomedical Informatics, Harvard Medical School; Boston, MA, USA
| | - Katherine H. Xu
- Mass General Cancer Center, Harvard Medical School; Charlestown, MA, USA
| | - Christopher Jaicks
- Mass General Cancer Center, Harvard Medical School; Charlestown, MA, USA
| | - Martin S. Taylor
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School; Boston, MA, USA
| | - Connie Wu
- Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School; Boston, MA, USA
- Wyss Institute for Biologically Inspired Engineering, Harvard Medical School; Boston, MA, USA
| | - Katherine A. Alexander
- Epigenetics Institute, Departments of Cell and Developmental Biology, Genetics, and Biology, Perelman School of Medicine, University of Pennsylvania; Philadelphia, PA, USA
| | - Charly R. Good
- Epigenetics Institute, Departments of Cell and Developmental Biology, Genetics, and Biology, Perelman School of Medicine, University of Pennsylvania; Philadelphia, PA, USA
| | - Annamaria Szabolcs
- Mass General Cancer Center, Harvard Medical School; Charlestown, MA, USA
| | - Stefanie Gerstberger
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School; Boston, MA, USA
| | - Antuan V. Tran
- Department of Biomedical Informatics, Harvard Medical School; Boston, MA, USA
| | - Nova Xu
- Mass General Cancer Center, Harvard Medical School; Charlestown, MA, USA
| | - Richard Y. Ebright
- Mass General Cancer Center, Harvard Medical School; Charlestown, MA, USA
| | | | - Kevin D. Vo
- Mass General Cancer Center, Harvard Medical School; Charlestown, MA, USA
| | - Eric C. Tai
- Mass General Cancer Center, Harvard Medical School; Charlestown, MA, USA
| | - Chenyue Lu
- Mass General Cancer Center, Harvard Medical School; Charlestown, MA, USA
| | | | - Michael J. Raabe
- Mass General Cancer Center, Harvard Medical School; Charlestown, MA, USA
| | - Linda T. Nieman
- Mass General Cancer Center, Harvard Medical School; Charlestown, MA, USA
| | - Niyati Desai
- Mass General Cancer Center, Harvard Medical School; Charlestown, MA, USA
| | - Kshitij S. Arora
- Mass General Cancer Center, Harvard Medical School; Charlestown, MA, USA
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School; Boston, MA, USA
| | - Matteo Ligorio
- Mass General Cancer Center, Harvard Medical School; Charlestown, MA, USA
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School; Boston, MA, USA
| | - Vishal Thapar
- Mass General Cancer Center, Harvard Medical School; Charlestown, MA, USA
| | - Limor Cohen
- Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School; Boston, MA, USA
- Wyss Institute for Biologically Inspired Engineering, Harvard Medical School; Boston, MA, USA
| | - Padric M. Garden
- Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School; Boston, MA, USA
- Wyss Institute for Biologically Inspired Engineering, Harvard Medical School; Boston, MA, USA
| | - Yasmeen Senussi
- Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School; Boston, MA, USA
- Wyss Institute for Biologically Inspired Engineering, Harvard Medical School; Boston, MA, USA
| | - Hui Zheng
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Jill N. Allen
- Mass General Cancer Center, Harvard Medical School; Charlestown, MA, USA
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School; Boston, MA, USA
| | - Lawrence S. Blaszkowsky
- Mass General Cancer Center, Harvard Medical School; Charlestown, MA, USA
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School; Boston, MA, USA
| | - Jeffrey W. Clark
- Mass General Cancer Center, Harvard Medical School; Charlestown, MA, USA
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School; Boston, MA, USA
| | - Lipika Goyal
- Mass General Cancer Center, Harvard Medical School; Charlestown, MA, USA
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School; Boston, MA, USA
| | - Jennifer Y. Wo
- Mass General Cancer Center, Harvard Medical School; Charlestown, MA, USA
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School; Boston, MA, USA
| | - David P. Ryan
- Mass General Cancer Center, Harvard Medical School; Charlestown, MA, USA
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School; Boston, MA, USA
| | - Ryan B. Corcoran
- Mass General Cancer Center, Harvard Medical School; Charlestown, MA, USA
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School; Boston, MA, USA
| | - Vikram Deshpande
- Mass General Cancer Center, Harvard Medical School; Charlestown, MA, USA
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School; Boston, MA, USA
| | - Miguel N. Rivera
- Mass General Cancer Center, Harvard Medical School; Charlestown, MA, USA
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School; Boston, MA, USA
| | - Martin J. Aryee
- Mass General Cancer Center, Harvard Medical School; Charlestown, MA, USA
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School; Boston, MA, USA
| | - Theodore S. Hong
- Mass General Cancer Center, Harvard Medical School; Charlestown, MA, USA
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School; Boston, MA, USA
| | - Shelley L. Berger
- Epigenetics Institute, Departments of Cell and Developmental Biology, Genetics, and Biology, Perelman School of Medicine, University of Pennsylvania; Philadelphia, PA, USA
| | - David R. Walt
- Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School; Boston, MA, USA
- Wyss Institute for Biologically Inspired Engineering, Harvard Medical School; Boston, MA, USA
| | - Kathleen H. Burns
- Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School; Boston, MA, USA
- Department of Oncologic Pathology, Dana-Farber Cancer Institute, Harvard Medical School; Boston, MA, USA
| | - Peter J. Park
- Department of Biomedical Informatics, Harvard Medical School; Boston, MA, USA
| | - Benjamin D. Greenbaum
- Computational Oncology, Department of Epidemiology and Biostatistics; Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Physiology, Biophysics & Systems Biology, Weill Cornell Medicine, Weill Cornell Medical College, New York, NY, USA
| | - David T. Ting
- Mass General Cancer Center, Harvard Medical School; Charlestown, MA, USA
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School; Boston, MA, USA
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Bajaj SS, Jain B, Dee EC, Wo JY, Qadan M. ASO Research Letter: Trends in Location of Death for Individuals with Pancreatic Cancer in the United States. Ann Surg Oncol 2022; 29:2766-2768. [PMID: 34748124 DOI: 10.1245/s10434-021-11058-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 10/26/2021] [Indexed: 11/18/2022]
Affiliation(s)
| | - Bhav Jain
- Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Edward Christopher Dee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Harvard Medical School, Boston, MA, USA
| | - Jennifer Y Wo
- Harvard Medical School, Boston, MA, USA
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Motaz Qadan
- Harvard Medical School, Boston, MA, USA.
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.
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Shi DD, Guo JA, Hoffman HI, Su J, Mino-Kenudson M, Barth JL, Schenkel JM, Loeffler JS, Shih HA, Hong TS, Wo JY, Aguirre AJ, Jacks T, Zheng L, Wen PY, Wang TC, Hwang WL. Therapeutic avenues for cancer neuroscience: translational frontiers and clinical opportunities. Lancet Oncol 2022; 23:e62-e74. [PMID: 35114133 PMCID: PMC9516432 DOI: 10.1016/s1470-2045(21)00596-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/28/2021] [Accepted: 10/08/2021] [Indexed: 02/03/2023]
Abstract
With increasing attention on the essential roles of the tumour microenvironment in recent years, the nervous system has emerged as a novel and crucial facilitator of cancer growth. In this Review, we describe the foundational, translational, and clinical advances illustrating how nerves contribute to tumour proliferation, stress adaptation, immunomodulation, metastasis, electrical hyperactivity and seizures, and neuropathic pain. Collectively, this expanding knowledge base reveals multiple therapeutic avenues for cancer neuroscience that warrant further exploration in clinical studies. We discuss the available clinical data, including ongoing trials investigating novel agents targeting the tumour-nerve axis, and the therapeutic potential for repurposing existing neuroactive drugs as an anti-cancer approach, particularly in combination with established treatment regimens. Lastly, we discuss the clinical challenges of these treatment strategies and highlight unanswered questions and future directions in the burgeoning field of cancer neuroscience.
