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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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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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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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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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Anteby R, Blaszkowsky LS, Hong TS, Qadan M. ASO Visual Abstract: Disparities in Receipt of Adjuvant Therapy after Upfront Surgical Resection for Pancreatic Ductal Adenocarcinoma. Ann Surg Oncol 2023; 30:2484-2485. [PMID: 36681738 DOI: 10.1245/s10434-022-13069-9] [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: 01/22/2023]
Affiliation(s)
- Roi Anteby
- School of Public Health, Harvard University, Boston, MA, USA
- Department of Surgery, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA, USA
| | - Lawrence S Blaszkowsky
- Department of Medicine, Division of Hematology-Oncology, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA, USA
| | - Theodore S Hong
- Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA, USA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA, USA.
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Anteby R, Blaszkowsky LS, Hong TS, Qadan M. Disparities in Receipt of Adjuvant Therapy After Upfront Surgical Resection for Pancreatic Ductal Adenocarcinoma. Ann Surg Oncol 2023; 30:2473-2481. [PMID: 36585536 DOI: 10.1245/s10434-022-12976-1] [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: 07/18/2022] [Accepted: 12/05/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND A multimodal approach of surgery and chemotherapy, with or without radiation, is the mainstay of therapy with curative-intent for resectable pancreatic ductal adenocarcinoma (PDAC). This study compared utilization trends and outcomes of upfront surgery with and without adjuvant therapy. METHODS The National Cancer Database was queried for patients with a diagnosis of stage 1 or 2 PDAC who underwent upfront resection. Multivariable regression was applied to identify factors associated with initiation of adjuvant therapy. RESULTS Of the 39,128 patients in the study, 67% initiated adjuvant therapy after resection, whereas 33% received upfront surgery alone. Receipt of adjuvant multimodal therapy increased from 59% in 2006 to 69% in 2017 (P < 0.0001). Non-white race was associated with lower odds of receiving adjuvant therapy after adjustment for income status, education attainment, and other variables (Hispanic/Spanish [odds ratio {OR}, 0.77; 95% confidence interval {CI}, 0.69-0.86] and non-Hispanic black [OR 0.84; 95% CI 0.78-0.91 vs non-Hispanic white; P < 0.001). The variables that contributed to receipt of adjuvant therapy were place of residence in high versus low education attainment area (OR 1.30; 95% CI 1.18-1.44; P < 0.0001) and lower odds for initiation of adjuvant therapy with increasing distance from the treating facility (> 50 miles [OR 0.51; 95% CI 0.47-0.54] vs <12.5 miles; P < 0.0001). The median unadjusted overall survival (OS) time was 18.2 months (95% CI 17.7-18.8 months) for upfront surgery alone and 25.3 months (95% CI 24.9-25.8 months) for surgery with adjuvant therapy. CONCLUSIONS The patients who underwent upfront surgical resection for PDAC showed wide socioeconomic disparities in the use of adjuvant therapy independent of insurance status, facility type, or travel distance.
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Affiliation(s)
- Roi Anteby
- School of Public Health, Harvard University, Boston, MA, USA
- Department of Surgery, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA, USA
| | - Lawrence S Blaszkowsky
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, Massachusetts, USA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital and Newton-Wellesley Hospital, Harvard Medical School, Boston, MA, USA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA, USA.
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8
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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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9
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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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10
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Zafar A, Drobni ZD, Lei M, Gongora CA, Quinaglia T, Lou UY, Mosarla R, Murphy SP, Jones-O’Connor M, Mahmood A, Hartmann S, Gilman HK, Weekes CD, Nipp R, Clark JR, Clark JW, Blaszkowsky LS, Tavares E, Neilan TG. The efficacy and safety of cardio-protective therapy in patients with 5-FU (Fluorouracil)-associated coronary vasospasm. PLoS One 2022; 17:e0265767. [PMID: 35390017 PMCID: PMC8989300 DOI: 10.1371/journal.pone.0265767] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 03/08/2022] [Indexed: 11/18/2022] Open
Abstract
Background Coronary vasospasm is a known side effect of 5-FU (fluorouracil) therapy. Beyond switching to non-5FU-based chemotherapy, there are no established treatments for 5-FU associated coronary vasospam. Our objective was to assess the safety and efficacy of re-challenge with 5-FU after pre-treatment with calcium channel blockers (CCBs) and long-acting nitrates among patients 5-FU associated coronary vasospasm. Methods We conducted a retrospective study of patients with 5-FU coronary vasospasm at a single academic center. By protocol, those referred to cardio-oncology received pre-treatment with either combination [nitrates and CCBs] or single-agent therapy [nitrates or CCBs]) prior to re-challenge with 5-FU. Our primary outcome was overall survival. Other important outcomes included progression-free survival and safety. Results Among 6,606 patients who received 5-FU from January 2001 to Dec 2020, 115 (1.74%) developed coronary vasospasm. Of these 115 patients, 81 patients continued 5-FU therapy, while 34 stopped. Of the 81 who continued, 78 were referred to cardio-oncology and prescribed CCBs and/or nitrates prior to subsequent 5-FU, while the remaining 3 continued 5-FU without cardiac pre-treatment. Of the 78, 56.4% (44/78) received both nitrates and CCBs, 19.2% (15/78) received CCBs alone, and 24.4% (19/78) received nitrates alone. When compared to patients who stopped 5-FU, those who continued 5-FU after pre-treatment (single or combination therapy) had a decreased risk of death (HR 0.42, P = 0.005 [95% CI 0.23–0.77]) and a trend towards decreased cancer progression (HR 0.60, P = 0.08 [95% CI 0.34–1.06]). No patient in the pre-treatment group had a myocardial infarct after re-challenge; however, chest pain (without myocardial infarction) recurred in 19.2% (15/78) among those who received cardiac pre-treatment vs. 66.7% (2/3) among those who did not (P = 0.048). There was no difference in efficacy or the recurrence of vasospasm among patients who received pre-treatment with a single agent (nitrates or CCBs) or combination therapy (14.7% (5/34) vs. 25.0% (11/44), P = 0.26). Conclusion Re-challenge after pre-treatment with CCBs and nitrates guided by a cardio-oncology service was safe and allowed continued 5-FU therapy.
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Affiliation(s)
- Amna Zafar
- Department of Radiology and Division of Cardiology, Cardiovascular Imaging Research Center (CIRC), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Cardiovascular Diseases and Hypertension, Department of Medicine, Robert Wood Johnson University Hospital, Rutgers Medical School, New Brunswick, New Jersey, United States of America
| | - Zsofia D. Drobni
- Department of Radiology and Division of Cardiology, Cardiovascular Imaging Research Center (CIRC), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Matthew Lei
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Carlos A. Gongora
- Department of Radiology and Division of Cardiology, Cardiovascular Imaging Research Center (CIRC), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Thiago Quinaglia
- Department of Radiology and Division of Cardiology, Cardiovascular Imaging Research Center (CIRC), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Uvette Y. Lou
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Ramya Mosarla
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Sean P. Murphy
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Maeve Jones-O’Connor
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Ali Mahmood
- Division of Cardiology, Department of Medicine, Morristown Medical Center, Morristown, New Jersey, United States of America
| | - Sarah Hartmann
- Department of Radiology and Division of Cardiology, Cardiovascular Imaging Research Center (CIRC), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Hannah K. Gilman
- Department of Radiology and Division of Cardiology, Cardiovascular Imaging Research Center (CIRC), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Colin D. Weekes
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Ryan Nipp
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - John R. Clark
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Jeffrey W. Clark
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Lawrence S. Blaszkowsky
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Erica Tavares
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Tomas G. Neilan
- Department of Radiology and Division of Cardiology, Cardiovascular Imaging Research Center (CIRC), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Cardiology, Department of Medicine, Cardio-Oncology Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
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11
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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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12