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Affiliation(s)
- Diana D Shi
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Jimmy A Guo
- Department of Radiation Oncology, Massachusetts General Hospital Cancer Center, Boston, MA, USA; School of Medicine, University of California, San Francisco, San Francisco, CA, USA; Broad Institute of MIT and Harvard, Cambridge, MA, USA; Biological and Biomedical Sciences Program, Harvard University, Boston, MA, USA; Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Hannah I Hoffman
- Department of Radiation Oncology, Massachusetts General Hospital Cancer Center, Boston, MA, USA; Broad Institute of MIT and Harvard, Cambridge, MA, USA; Department of Biology, Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA; Harvard-MIT Health Sciences and Technology Program, Harvard Medical School, Boston, MA, USA
| | - Jennifer Su
- Department of Radiation Oncology, Massachusetts General Hospital Cancer Center, Boston, MA, USA; Broad Institute of MIT and Harvard, Cambridge, MA, USA; Department of Biology, Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jaimie L Barth
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jason M Schenkel
- Department of Biology, Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA; Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jay S Loeffler
- Department of Radiation Oncology, Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - Helen A Shih
- Department of Radiation Oncology, Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - Andrew J Aguirre
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Tyler Jacks
- Department of Biology, Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Lei Zheng
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Patrick Y Wen
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Timothy C Wang
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY, USA
| | - William L Hwang
- Department of Radiation Oncology, Massachusetts General Hospital Cancer Center, Boston, MA, USA; Broad Institute of MIT and Harvard, Cambridge, MA, USA; Department of Biology, Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA.
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Parikh AR, Weekes CD, Blaszkowsky LS, Franses JW, Ting DT, Mehta A, Roeland E, Ryan DP, Allen JN, Clark JW, Ly L, Loosbrock I, Jarnagin JX, Bannon A, Caldwell DK, Yeap BY, Wo JY, Hong TS. A phase II study of niraparib and dostarlimab with radiation in patients with metastatic pancreatic cancer. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.4_suppl.564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
564 Background: PARP inhibitors have activity as monotherapy in BRCA1/2 mutated metastatic pancreatic cancer; however, several other genes and associated proteins exist in the homologous recombination repair (HRR) pathway promoting resistance to chemotherapy and radiation-induced damage. Tumors with HRR deficiency have an impaired ability to repair themselves and are susceptible to PARP inhibition, but ionizing radiation can also induce DNA breaks. Ongoing research suggests that PARP inhibitors may cause radio-sensitization and may also enhance sensitivity to immunotherapy. We conducted a phase 2 study of niraparib and dostarlimab with radiation in a biomarker unselected PDAC population given PARP inhibitors' immunomodulatory and radiosensitizing effects. Methods: In this open-label, single-arm, phase-2 study, eligible patients had histologically confirmed MSS PDAC, ECOG PS 0-1, and progressed on at least one line of jm. Treatment consisted of niraparib 200 mg daily on a 21-day cycle, dostarlimab 500 mg every 3 weeks every 4 weeks for the first four doses, then 1000 mg every 6 weeks, and 3 fractions of 8 Gy at Cycle 2. Treatment continued until progressive disease, discontinuation, or withdrawal. The primary endpoint was DCR by RECIST 1.1 with radiological evaluations every 3 months. Secondary endpoints included DCR by irRECIST, PFS, OS, and safety. Responses were defined as disease control outside the radiation field. We obtained serial tumor biopsies, including pre-treatment. A two-stage design was used, requiring disease control in at least one of the first 15 patients before proceeding to the full accrual of 25 patients. Intention to treat analysis included all patients receiving at least one dose of any study agent. Results: We enrolled and treated 15 pts (median age 60 years [range 37-77], 53% male) from 08/2020 to 05/2021. Overall, DCR was 0/15 (95% CI: 0-22%), median PFS was 1.6 months (95% CI: 1.1-2.7), and median OS 3.1 months (95% CI: 1.5-7.7). Among 27 treatment-related serious adverse events, 15 (56%) were grade 3, including decreased CD4 lymphocytes, thrombocytopenia, anemia, and fatigue being the most common. Conclusions: The combination of niraparib and dostarlimab with radiation did not meet the pre-specified criteria for expansion to full accrual. Further analyses of dose intensity in this heavily pretreated and evaluation of in-field responses are underway. Further investigation of the combination with biomarker selection is warranted. Clinical trial information: NCT04409002.
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Affiliation(s)
| | | | | | | | | | - Arnav Mehta
- Massachusetts General Hospital Cancer Center, Boston, MA
| | - Eric Roeland
- Massachusetts General Hospital Cancer Center, Boston, MA
| | - David P. Ryan
- Massachusetts General Hospital Cancer Center, Boston, MA
| | - Jill N. Allen
- Massachusetts General Hospital Cancer Center, Boston, MA
| | | | - Leilana Ly
- Massachusetts General Hospital Cancer Center, Boston, MA
| | | | | | - Allison Bannon
- Massachusetts General Hospital Cancer Center, Boston, MA
| | | | - Beow Y. Yeap
- Massachusetts General Hospital Cancer Center, Boston, MA
| | - Jennifer Y. Wo
- Massachusetts General Hospital Cancer Center, Boston, MA
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Hank T, Sandini M, Ferrone CR, Ryan DP, Mino-Kenudson M, Qadan M, Wo JY, Klaiber U, Weekes CD, Weniger M, Hinz U, Harrison JM, Heckler M, Warshaw AL, Hong TS, Hackert T, Clark JW, Büchler MW, Lillemoe KD, Strobel O, Castillo CFD. A Combination of Biochemical and Pathological Parameters Improves Prediction of Postresection Survival After Preoperative Chemotherapy in Pancreatic Cancer: The PANAMA-score. Ann Surg 2022; 275:391-397. [PMID: 32649455 DOI: 10.1097/sla.0000000000004143] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To build a prognostic score for patients with primary chemotherapy undergoing surgery for pancreatic cancer based on pathological parameters and preoperative Carbohydrate antigen 19-9 (CA19-9) levels. BACKGROUND Prognostic stratification after primary chemotherapy for pancreatic cancer is challenging and prediction models, such as the AJCC staging system, lack validation in the setting of preoperative chemotherapy. METHODS Patients with primary chemotherapy resected at the Massachusetts General Hospital between 2007 and 2017 were analyzed. Tumor characteristics independently associated with overall survival were identified and weighted by Cox-proportional regression. The pancreatic neoadjuvant Massachusetts-score (PANAMA-score) was computed from these variables and its performance assessed by Harrel concordance index and area under the receiving characteristics curves analysis. Comparisons were made with the AJCC staging system and external validation was performed in an independent cohort with primary chemotherapy from Heidelberg, Germany. RESULTS A total of 216 patients constituted the training cohort. The multivariate analysis demonstrated tumor size, number of positive lymph-nodes, R-status, and high CA19-9 to be independently associated with overall survival. Kaplan-Meier analysis according to low, intermediate, and high PANAMA-score showed good discriminatory power of the new metrics (P < 0.001). The median overall survival for the three risk-groups was 45, 27, and 12 months, respectively. External validation in 258 patients confirmed the prognostic ability of the score and demonstrated better accuracy compared with the AJCC staging system. CONCLUSION The proposed PANAMA-score, based on independent predictors of postresection survival, including pathologic variables and CA19-9, not only provides better discrimination compared to the AJCC staging system, but also identifies patients at high-risk for early death.