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Zhang C, O'Shea A, Parente CA, Amorim BJ, Caravan P, Ferrone CR, Blaszkowsky LS, Soricelli A, Salvatore M, Groshar D, Bernstine H, Domachevsky L, Canamaque LG, Umutlu L, Ken H, Catana C, Mahmood U, Catalano OA. Evaluation of the Diagnostic Performance of Positron Emission Tomography/Magnetic Resonance for the Diagnosis of Liver Metastases. Invest Radiol 2021; 56:621-628. [PMID: 33813576 DOI: 10.1097/rli.0000000000000782] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 12/23/2022]
Abstract
OBJECTIVE The aim of this study was to compare the performance of positron emission tomography (PET)/magnetic resonance (MR) versus stand-alone PET and stand-alone magnetic resonance imaging (MRI) in the detection and characterization of suspected liver metastases. MATERIALS AND METHODS This multi-institutional retrospective performance study was approved by the institutional review boards and was Health Insurance Portability and Accountability Act compliant, with waiver of informed consent. Seventy-nine patients with confirmed solid extrahepatic malignancies who underwent upper abdominal PET/MR between February 2017 and June 2018 were included. Where focal hepatic lesions were identified, the likelihood of a diagnosis of a liver metastasis was defined on an ordinal scale for MRI, PET, and PET/MRI by 3 readers: 1 nuclear medicine physician and 2 radiologists. The number of lesions per patient, lesion size, and involved hepatic segments were recorded. Proof of metastases was based on histopathologic correlation or clinical/imaging follow-up. Diagnostic performance was assessed using sensitivity, specificity, positive and negative predictive values, and receiver operator characteristic curve analysis. RESULTS A total of 79 patients (53 years, interquartile range, 50-68; 43 men) were included. PET/MR had a sensitivity of 95%, specificity of 97%, positive predictive value of 97%, and negative predictive value of 95%. The sensitivity, specificity, positive predictive value, and negative predictive value of MRI were 88%, 98%, 98%, and 90% and for PET were 83%, 97%, 97%, and 86%, respectively. The areas under the curve for PET/MRI, MRI, and PET were 95%, 92%, and 92%, respectively. CONCLUSIONS Contrast-enhanced PET/MR has a higher sensitivity and negative predictive value than either PET or MRI alone in the setting of suspected liver metastases. Fewer lesions were characterized as indeterminate by PET/MR in comparison with PET and MRI. This superior performance could potentially impact treatment and management decisions for patients with suspected liver metastases.
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Affiliation(s)
- Caiyuan Zhang
- From The Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, and Department of Radiology, Xinhua Hospital, affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Aileen O'Shea
- Department of Radiology, Division of Abdominal Imaging, Massachusetts General Hospital, Boston
| | - Chiara Anna Parente
- IRCCS, Department of Radiology, The Institute for Hospitalization and Healthcare (IRCCS) SDN, Napoli, Italy
| | - Barbara Juarez Amorim
- Division of Nuclear Medicine, Department of Radiology, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (Unicamp), Campinas, São Paulo, Brazil
| | - Peter Caravan
- The Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston
| | | | | | - Andrea Soricelli
- The Institute for Hospitalization and Healthcare (IRCCS) SDN, Napoli, Italy
| | - Marco Salvatore
- Department of Radiology and Nuclear Medicine, University Suor Orsola Benincasa and SDN IRCCS, Napoli, Italy
| | - David Groshar
- Department of Radiology and Nuclear Medicine, Assuta Medical Center and School of Medicine, Tel Aviv University, TLV, Israel
| | - Hanna Bernstine
- Department of Radiology and Nuclear Medicine, Assuta Medical Center and School of Medicine, Tel Aviv University, TLV, Israel
| | - Liran Domachevsky
- Department of Nuclear Medicine, The Chaim Sheba Medical Center Tel Hashomer Israel
| | | | - Lale Umutlu
- Institute of Diagnostic and Interventional Radiology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Herrmann Ken
- Institute of Diagnostic and Interventional Radiology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Ciprian Catana
- The Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Umar Mahmood
- Department of Radiology and Nuclear Medicine, Massachusetts General Hospital, Boston, MA
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13
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Shah MH, Goldner WS, Benson AB, Bergsland E, Blaszkowsky LS, Brock P, Chan J, Das S, Dickson PV, Fanta P, Giordano T, Halfdanarson TR, Halperin D, He J, Heaney A, Heslin MJ, Kandeel F, Kardan A, Khan SA, Kuvshinoff BW, Lieu C, Miller K, Pillarisetty VG, Reidy D, Salgado SA, Shaheen S, Soares HP, Soulen MC, Strosberg JR, Sussman CR, Trikalinos NA, Uboha NA, Vijayvergia N, Wong T, Lynn B, Hochstetler C. Neuroendocrine and Adrenal Tumors, Version 2.2021, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2021; 19:839-868. [PMID: 34340212 DOI: 10.6004/jnccn.2021.0032] [Citation(s) in RCA: 219] [Impact Index Per Article: 73.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Neuroendocrine and Adrenal Gland Tumors focus on the diagnosis, treatment, and management of patients with neuroendocrine tumors (NETs), adrenal tumors, pheochromocytomas, paragangliomas, and multiple endocrine neoplasia. NETs are generally subclassified by site of origin, stage, and histologic characteristics. Appropriate diagnosis and treatment of NETs often involves collaboration between specialists in multiple disciplines, using specific biochemical, radiologic, and surgical methods. Specialists include pathologists, endocrinologists, radiologists (including nuclear medicine specialists), and medical, radiation, and surgical oncologists. These guidelines discuss the diagnosis and management of both sporadic and hereditary neuroendocrine and adrenal tumors and are intended to assist with clinical decision-making. This article is focused on the 2021 NCCN Guidelines principles of genetic risk assessment and counseling and recommendations for well-differentiated grade 3 NETs, poorly differentiated neuroendocrine carcinomas, adrenal tumors, pheochromocytomas, and paragangliomas.
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Affiliation(s)
- Manisha H Shah
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | - Al B Benson
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | | | - Pamela Brock
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | | | - Paxton V Dickson
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | | | | | | | | | - Jin He
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | | | | | | | - Arash Kardan
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | | | | | | | | | | | | | | | | | | | | | | | - Nikolaos A Trikalinos
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | | | - Beth Lynn
- National Comprehensive Cancer Network
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14
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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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15
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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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16
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McDuff SGR, Hardiman KM, Ulintz PJ, Parikh AR, Zheng H, Kim DW, Lennerz JK, Hazar-Rethinam M, Van Seventer EE, Fetter IJ, Nadres B, Eyler CE, Ryan DP, Weekes CD, Clark JW, Cusack JC, Goyal L, Zhu AX, Wo JY, Blaszkowsky LS, Allen J, Corcoran RB, Hong TS. Circulating Tumor DNA Predicts Pathologic and Clinical Outcomes Following Neoadjuvant Chemoradiation and Surgery for Patients With Locally Advanced Rectal Cancer. JCO Precis Oncol 2021; 5:PO.20.00220. [PMID: 34250394 DOI: 10.1200/po.20.00220] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 10/16/2020] [Accepted: 11/19/2020] [Indexed: 12/13/2022] Open
Abstract
PURPOSE This study was designed to assess the ability of perioperative circulating tumor DNA (ctDNA) to predict surgical outcome and recurrence following neoadjuvant chemoradiation for locally advanced rectal cancer (LARC). MATERIALS AND METHODS Twenty-nine patients with newly diagnosed LARC treated between January 2014 and February 2018 were enrolled. Patients received long-course neoadjuvant chemoradiation prior to surgery. Plasma ctDNA was collected at baseline, preoperatively, and postoperatively. Next-generation sequencing was used to identify mutations in the primary tumor, and mutation-specific droplet digital polymerase chain reaction was used to assess mutation fraction in ctDNA. RESULTS The median age was 54 years. The overall margin-negative, node-negative resection rate was 73% and was significantly higher among patients with undetectable preoperative ctDNA (n = 17, 88%) versus patients with detectable preoperative ctDNA (n = 9, 44%; P = .028). Undetectable ctDNA was also associated with more favorable neoadjuvant rectal scores (univariate linear regression, P = .029). Recurrence-free survival (RFS) was calculated for the subset (n = 19) who both underwent surgery and had postoperative ctDNA available. At a median follow-up of 20 months, patients with detectable postoperative ctDNA experienced poorer RFS (hazard ratio, 11.56; P = .007). All patients (4 of 4) with detectable postoperative ctDNA recurred (positive predictive value = 100%), whereas only 2 of 15 patients with undetectable ctDNA recurred (negative predictive value = 87%). CONCLUSION Among patients treated with neoadjuvant chemoradiation for LARC, patients with undetectable preoperative ctDNA were more likely to have a favorable surgical outcome as measured by the rate of margin-negative, node-negative resections and neoadjuvant rectal score. Furthermore, we have confirmed prior reports indicating that detectable postoperative ctDNA is associated with worse RFS. Future prospective study is needed to assess the potential for ctDNA to assist with personalizing treatment for LARC.