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Affiliation(s)
- Thomas Hank
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Marta Sandini
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - David P Ryan
- Cancer Center, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jennifer Y Wo
- Cancer Center, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ulla Klaiber
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Colin D Weekes
- Cancer Center, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Maximilian Weniger
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ulf Hinz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Jon M Harrison
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Max Heckler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Theodore S Hong
- Cancer Center, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Jeffrey W Clark
- Cancer Center, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Oliver Strobel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
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Russo AL, Lee LJ, Wo JY, Niemierko A, Park D, Alban G, King M, Philp L, Growdon WB, Oliva E, Spriggs DR, Yeku OO. Effect of Mismatch Repair Status on Outcome of Early-Stage Grade 1 to 2 Endometrial Cancer Treated With Vaginal Brachytherapy. Am J Clin Oncol 2022; 45:36-39. [PMID: 34817442 DOI: 10.1097/coc.0000000000000871] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objective of this study was to determine if deficiency of mismatch repair (dMMR) proteins in patients with early-stage favorable endometrial cancer treated with vaginal brachytherapy (VB) is associated with increased recurrence. MATERIALS AND METHODS A multi-institutional retrospective cohort study of 141 patients with stage I to II grade 1 and 2 endometrioid adenocarcinoma treated with surgery and adjuvant VB was performed to compare recurrence risk in dMMR (n=41) versus MMR-preserved (pMMR) (n=100). Additional clinical and pathologic risk factors were also collected. Univariate analysis and multivariable analysis Cox regression analysis was performed to identify factors associated with any recurrence. Kaplan-Meier method and log rank test were used to compare recurrence free survival and overall survival (OS). RESULTS Median follow up was 42 months. Forty-one patients (29%) were dMMR. There were 7 recurrences (17%) in dMMR versus 4 recurrences (4%) in pMMR (P=0.009). On univariate analysis of any recurrence, both dMMR (hazard ratio: 5.3, P=0.008) and stage (hazard ratio: 3.8, P=0.05) were statistically significantly associated with time to first recurrence. The 5-year recurrence free survival was 90% (95% CI: 73%-96%) in pMMR versus 61.0% (95% CI: 19%-86%) in dMMR (P=0.003). Five-year OS was 96% (95% CI: 76%-99%) in pMMR versus 86% (95% CI: 62%-95%) in dMMR (P=0.03). CONCLUSIONS MMR deficiency in stage I to II grade 1 to 2 endometrial cancer patients treated with adjuvant VB alone was associated with statistically significant increased risk for any recurrence and worse OS. MMR status may be an important prognosticator in this cohort of patients warranting adjuvant treatment intensification in the clinical trial setting.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Oladapo O Yeku
- Hematology/Medical Oncology, Massachusetts General Hospital
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35
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Willett GCECG, Chang DT, Czito BG, Liauw SL, Wo JY, Klein PEE, Chen Z, Carlson DJ, Chetty IJ. Reflections on Anthony Zietman From Gastrointestinal Cancer and Physics Editors. Int J Radiat Oncol Biol Phys 2021; 111:1114-1117. [PMID: 34793734 DOI: 10.1016/j.ijrobp.2021.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 09/03/2021] [Indexed: 11/20/2022]
Affiliation(s)
| | - Daniel T Chang
- Department of Radiation Oncology, Stanford University, Stanford, CA
| | - Brian G Czito
- Department of Radiation Oncology, Duke University, Durham, NC
| | - Stanley L Liauw
- Department of Radiation Oncology, University of Chicago, Chicago, IL
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Boston MA
| | | | - Zhe Chen
- Department of Therapeutic Radiology, Yale University, New Haven CT
| | - David J Carlson
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
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Roberts HJ, Wo JY. Stereotactic body radiation therapy for primary liver tumors: An effective liver-directed therapy in the toolbox. Cancer 2021; 128:956-965. [PMID: 34847255 DOI: 10.1002/cncr.34033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 10/04/2021] [Accepted: 10/29/2021] [Indexed: 12/25/2022]
Abstract
The use of radiation for primary liver cancers has historically been limited because of the risk of radiation-induced liver disease. Treatment fields have become more conformal because of several technical advances, and this has allowed for dose escalation. Stereotactic body radiation therapy (SBRT), also known as stereotactic ablative radiotherapy, is now able to safely treat liver tumors to ablative doses while sparing functional liver parenchyma by using highly conformal therapy. Several retrospective and small prospective studies have examined the use of SBRT for liver cancers; however, there is a lack of well-powered randomized studies to definitively guide management in these settings. Recent advances in systemic therapy for primary liver cancers have improved outcomes; however, the optimal selection criteria for SBRT as a local therapy remain unclear among other liver-directed options such as radiofrequency ablation, transarterial chemoembolization, and radioembolization.
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Affiliation(s)
- Hannah J Roberts
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
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37
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Parikh AR, Szabolcs A, Allen JN, Clark JW, Wo JY, Raabe M, Thel H, Hoyos D, Mehta A, Arshad S, Lieb DJ, Drapek LC, Blaszkowsky LS, Giantonio BJ, Weekes CD, Zhu AX, Goyal L, Nipp RD, Dubois JS, Van Seventer EE, Foreman BE, Matlack LE, Ly L, Meurer JA, Hacohen N, Ryan DP, Yeap BY, Corcoran RB, Greenbaum BD, Ting DT, Hong TS. Radiation therapy enhances immunotherapy response in microsatellite stable colorectal and pancreatic adenocarcinoma in a phase II trial. Nat Cancer 2021; 2:1124-1135. [PMID: 35122060 PMCID: PMC8809884 DOI: 10.1038/s43018-021-00269-7] [Citation(s) in RCA: 100] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 09/15/2021] [Indexed: 02/06/2023]
Abstract
Overcoming intrinsic resistance to immune checkpoint blockade for microsatellite stable (MSS) colorectal cancer (CRC) and pancreatic ductal adenocarcinoma (PDAC) remains challenging. We conducted a single-arm, non-randomized, phase II trial (NCT03104439) combining radiation, ipilimumab and nivolumab to treat patients with metastatic MSS CRC (n = 40) and PDAC (n = 25) with an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1. The primary endpoint was disease control rate (DCR) by intention to treat. DCRs were 25% for CRC (ten of 40; 95% confidence interval (CI), 13-41%) and 20% for PDAC (five of 25; 95% CI, 7-41%). In the per-protocol analysis, defined as receipt of radiation, DCR was 37% (ten of 27; 95% CI, 19-58%) in CRC and 29% (five of 17; 95% CI, 10-56%) in PDAC. Pretreatment biopsies revealed low tumor mutational burden for all samples but higher numbers of natural killer (NK) cells and expression of the HERVK repeat RNA in patients with disease control. This study provides proof of concept of combining radiation with immune checkpoint blockade in immunotherapy-resistant cancers.