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Affiliation(s)
- Susan G R McDuff
- Department of Radiation Oncology, Duke Cancer Center, Duke University Medical Center, Duke Medicine Circle, Durham, NC.,Harvard Radiation Oncology Program, Boston, MA
| | - Karin M Hardiman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Peter J Ulintz
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI
| | - Aparna R Parikh
- Department of Internal Medicine and Hematology/Oncology, Massachusetts General Hospital, Boston, MA
| | - Hui Zheng
- Biostatistics Center, Massachusetts General Hospital, Boston, MA
| | | | - Jochen K Lennerz
- Department of Pathology, Center for Integrated Diagnostics, Massachusetts General Hospital, Boston, MA
| | | | | | | | - Brandon Nadres
- Massachusetts General Hospital Cancer Center, Boston, MA
| | - Christine E Eyler
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
| | - David P Ryan
- Department of Internal Medicine and Hematology/Oncology, Massachusetts General Hospital, Boston, MA
| | - Colin D Weekes
- Department of Internal Medicine and Hematology/Oncology, Massachusetts General Hospital, Boston, MA
| | - Jeffrey W Clark
- Department of Internal Medicine and Hematology/Oncology, Massachusetts General Hospital, Boston, MA
| | - James C Cusack
- The Division of Gastrointestinal and Oncologic Surgery, Massachusetts General Hospital, Boston, MA
| | - Lipika Goyal
- Department of Internal Medicine and Hematology/Oncology, Massachusetts General Hospital, Boston, MA
| | - Andrew X Zhu
- Department of Internal Medicine and Hematology/Oncology, Massachusetts General Hospital, Boston, MA.,Jiahui International Cancer Center, Jiahui Health, Shanghai, China
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
| | - Lawrence S Blaszkowsky
- Department of Internal Medicine and Hematology/Oncology, Massachusetts General Hospital, Boston, MA
| | - Jill Allen
- Department of Internal Medicine and Hematology/Oncology, Massachusetts General Hospital, Boston, MA
| | - Ryan B Corcoran
- Department of Internal Medicine and Hematology/Oncology, Massachusetts General Hospital, Boston, MA.,Massachusetts General Hospital Cancer Center, Boston, MA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
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17
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Catalano OA, Lee SI, Parente C, Cauley C, Furtado FS, Striar R, Soricelli A, Salvatore M, Li Y, Umutlu L, Cañamaque LG, Groshar D, Mahmood U, Blaszkowsky LS, Ryan DP, Clark JW, Wo J, Hong TS, Kunitake H, Bordeianou L, Berger D, Ricciardi R, Rosen B. Improving staging of rectal cancer in the pelvis: the role of PET/MRI. Eur J Nucl Med Mol Imaging 2020; 48:1235-1245. [PMID: 33034673 DOI: 10.1007/s00259-020-05036-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 09/11/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE The role of positron emission tomography/magnetic resonance (PET/MR) in evaluating the local extent of rectal cancer remains uncertain. This study aimed to investigate the possible role of PET/MR versus magnetic resonance (MR) in clinically staging rectal cancer. METHODS This retrospective two-center cohort study of 62 patients with untreated rectal cancer investigated the possible role of baseline staging PET/MR versus stand-alone MR in determination of clinical stage. Two readers reviewed T and N stage, mesorectal fascia involvement, tumor length, distance from the anal verge, sphincter involvement, and extramural vascular invasion (EMVI). Sigmoidoscopy, digital rectal examination, and follow-up imaging, along with surgery when available, served as the reference standard. RESULTS PET/MR outperformed MR in evaluating tumor size (42.5 ± 21.03 mm per the reference standard, 54 ± 20.45 mm by stand-alone MR, and 44 ± 20 mm by PET/MR, P = 0.004), and in identifying N status (correct by MR in 36/62 patients [58%] and by PET/MR in 49/62 cases [79%]; P = 0.02) and external sphincter infiltration (correct by MR in 6/10 and by PET/MR in 9/10; P = 0.003). No statistically significant differences were observed in relation to any other features. CONCLUSION PET/MR provides a more precise assessment of the local extent of rectal cancers in evaluating cancer length, N status, and external sphincter involvement. PET/MR offers the opportunity to improve clinical decision-making, especially when evaluating low rectal tumors with possible external sphincter involvement.