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Affiliation(s)
- Aparna R Parikh
- Department of Medicine, Division of Hematology & Oncology, Harvard Medical School, Boston, MA, USA
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Annamaria Szabolcs
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Jill N Allen
- Department of Medicine, Division of Hematology & Oncology, Harvard Medical School, Boston, MA, USA
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Jeffrey W Clark
- Department of Medicine, Division of Hematology & Oncology, Harvard Medical School, Boston, MA, USA
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael Raabe
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Hannah Thel
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - David Hoyos
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Arnav Mehta
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
- The Broad Institute, Cambridge, MA, USA
| | - Sanya Arshad
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | | | - Lorraine C Drapek
- Department of Medicine, Division of Hematology & Oncology, Harvard Medical School, Boston, MA, USA
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Lawrence S Blaszkowsky
- Department of Medicine, Division of Hematology & Oncology, Harvard Medical School, Boston, MA, USA
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Bruce J Giantonio
- Department of Medicine, Division of Hematology & Oncology, Harvard Medical School, Boston, MA, USA
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Colin D Weekes
- Department of Medicine, Division of Hematology & Oncology, Harvard Medical School, Boston, MA, USA
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Andrew X Zhu
- Department of Medicine, Division of Hematology & Oncology, Harvard Medical School, Boston, MA, USA
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Lipika Goyal
- Department of Medicine, Division of Hematology & Oncology, Harvard Medical School, Boston, MA, USA
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Ryan D Nipp
- Department of Medicine, Division of Hematology & Oncology, Harvard Medical School, Boston, MA, USA
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Jon S Dubois
- Department of Medicine, Division of Hematology & Oncology, Harvard Medical School, Boston, MA, USA
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Emily E Van Seventer
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Bronwen E Foreman
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Lauren E Matlack
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Leilana Ly
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Jessica A Meurer
- Department of Medicine, Division of Hematology & Oncology, Harvard Medical School, Boston, MA, USA
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Nir Hacohen
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
- The Broad Institute, Cambridge, MA, USA
| | - David P Ryan
- Department of Medicine, Division of Hematology & Oncology, Harvard Medical School, Boston, MA, USA
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Beow Y Yeap
- Department of Medicine, Division of Hematology & Oncology, Harvard Medical School, Boston, MA, USA
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Ryan B Corcoran
- Department of Medicine, Division of Hematology & Oncology, Harvard Medical School, Boston, MA, USA
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | | | - David T Ting
- Department of Medicine, Division of Hematology & Oncology, Harvard Medical School, Boston, MA, USA.
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA.
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Michelakos T, Sekigami Y, Kontos F, Fernández-Del Castillo C, Qadan M, Deshpande V, Ting DT, Clark JW, Weekes CD, Parikh A, Ryan DP, Wo JY, Hong TS, Allen JN, Catalano O, Warshaw AL, Lillemoe KD, Ferrone CR. Conditional Survival in Resected Pancreatic Ductal Adenocarcinoma Patients Treated with Total Neoadjuvant Therapy. J Gastrointest Surg 2021; 25:2859-2870. [PMID: 33501584 DOI: 10.1007/s11605-020-04897-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 12/19/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Dynamic survival data based on time already survived are lacking for resected borderline resectable/locally advanced (BR/LA) pancreatic ductal adenocarcinoma (PDAC) patients who received total neoadjuvant therapy (TNT) with FOLFIRINOX followed by chemoradiation. Conditional survival, i.e., the probability of surviving an additional length of time after having already survived an amount of time, offers such information. We aimed to determine actuarial and conditional overall (OS, COS) and disease-free survival (DFS, CDFS) among this cohort. METHODS Clinicopathologic data were retrospectively collected for resected BR/LA PDAC patients who received TNT (2011-2019). COS and CDFS rates were calculated for patients being event (death/recurrence)-free at multiple intervals and by recurrence status. RESULTS After a median follow-up of 32.1 months, the 183 patients had a median OS and DFS of 39.1 months and 16.8 months, respectively. COS and CDFS increased as a function of time already survived. The probability of surviving an additional 24 months if a patient survived 2 years post-operatively was 70%, whereas the 4-year actuarial OS was 47%. Similarly, the probability of surviving disease-free an additional 24 months after 2 years was 66%, while actuarial 48-month DFS was 27%. COS for disease-free patients increased further over time. For patients remaining disease-free 12 months post-operatively, BR vs. LA status at diagnosis, tumor ≤ 4 cm at diagnosis, and R0 resection were independent predictors of favorable additional OS and DFS. CONCLUSIONS For resected TNT-treated BR/LA PDAC patients, the probability of surviving an additional length of time increases as a function of survival already accrued. Dynamic survival estimates may allow personalized follow-up and counseling.
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Affiliation(s)
- Theodoros Michelakos
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, Boston, MA, 02114-3117, USA
| | - Yurie Sekigami
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, Boston, MA, 02114-3117, USA
| | - Filippos Kontos
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, Boston, MA, 02114-3117, USA
| | - Carlos Fernández-Del Castillo
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, Boston, MA, 02114-3117, USA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, Boston, MA, 02114-3117, USA
| | - Vikram Deshpande
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - David T Ting
- Massachusetts General Hospital Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jeffrey W Clark
- Department of Hematology/Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Colin D Weekes
- Department of Hematology/Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Aparna Parikh
- Department of Hematology/Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - David P Ryan
- Department of Hematology/Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jill N Allen
- Department of Hematology/Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Onofrio Catalano
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, Boston, MA, 02114-3117, USA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, Boston, MA, 02114-3117, USA
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, Boston, MA, 02114-3117, USA.
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Kim DW, Lee G, Hong TS, Li G, Horick NK, Roeland E, Keane FK, Eyler C, Drapek LC, Ryan DP, Allen JN, Berger D, Parikh AR, Mullen JT, Klempner S, Clark JW, Wo JY. ASO Visual Abstract: Neoadjuvant versus Postoperative Chemoradiotherapy Is Associated with Improved Survival in Patients with Resectable Gastric and Gastroesophageal Cancer. Ann Surg Oncol 2021. [PMID: 34490528 DOI: 10.1245/s10434-021-10753-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Daniel W Kim
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Grace Lee
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Guichao Li
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Nora K Horick
- Massachusetts General Hospital Biostatistics Center, Boston, MA, USA
| | - Eric Roeland
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Florence K Keane
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Christine Eyler
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Lorraine C Drapek
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - David P Ryan
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Jill N Allen
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - David Berger
- Department of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Aparna R Parikh
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - John T Mullen
- Department of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Sam Klempner
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Jeffrey W Clark
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA. .,Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.
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40
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Kim DW, Lee G, Hong TS, Li G, Horick NK, Roeland E, Keane FK, Eyler C, Drapek LC, Ryan DP, Allen JN, Berger D, Parikh AR, Mullen JT, Klempner SJ, Clark JW, Wo JY. Neoadjuvant versus Postoperative Chemoradiotherapy is Associated with Improved Survival for Patients with Resectable Gastric and Gastroesophageal Cancer. Ann Surg Oncol 2021; 29:242-252. [PMID: 34480285 DOI: 10.1245/s10434-021-10666-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 08/01/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND The optimal timing of chemoradiotherapy (CRT) for patients with localized gastric cancer remains unclear. This study aimed to compare the survival outcomes between neoadjuvant and postoperative CRT for patients with gastric and gastroesophageal junction (GEJ) cancer. METHODS This retrospective study analyzed 152 patients with gastric (42%) or GEJ (58%) adenocarcinoma who underwent definitive surgical resection and received either neoadjuvant or postoperative CRT between 2005 and 2017 at the authors' institution. The primary end point of the study was overall survival (OS). RESULTS The median follow-up period was 37.5 months. Neoadjuvant CRT was performed for 102 patients (67%) and postoperative CRT for 50 patients (33%). The patients who received neoadjuvant CRT were more likely to be male and to have a GEJ tumor, positive lymph nodes, and a higher clinical stage. The median radiotherapy (RT) dose was 50.4 Gy for neoadjuvant RT and 45.0 Gy for postoperative RT (p < 0.001). The neoadjuvant CRT group had a pathologic complete response (pCR) rate of 26% and a greater rate of R0 resection than the postoperative CRT group (95% vs. 76%; p = 0.002). Neoadjuvant versus postoperative CRT was associated with a lower rate of any grade 3+ toxicity (10% vs. 54%; p < 0.001). The multivariable analysis of OS showed lower hazards of death to be independently associated neoadjuvant versus postoperative CRT (hazard ratio [HR] 0.57; 95% confidence interval [CI] 0.36-0.91; p = 0.020) and R0 resection (HR 0.50; 95% CI 0.27-0.90; p = 0.021). CONCLUSIONS Neoadjuvant CRT was associated with a longer OS, a higher rate of R0 resection, and a lower treatment-related toxicity than postoperative CRT. The findings suggest that neoadjuvant CRT is superior to postoperative CRT in the treatment of gastric and GEJ cancer.