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Affiliation(s)
- Onofrio A Catalano
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, White Building Rm 250, 55 Fruit St, Boston, MA, 02114, USA. .,Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA. .,Department of Radiology, University of Naples "Parthenope", Naples, Italy.
| | - Susanna I Lee
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, White Building Rm 250, 55 Fruit St, Boston, MA, 02114, USA
| | | | - Christy Cauley
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Felipe S Furtado
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, White Building Rm 250, 55 Fruit St, Boston, MA, 02114, USA.,Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Robin Striar
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, White Building Rm 250, 55 Fruit St, Boston, MA, 02114, USA.,Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Andrea Soricelli
- Department of Radiology, University of Naples "Parthenope", Naples, Italy.,SDN IRCCS, Naples, Italy
| | - Marco Salvatore
- SDN IRCCS, Naples, Italy.,University of Naples Suor Orsola Benincasa, Napoli, NA, Italy
| | - Yan Li
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Lale Umutlu
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | | | - David Groshar
- Department of Nuclear Medicine, Assuta Medical Centers, Tel Aviv, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Umar Mahmood
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, White Building Rm 250, 55 Fruit St, Boston, MA, 02114, USA.,Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Lawrence S Blaszkowsky
- Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Vernon Cancer Center, Newton-Wellesley Hospital, 2014 Washington Street, Newton, MA, 02462, USA
| | - David P Ryan
- Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jeffrey W Clark
- Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Jennifer Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Hiroko Kunitake
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Liliana Bordeianou
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - David Berger
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Rocco Ricciardi
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Bruce Rosen
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, White Building Rm 250, 55 Fruit St, Boston, MA, 02114, USA.,Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
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18
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Chaudhary SP, Kwak EL, Hwang KL, Lennerz JK, Corcoran RB, Heist RS, Russo AL, Parikh A, Borger DR, Blaszkowsky LS, Faris JE, Murphy JE, Azzoli CG, Roeland EJ, Goyal L, Allen J, Mullen JT, Ryan DP, Iafrate AJ, Klempner SJ, Clark JW, Hong TS. Revisiting MET: Clinical Characteristics and Treatment Outcomes of Patients with Locally Advanced or Metastatic, MET-Amplified Esophagogastric Cancers. Oncologist 2020; 25:e1691-e1700. [PMID: 32820577 DOI: 10.1634/theoncologist.2020-0274] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 07/16/2020] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Metastatic esophagogastric cancers (EGCs) have a poor prognosis with an approximately 5% 5-year survival. Additional treatment approaches are needed. c-MET gene-amplified tumors are an uncommon but potentially targetable subset of EGC. Clinical characteristics and outcomes were evaluated in patients with MET-amplified EGC and compared with those without MET amplification to facilitate identification of these patients and possible treatment approaches. PATIENTS AND METHODS Patients with locally advanced or metastatic MET-amplified EGC at Massachusetts General Hospital (MGH) were identified using fluorescent in situ hybridization analysis, with a gene-to-control ratio of ≥2.2 defined as positive. Non-MET-amplified patients identified during the same time period who had undergone tumor genotyping and treatment at MGH were evaluated as a comparison group. RESULTS We identified 233 patients evaluated for MET amplification from 2002 to 2019. MET amplification was seen in 28 (12%) patients versus 205 (88%) patients without amplification. Most MET-amplified tumors occurred in either the distal esophagus (n = 9; 32%) or gastroesophageal junction (n = 10; 36%). Of MET-amplified patients, 16 (57%) had a TP53 mutation, 5(18%) had HER2 co-amplification, 2 (7.0%) had EGFR co-amplification, and 1 (3.5%) had FGFR2 co-amplification. MET-amplified tumors more frequently had poorly differentiated histology (19/28, 68.0% vs. 66/205, 32%; p = .02). Progression-free survival to initial treatment was substantially shorter for all MET-amplified patients (5.6 vs. 8.8 months, p = .026) and for those with metastatic disease at presentation (4.0 vs. 7.6 months, p = .01). Overall, patients with MET amplification had shorter overall survival (19.3 vs. 24.6 months, p = .049). No difference in survival was seen between low MET-amplified tumors (≥2.2 and <25 MET copy number) compared with highly amplified tumors (≥25 MET copy number). CONCLUSION MET-amplified EGC represents a distinct clinical entity characterized by rapid progression and short survival. Ideally, the identification of these patients will provide opportunities to participate in clinical trials in an attempt to improve outcomes. IMPLICATIONS FOR PRACTICE This article describes 233 patients who received MET amplification testing and reports (a) a positivity rate of 12%, similar to the rate of HER2 positivity in this data set; (b) the clinical characteristics of poorly differentiated tumors and nodal metastases; and (c) markedly shorter progression-free survival and overall survival in MET-amplified tumors. Favorable outcomes are reported for patients treated with MET inhibitors. Given the lack of published data in MET-amplified esophagogastric cancers and the urgent clinical importance of identifying patients with MET amplification for MET-directed therapy, this large series is a valuable addition to the literature and will have an impact on future practice.