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Affiliation(s)
- Daniel W Kim
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Grace Lee
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Guichao Li
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Nora K Horick
- Massachusetts General Hospital Biostatistics Center, Boston, MA, USA
| | - Eric Roeland
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Florence K Keane
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Christine Eyler
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Lorraine C Drapek
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - David P Ryan
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Jill N Allen
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - David Berger
- Department of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Aparna R Parikh
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - John T Mullen
- Department of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Sam J Klempner
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Jeffrey W Clark
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA.
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Franco I, Oladeru OT, Saraf A, Liu KX, Milligan MG, Wo JY, Zietman AL, Nguyen PL, Hirsch AE, Jimenez RB. RISE: An Equity and Inclusion-based Virtual Pipeline Program for Medical Students Underrepresented in Medicine. Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.05.149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Wo JY, Clark JW, Eyler CE, Mino-Kenudson M, Klempner SJ, Allen JN, Keane FK, Parikh AR, Roeland E, Drapek LC, Ryan DP, Corcoran RB, Van Seventer E, Fetter IJ, Shahzade HA, Khandekar MJ, Lanuti M, Morse CR, Heist RS, Ulysse CA, Christopher B, Baglini C, Yeap BY, Mullen JT, Hong TS. Results and molecular correlates from a pilot study of neoadjuvant induction FOLFIRINOX followed by chemoradiation and surgery for gastroesophageal adenocarcinomas. Clin Cancer Res 2021; 27:6343-6353. [PMID: 34330715 DOI: 10.1158/1078-0432.ccr-21-0331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 04/08/2021] [Accepted: 07/28/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE We performed a NCI-sponsored, prospective study of neoadjuvant FOLFIRINOX followed by chemoradiation (CRT) with carboplatin/paclitaxel followed by surgery in patients with locally advanced gastric or gastroesophageal (GEA) cancer. EXPERIMENTAL DESIGN The primary objective was to determine completion rate of neoadjuvant FOLFIRINOX x 8 followed by CRT. Secondary endpoints were toxicity and pathologic complete response (pCR) rate. Exploratory analysis was performed of ctDNA to treatment response. RESULTS From Oct 2017 to June 2018, 25 patients were enrolled. All patients started FOLFIRINOX, 92% completed all 8 planned cycles, and 88% completed CRT. Twenty (80%) patients underwent surgical resection, and 7 had a pCR (35% in resected cohort, 28% ITT ). Tumor-specific mutations were identified in 21 (84%) patients, of whom 4 and 17 patients had undetectable and detectable ctDNA at baseline, respectively. Presence of detectable post-CRT ctDNA (p=0.004) and/or postoperative ctDNA (p=0.045) were associated with disease recurrence. CONCLUSIONS Here we show neoadjuvant FOLFIRINOX followed by CRT for locally advanced GEA is feasible and yields a high rate of pCR. ctDNA appears to be a promising predictor of postoperative recurrence.
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Affiliation(s)
- Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School
| | | | | | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School
| | | | - Jill N Allen
- Hematology Oncology, Massachusetts General Hospital
| | | | - Aparna R Parikh
- Division of Hematology and Oncology, Massachusetts General Hospital
| | - Eric Roeland
- Division of Hematology and Oncology, Massachusetts General Hospital
| | | | - David P Ryan
- Massachusetts General Hospital Cancer Center, Harvard Medical School
| | | | | | | | | | | | | | | | | | | | | | | | - Beow Y Yeap
- Department of Medicine, Massachusetts General Hospital
| | - John T Mullen
- Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital
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Hwang WL, Jagadeesh KA, Guo JA, Hoffman HI, Yadollahpour P, Reeves J, Drokhlyansky E, Van Wittenberghe N, Farhi S, Schapiro D, Eng G, Schenkel JM, Freed-Pastor WA, Ashenberg O, Rodrigues C, Abbondanza D, Delorey T, Phillips D, Roldan J, Ciprani D, Kern M, Barth JL, Zollinger DR, Fuhrman K, Fropf R, Beechem J, Weekes C, Ferrone CR, Wo JY, Hong TS, Rozenblatt-Rosen O, Aguirre AJ, Mino-Kenudson M, Fernandez-del- Castillo C, Liss AS, Ting DT, Jacks T, Regev A. Abstract 94: Multi-compartment reprogramming and spatially-resolved interactions in frozen pancreatic cancer with and without neoadjuvant chemotherapy and radiotherapy at single-cell resolution. Cancer Res 2021. [DOI: 10.1158/1538-7445.am2021-94] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
A molecular classification of pancreatic ductal adenocarcinoma (PDAC) that informs clinical management remains elusive. Previously identified bulk expression subtypes in the untreated setting were influenced by contaminating stroma whereas single cell RNA-seq (scRNA-seq) of fresh tumors under-represented key cell types. Two consensus subtypes have arisen from these prior efforts: (1) classical-like, and (2) basal-like. Basal-like tumors were associated with worse survival in the metastatic setting but attempts to refine this binary classification have failed to further stratify patient survival. Here, we developed a robust single-nucleus RNA-seq (snRNA-seq) technique for banked frozen PDAC specimens and studied a cohort of untreated resected primary tumors (n ~ 20). Gene expression programs learned across malignant cell and cancer-associated fibroblast (CAF) profiles uncovered a clinically-relevant molecular taxonomy with improved prognostic stratification compared to prior classifications. Digital spatial profiling revealed an association between malignant cells expressing basal-like programs and greater immune infiltration with relatively fewer macrophages, whereas those exhibiting classical-like programs were linked to inflammatory CAFs and macrophage-predominant microniches. Recent clinical trials have supported the increasing adoption of neoadjuvant therapy to aggressively address the risk of micro-metastatic spread and to circumvent concerns of treatment tolerance in the postoperative setting. There is an urgent need to understand how preoperative treatment impacts residual tumor cells and their interactions with other cell types in the tumor microenvironment to identify additional therapeutic vulnerabilities that can be exploited. Towards this end, we performed snRNA-seq on an unmatched cohort of neoadjuvant-treated resected primary tumors (n ~ 25) with most cases involving FOLFIRINOX chemotherapy followed by chemoradiation. Remarkably, the quality of single-nucleus mRNA profiles was comparable between heavily pre-treated and untreated specimens. We identified differentially expressed genes between treated and untreated samples to infer cell-type specific reprogramming in the residual tumor. This analysis revealed that in the neoadjuvant treatment context, there was lower expression of classical-like phenotypes in malignant cells in favor of basal-like phenotypes associated with TNF-NFkB and interferon signaling as well as the presence of novel acinar and neuroendocrine classical-like states. Our refined molecular taxonomy and spatial resolution may help advance precision oncology in PDAC through informative stratification in clinical trials and insights into compartment-specific therapies.
Citation Format: William L. Hwang, Karthik A. Jagadeesh, Jimmy A. Guo, Hannah I. Hoffman, Payman Yadollahpour, Jason Reeves, Eugene Drokhlyansky, Nicholas Van Wittenberghe, Samouil Farhi, Denis Schapiro, George Eng, Jason M. Schenkel, William A. Freed-Pastor, Orr Ashenberg, Clifton Rodrigues, Domenic Abbondanza, Toni Delorey, Devan Phillips, Jorge Roldan, Debora Ciprani, Marina Kern, Jaimie L. Barth, Daniel R. Zollinger, Kit Fuhrman, Robin Fropf, Joseph Beechem, Colin Weekes, Cristina R. Ferrone, Jennifer Y. Wo, Theodore S. Hong, Orit Rozenblatt-Rosen, Andrew J. Aguirre, Mari Mino-Kenudson, Carlos Fernandez-del- Castillo, Andrew S. Liss, David T. Ting, Tyler Jacks, Aviv Regev. Multi-compartment reprogramming and spatially-resolved interactions in frozen pancreatic cancer with and without neoadjuvant chemotherapy and radiotherapy at single-cell resolution [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 94.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - George Eng
- 1Massachusetts General Hospital, Boston, MA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Tyler Jacks
- 3Massachusetts Institute of Technology, Cambridge, MA
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Michelakos T, Cai L, Villani V, Sabbatino F, Kontos F, Fernández-Del Castillo C, Yamada T, Neyaz A, Taylor MS, Deshpande V, Kurokawa T, Ting DT, Qadan M, Weekes CD, Allen JN, Clark JW, Hong TS, Ryan DP, Wo JY, Warshaw AL, Lillemoe KD, Ferrone S, Ferrone CR. Tumor Microenvironment Immune Response in Pancreatic Ductal Adenocarcinoma Patients Treated With Neoadjuvant Therapy. J Natl Cancer Inst 2021; 113:182-191. [PMID: 32497200 DOI: 10.1093/jnci/djaa073] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 04/08/2020] [Accepted: 05/11/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Neoadjuvant folinic acid, fluorouracil, irinotecan, and oxaliplatin (FOLFIRINOX) and chemoradiation have been used to downstage borderline and locally advanced pancreatic ductal adenocarcinoma (PDAC). Whether neoadjuvant therapy-induced tumor immune response contributes to the improved survival is unknown. Therefore, we evaluated whether neoadjuvant therapy induces an immune response towards PDAC. METHODS Clinicopathological variables were collected for surgically resected PDACs at the Massachusetts General Hospital (1998-2016). Neoadjuvant regimens included FOLFIRINOX with or without chemoradiation, proton chemoradiation (25 Gy), photon chemoradiation (50.4 Gy), or no neoadjuvant therapy. Human leukocyte antigen (HLA) class I and II expression and immune cell infiltration (CD4+, FoxP3+, CD8+, granzyme B+ cells, and M2 macrophages) were analyzed immunohistochemically and correlated with clinicopathologic variables. The antitumor immune response was compared among neoadjuvant therapy regimens. All statistical tests were 2-sided. RESULTS Two hundred forty-eight PDAC patients were included. The median age was 64 years and 50.0% were female. HLA-A defects were less frequent in the FOLFIRINOX cohort (P = .006). HLA class II expression was lowest in photon and highest in proton patients (P = .02). The FOLFIRINOX cohort exhibited the densest CD8+ cell infiltration (P < .001). FOLFIRINOX and proton patients had the highest CD4+ and lowest T regulatory (FoxP3+) cell density, respectively. M2 macrophage density was statistically significantly higher in the treatment-naïve group (P < .001) in which dense M2 macrophage infiltration was an independent predictor of poor overall survival. CONCLUSIONS Neoadjuvant FOLFIRINOX with or without chemoradiation may induce immunologically relevant changes in the tumor microenvironment. It may reduce HLA-A defects, increase CD8+ cell density, and decrease T regulatory cell and M2 macrophage density. Therefore, neoadjuvant FOLFIRINOX therapy may benefit from combinations with checkpoint inhibitors, which can enhance patients' antitumor immune response.
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Affiliation(s)
- Theodoros Michelakos
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lei Cai
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Vincenzo Villani
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Francesco Sabbatino
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Filippos Kontos
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Teppei Yamada
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Azfar Neyaz
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Martin S Taylor
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Vikram Deshpande
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Tomohiro Kurokawa
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - David T Ting
- Massachusetts General Hospital Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Colin D Weekes
- Department of Hematology/Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jill N Allen
- Department of Hematology/Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jeffrey W Clark
- Department of Hematology/Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - David P Ryan
- Department of Hematology/Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Soldano Ferrone
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Kanter K, Fish M, Mauri G, Horick NK, Allen JN, Blaszkowsky LS, Clark JW, Ryan DP, Nipp RD, Giantonio BJ, Goyal L, Dubois J, Murphy JE, Franses J, Klempner SJ, Roeland EJ, Weekes CD, Wo JY, Hong TS, Van Seventer EE, Corcoran RB, Parikh AR. Care Patterns and Overall Survival in Patients With Early-Onset Metastatic Colorectal Cancer. JCO Oncol Pract 2021; 17:e1846-e1855. [PMID: 34043449 DOI: 10.1200/op.20.01010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Colorectal cancer (CRC) incidence in patients younger than 50 years of age, commonly defined as early-onset (EO-CRC), is rising. EO-CRC often presents with distinct clinicopathologic features. However, data on prognosis are conflicting and outcomes with modern treatment approaches for metastatic disease are still limited. MATERIALS AND METHODS We prospectively enrolled patients with metastatic CRC (mCRC) to a biobanking and clinical data collection protocol from 2014 to 2018. We grouped the cohort based on age at initial diagnosis: < 40 years, 40-49 years, and ≥ 50 years. We used regression models to examine associations among age at initial diagnosis, treatments, clinicopathologic features, and survival. RESULTS We identified 466 patients with mCRC (45 [10%] age < 40 years, 109 [23%] age 40-49 years, and 312 [67%] age ≥ 50 years). Patients < 40 years of age were more likely to have received multiple metastatic resections (odds ratio [OR], 3.533; P = .0066) than their older counterparts. Patients with EO-CRC were more likely to receive triplet therapy than patients > 50 years of age (age < 40 years: OR, 6.738; P = .0002; age 40-49 years: OR, 2.949; P = .0166). Patients 40-49 years of age were more likely to have received anti-EGFR therapy (OR, 2.633; P = .0016). Despite differences in care patterns, age did not predict overall survival. CONCLUSION Despite patients with EO-CRC receiving more intensive treatments, survival was similar to the older counterpart. However, EO-CRC had clinical and molecular features associated with worse prognoses. Improved biologic understanding is needed to optimize clinical management of EO-CRC. The cost-benefit ratio of exposing patients with EO-CRC to more intensive treatments has to be carefully evaluated.