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Affiliation(s)
- Surendra Pal Chaudhary
- Department of Medical Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Eunice L Kwak
- Department of Medical Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Katie L Hwang
- Department of Pathology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Jochen K Lennerz
- Department of Radiation Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Ryan B Corcoran
- Department of Medical Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Rebecca S Heist
- Department of Medical Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Andrea L Russo
- Department of Surgery, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Aparna Parikh
- Department of Medical Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Darrell R Borger
- Department of Radiation Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Lawrence S Blaszkowsky
- Department of Medical Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Jason E Faris
- Department of Medical Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts, USA
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center and Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, USA
| | - Janet E Murphy
- Department of Medical Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher G Azzoli
- Department of Medical Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Eric J Roeland
- Department of Medical Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Lipika Goyal
- Department of Medical Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Jill Allen
- Department of Medical Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts, USA
| | - John T Mullen
- Department of Surgery, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts, USA
| | - David P Ryan
- Department of Medical Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts, USA
| | - A John Iafrate
- Department of Radiation Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Samuel J Klempner
- Department of Medical Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Jeffrey W Clark
- Department of Medical Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts, USA
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Lee G, Kim DW, Muralidhar V, Mitra D, Horick NK, Eyler CE, Hong TS, Drapek LC, Allen JN, Blaszkowsky LS, Giantonio B, Parikh AR, Ryan DP, Clark JW, Wo JY. Chemoradiation-Related Lymphopenia and Its Association with Survival in Patients with Squamous Cell Carcinoma of the Anal Canal. Oncologist 2020; 25:1015-1022. [PMID: 32827337 DOI: 10.1634/theoncologist.2019-0759] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 07/29/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Although treatment-related lymphopenia (TRL) is common and associated with poorer survival in multiple solid malignancies, few data exist for anal cancer. We evaluated TRL and its association with survival in patients with anal cancer treated with chemoradiation (CRT). MATERIALS AND METHODS A retrospective analysis of 140 patients with nonmetastatic anal squamous cell carcinoma (SCC) treated with definitive CRT was performed. Total lymphocyte counts (TLC) at baseline and monthly intervals up to 12 months after initiating CRT were analyzed. Multivariable Cox regression analysis was performed to evaluate the association between overall survival (OS) and TRL, dichotomized by grade (G)4 TRL (<0.2k/μL) 2 months after initiating CRT. Kaplan-Meier and log-rank tests were used to compare OS between patients with versus without G4 TRL. RESULTS Median time of follow-up was 55 months. Prior to CRT, 95% of patients had a normal TLC (>1k/μL). Two months after initiating CRT, there was a median of 71% reduction in TLC from baseline and 84% of patients had TRL: 11% G1, 31% G2, 34% G3, and 8% G4. On multivariable Cox model, G4 TRL at two months was associated with a 3.7-fold increased risk of death. On log-rank test, the 5-year OS rate was 32% in the cohort with G4 TRL versus 86% in the cohort without G4 TRL. CONCLUSION TRL is common and may be another prognostic marker of OS in anal cancer patients treated with CRT. The association between TRL and OS suggests an important role of the host immunity in anal cancer outcomes. IMPLICATIONS FOR PRACTICE This is the first detailed report demonstrating that standard chemoradiation (CRT) commonly results in treatment-related lymphopenia (TRL), which may be associated with a poorer overall survival (OS) in patients with anal squamous cell carcinoma. The association between TRL and worse OS observed in this study supports the importance of host immunity in survival among patients with anal cancer. These findings encourage larger, prospective studies to further investigate TRL, its predictors, and its relationship with survival outcomes. Furthermore, the results of this study support ongoing efforts of clinical trials to investigate the potential role of immunotherapy in anal cancer.