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Affiliation(s)
- Katie Kanter
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
| | - Madeleine Fish
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
| | - Gianluca Mauri
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA.,Niguarda Cancer Center, Grande Ospedale Metropolitano Niguarda, Dipartimento di Oncologia e Emato-Oncologia, Università degli Studi di Milano (La Statale), Milan, Italy
| | - Nora K Horick
- Department of Statistics, Massachusetts General Hospital & Harvard Medical School, Boston, MA
| | - Jill N Allen
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
| | - Lawrence S Blaszkowsky
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
| | - Jeffrey W Clark
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
| | - David P Ryan
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
| | - Ryan D Nipp
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
| | - Bruce J Giantonio
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
| | - Lipika Goyal
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
| | - Jon Dubois
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
| | - Janet E Murphy
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
| | - Joseph Franses
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
| | - Samuel J Klempner
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
| | - Eric J Roeland
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
| | - Colin D Weekes
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, MA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital & Harvard Medical School, Boston, MA
| | - Emily E Van Seventer
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
| | - Ryan B Corcoran
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
| | - Aparna R Parikh
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, MA
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Bent EH, Wehrenberg-Klee E, Koay EJ, Goyal L, Wo JY. Integration of Systemic and Liver-Directed Therapies for Locally Advanced Hepatocellular Cancer: Harnessing Potential Synergy for New Therapeutic Horizons. J Natl Compr Canc Netw 2021; 19:567-576. [PMID: 34030132 DOI: 10.6004/jnccn.2021.7037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 03/16/2021] [Indexed: 11/17/2022]
Abstract
Treatment options in locally advanced hepatocellular carcinoma (HCC) have evolved considerably over the past few years with the recent approval of multiple systemic therapies and significant advances in locoregional therapy. Given the poor prognosis for patients with unresectable HCC, there is significant interest in rationally designed combination therapies. This article reviews the treatment options available to patients with locally advanced HCC and discusses the rationale, ongoing trials, and future prospects for combining locoregional and systemic therapy in both the definitive and neoadjuvant settings.
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Affiliation(s)
| | - Eric Wehrenberg-Klee
- 2Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Eugene J Koay
- 3Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas; and
| | - Lipika Goyal
- 4Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Parikh AR, Van Seventer EE, Siravegna G, Hartwig AV, Jaimovich A, He Y, Kanter K, Fish MG, Fosbenner KD, Miao B, Phillips S, Carmichael JH, Sharma N, Jarnagin J, Baiev I, Shah YS, Fetter IJ, Shahzade HA, Allen JN, Blaszkowsky LS, Clark JW, Dubois JS, Franses JW, Giantonio BJ, Goyal L, Klempner SJ, Nipp RD, Roeland EJ, Ryan DP, Weekes CD, Wo JY, Hong TS, Bordeianou L, Ferrone CR, Qadan M, Kunitake H, Berger D, Ricciardi R, Cusack JC, Raymond VM, Talasaz A, Boland GM, Corcoran RB. Minimal Residual Disease Detection using a Plasma-only Circulating Tumor DNA Assay in Patients with Colorectal Cancer. Clin Cancer Res 2021; 27:5586-5594. [PMID: 33926918 DOI: 10.1158/1078-0432.ccr-21-0410] [Citation(s) in RCA: 158] [Impact Index Per Article: 52.7] [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: 02/01/2021] [Revised: 03/23/2021] [Accepted: 04/26/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE Detection of persistent circulating tumor DNA (ctDNA) after curative-intent surgery can identify patients with minimal residual disease (MRD) who will ultimately recur. Most ctDNA MRD assays require tumor sequencing to identify tumor-derived mutations to facilitate ctDNA detection, requiring tumor and blood. We evaluated a plasma-only ctDNA assay integrating genomic and epigenomic cancer signatures to enable tumor-uninformed MRD detection. EXPERIMENTAL DESIGN A total of 252 prospective serial plasma specimens from 103 patients with colorectal cancer undergoing curative-intent surgery were analyzed and correlated with recurrence. RESULTS Of 103 patients, 84 [stage I (9.5%), II (23.8%), III (47.6%), IV (19%)] had evaluable plasma drawn after completion of definitive therapy, defined as surgery only (n = 39) or completion of adjuvant therapy (n = 45). In "landmark" plasma drawn 1-month (median, 31.5 days) after definitive therapy and >1 year follow-up, 15 patients had detectable ctDNA, and all 15 recurred [positive predictive value (PPV), 100%; HR, 11.28 (P < 0.0001)]. Of 49 patients without detectable ctDNA at the landmark timepoint, 12 (24.5%) recurred. Landmark recurrence sensitivity and specificity were 55.6% and 100%. Incorporating serial longitudinal and surveillance (drawn within 4 months of recurrence) samples, sensitivity improved to 69% and 91%. Integrating epigenomic signatures increased sensitivity by 25%-36% versus genomic alterations alone. Notably, standard serum carcinoembryonic antigen levels did not predict recurrence [HR, 1.84 (P = 0.18); PPV = 53.9%]. CONCLUSIONS Plasma-only MRD detection demonstrated favorable sensitivity and specificity for recurrence, comparable with tumor-informed approaches. Integrating analysis of epigenomic and genomic alterations enhanced sensitivity. These findings support the potential clinical utility of plasma-only ctDNA MRD detection.
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Affiliation(s)
- Aparna R Parikh
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Emily E Van Seventer
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Giulia Siravegna
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | | | | | - Yupeng He
- Guardant Health, Inc, Redwood City, California
| | - Katie Kanter
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Madeleine G Fish
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Kathryn D Fosbenner
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Benchun Miao
- Department of Surgical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Susannah Phillips
- Department of Surgical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - John H Carmichael
- Department of Surgical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Nihaarika Sharma
- Department of Surgical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Joy Jarnagin
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Islam Baiev
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Yojan S Shah
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Isobel J Fetter
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Heather A Shahzade
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Jill N Allen
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Lawrence S Blaszkowsky
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Jeffrey W Clark
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Jon S Dubois
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Joseph W Franses
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Bruce J Giantonio
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Lipika Goyal
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Samuel J Klempner
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Ryan D Nipp
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Eric J Roeland
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - David P Ryan
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Colin D Weekes
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Liliana Bordeianou
- Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Cristina R Ferrone
- Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Motaz Qadan
- Department of Surgical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Hiroko Kunitake
- Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - David Berger
- Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Rocco Ricciardi
- Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - James C Cusack
- Department of Surgical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | | | | | - Genevieve M Boland
- Department of Surgical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Ryan B Corcoran
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts.
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48
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Abstract
Prior to the 1980s, the primary management of localized anal cancer was surgical resection. Dr. Norman Nigro and colleagues introduced neoadjuvant chemoradiotherapy prior to abdominoperineal resection. Chemoradiotherapy 5-fluorouracil and mitomycin C afforded patients complete pathologic response and obviated the need for upfront surgery. More recent studies have attempted to alter or exclude chemotherapy used in the Nigro regimen to mitigate toxicity, often with worse outcomes. Reductions in acute adverse effects have been associated with marked advancements in radiotherapy delivery using intensity-modulated radiation therapy (IMRT) and image-guidance radiation delivery, resulting in increased tolerance to greater radiation doses. Ongoing trials are attempting to improve IMRT-based treatment of locally advanced disease with efforts to increase personalized treatment. Studies are also examining the role of newer treatment modalities such as proton therapy in treating anal cancer. Here we review the evolution of radiotherapy for anal cancer and describe recent advances. We also elaborate on radiotherapy's role in locally persistent or recurrent anal cancer.
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Affiliation(s)
| | - James D. Byrne
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA 02115, USA;
| | - Jennifer Y. Wo
- Harvard Medical School, 25 Shattuck St., Boston, MA 02115, USA;
- Department of Radiation Oncology, Massachusetts General Hospital, 100 Blossom St., Boston, MA 02114, USA
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49
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Guo JA, Hoffman HI, Shroff SG, Chen P, Hwang PG, Kim DY, Kim DW, Cheng SW, Zhao D, Mahal BA, Alshalalfa M, Niemierko A, Wo JY, Loeffler JS, Fernandez-Del Castillo C, Jacks T, Aguirre AJ, Hong TS, Mino-Kenudson M, Hwang WL. Pan-cancer Transcriptomic Predictors of Perineural Invasion Improve Occult Histopathologic Detection. Clin Cancer Res 2021; 27:2807-2815. [PMID: 33632928 DOI: 10.1158/1078-0432.ccr-20-4382] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 01/16/2021] [Accepted: 02/19/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE Perineural invasion (PNI) is associated with aggressive tumor behavior, recurrence, and metastasis, and can influence the administration of adjuvant treatment. However, standard histopathologic examination has limited sensitivity in detecting PNI and does not provide insights into its mechanistic underpinnings. EXPERIMENTAL DESIGN A multivariate Cox regression was performed to validate associations between PNI and survival in 2,029 patients across 12 cancer types. Differential expression and gene set enrichment analysis were used to learn PNI-associated programs. Machine learning models were applied to build a PNI gene expression classifier. A blinded re-review of hematoxylin and eosin (H&E) slides by a board-certified pathologist helped determine whether the classifier could improve occult histopathologic detection of PNI. RESULTS PNI associated with both poor overall survival [HR, 1.73; 95% confidence interval (CI), 1.27-2.36; P < 0.001] and disease-free survival (HR, 1.79; 95% CI, 1.38-2.32; P < 0.001). Neural-like, prosurvival, and invasive programs were enriched in PNI-positive tumors (P adj < 0.001). Although PNI-associated features likely reflect in part the increased presence of nerves, many differentially expressed genes mapped specifically to malignant cells from single-cell atlases. A PNI gene expression classifier was derived using random forest and evaluated as a tool for occult histopathologic detection. On a blinded H&E re-review of sections initially described as PNI negative, more specimens were reannotated as PNI positive in the high classifier score cohort compared with the low-scoring cohort (P = 0.03, Fisher exact test). CONCLUSIONS This study provides salient biological insights regarding PNI and demonstrates a role for gene expression classifiers to augment detection of histopathologic features.
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Affiliation(s)
- Jimmy A Guo
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts.,Koch Institute for Integrative Cancer Research and Howard Hughes Medical Institute, Department of Biology, Massachusetts Institute of Technology, Cambridge, Massachusetts.,Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts.,Program in Biological and Biomedical Sciences, Harvard Medical School, Boston, Massachusetts.,School of Medicine, University of California, San Francisco, San Francisco, California.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Hannah I Hoffman
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts.,Koch Institute for Integrative Cancer Research and Howard Hughes Medical Institute, Department of Biology, Massachusetts Institute of Technology, Cambridge, Massachusetts.,Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Stuti G Shroff
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Peter Chen
- Raytheon Technologies, Brooklyn, New York
| | - Peter G Hwang
- Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Daniel Y Kim
- Molecular Pathology Unit, Massachusetts General Hospital, Charlestown, Massachusetts
| | - Daniel W Kim
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Daniel Zhao
- New York Medical College, Valhalla, New York
| | - Brandon A Mahal
- Department of Radiation Oncology, Miller School of Medicine, Miami, Florida
| | - Mohammed Alshalalfa
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, California
| | - Andrzej Niemierko
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jay S Loeffler
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Tyler Jacks
- Koch Institute for Integrative Cancer Research and Howard Hughes Medical Institute, Department of Biology, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Andrew J Aguirre
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - William L Hwang
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts. .,Koch Institute for Integrative Cancer Research and Howard Hughes Medical Institute, Department of Biology, Massachusetts Institute of Technology, Cambridge, Massachusetts.,Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
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50
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Kim DW, Lee G, Weekes CD, Ryan DP, Parikh AR, Allen JN, Giantonio BJ, Berger DL, Kunitake H, Ricciardi R, Cusack JC, Hwang WL, Hong TS, Wo JY. Severe lymphopenia predicts poorer survival in patients with rectal cancer undergoing neoadjuvant chemoradiation. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.3_suppl.138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
138 Background: Chemoradiation (CRT) induced lymphopenia is common and associated with poorer survival in multiple solid malignancies. The objective of this study was to evaluate the prognostic impact of lymphopenia in patients with rectal cancer undergoing neoadjuvant CRT. We hypothesized that severe lymphopenia would correlate with worse survival. Methods: The inclusion criteria for this single-institution retrospective study were: 1) biopsy-proven diagnosis of rectal adenocarcinoma, 2) receipt of neoadjuvant CRT followed by surgery, and 3) absolute lymphocyte count (ALC) available prior to and within 12 weeks of CRT. In general, CRT consisted of 5-fluorouracil or capecitabine and RT with 50.4 Gy over 28 fractions. Lymphopenia was graded according to CTCAE v5.0. The primary variable of interest was ALC nadir within 12 weeks of CRT, dichotomized by ALC of < 0.5 k/μl (Grade 3 lymphopenia). The primary endpoint was overall survival (OS). Cox modeling and Kaplan-Meier methods were used to perform survival analyses. Results: 193 patients were identified. Median follow-up for the entire cohort was 68 months. Median age was 58. 62% were male, 82% were Caucasian, and 90% had ECOG ≤1. Median tumor distance from anal verge was 8 cm. Overall clinical stage was 1 or 2 in 23% and 3 in 77%. Median baseline CEA was 3.2 ng/ml. 83% received chemotherapy following RT. Following CRT, 70% underwent low anterior resection and 30% underwent abdominoperineal resection. Median baseline ALC for the entire cohort was 1.7 k/ul. ALC nadir within 12 weeks of initiating CRT was < 0.5 k/ul among 110 (57%) patients. Patients who developed severe lymphopenia with CRT had a lower baseline hemoglobin (median 13.3 vs. 14.0 g/dl, p = 0.022) and lower baseline ALC (median 1.6 vs. 1.8 k/ul, p = 0.010) compared to those who did not develop severe lymphopenia. There were no differences in disease and treatment characteristics between the two groups. On multivariable Cox model, severe lymphopenia was significantly associated with increased hazards of death (HR = 3.52 [95% CI 1.47-8.44], p = 0.005). Receipt of chemotherapy post-CRT (HR = 0.22 [95% CI 0.09-0.54], p = 0.001) predicted better OS while higher pathologic T (HR = 8.01 [95% CI 2.98-17.21], p < 0.001) and N stage (HR = 9.43 [95% CI 3.19-27.86], p < 0.001) and positive surgical margin (HR = 3.77 [95% CI 1.13-12.62], p = 0.031) predicted worse OS. The 5-year OS was 79% vs. 92% in the cohort with vs. without severe lymphopenia, respectively (log-rank p = 0.001). Conclusions: CRT-induced lymphopenia is common and severe lymphopenia may be a prognostic marker of poorer survival in rectal cancer. Closer observation in high-risk patients and treatment modifications may be potential approaches to mitigating CRT-induced lymphopenia. Our findings also suggest an important role of the host immunity in rectal cancer outcomes, supporting the ongoing efforts of immunotherapy trials in rectal cancer.
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Affiliation(s)
| | - Grace Lee
- Massachusetts General Hospital, Boston, MA
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