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Affiliation(s)
- Grace Lee
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Daniel W Kim
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Vinayak Muralidhar
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Devarati Mitra
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nora K Horick
- Massachusetts General Hospital Biostatistics Center, Boston, Massachusetts, USA
| | - Christine E Eyler
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lorraine C Drapek
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jill N Allen
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lawrence S Blaszkowsky
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Bruce Giantonio
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Aparna R Parikh
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David P Ryan
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jeffrey W Clark
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
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20
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Alty IG, Dee EC, Cusack JC, Blaszkowsky LS, Goldstone RN, Francone TD, Wo JY, Qadan M. Refusal of surgery for colon cancer: Sociodemographic disparities and survival implications among US patients with resectable disease. Am J Surg 2020; 221:39-45. [PMID: 32723488 DOI: 10.1016/j.amjsurg.2020.06.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/14/2020] [Accepted: 06/16/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND We aimed to identify factors associated with refusal of surgery among patients with colon cancer. METHODS This 2004-2016 NCDB retrospective study identified AJCC stage I-III colon cancer patients who were recommended surgery. Multivariable logistic regression defined adjusted odds ratios of refusing treatment, with sociodemographic and clinical covariates. Treatment propensity-adjusted Cox proportional hazard ratios defined differential survival stratified by clinical stage, controlling for potential confounders. RESULTS Of 170,594 patients recommended surgery, 1116 refused. Increased rates of surgery refusal were associated with older age, African American race, CDCC>3, and female sex. Decreased rates of surgery refusal were associated with higher income and private insurance. Stratifying by stage, refusal rates among African Americans remained disparately high. Refusal of surgery was associated with worse overall survival. CONCLUSIONS Disparate rates of refusal of surgery for resectable colon cancer by race and other sociodemographic factors highlight potential treatment adherence reinforcement beneficiaries, necessitating further study of shared decision-making.
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Affiliation(s)
| | | | - James C Cusack
- Harvard Medical School, Boston, MA, USA; Massachusetts General Hospital, Boston, MA, USA
| | | | | | | | - Jennifer Y Wo
- Harvard Medical School, Boston, MA, USA; Massachusetts General Hospital, Boston, MA, USA; Newton-Wellesley Hospital, Newton, MA, USA
| | - Motaz Qadan
- Harvard Medical School, Boston, MA, USA; Massachusetts General Hospital, Boston, MA, USA; Newton-Wellesley Hospital, Newton, MA, USA.
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21
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Chawla A, Wo J, Castillo CFD, Ferrone CR, Ryan DP, Hong TS, Blaszkowsky LS, Lillemoe KD, Qadan M. Clinical staging in pancreatic adenocarcinoma underestimates extent of disease. Pancreatology 2020; 20:691-697. [PMID: 32222341 DOI: 10.1016/j.pan.2020.03.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 12/04/2019] [Revised: 03/10/2020] [Accepted: 03/16/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND/OBJECTIVES We sought to identify the reliability of AJCC clinical staging was in comparison to pathologic staging in surgically resected patients with pancreatic cancer. METHODS We used the National Cancer Database Pancreas from 2004 to 2016 and evaluated patients who underwent resection for PDAC with all documented components of clinical and pathologic stage. We first evaluated the distribution of overall clinical stage and pathologic stage and then evaluated for stage migration by assessing the number of patients who shifted from a clinical stage group to a respective pathologic stage group. To further characterize the migratory pattern, we assessed the distribution of clinical and pathologic T-stage and N-stage. RESULTS In our cohort of 28,338 patients who underwent resection for PDAC, AJCC clinical staging did not reliably predict pathologic stage. Stage migration after resection was responsible for discrepancies between the distribution of overall clinical stage and pathologic stage. The predominant migration was from patients with clinical stage I disease to pathologic stage II disease. Most patients with clinical T1 and T2 disease were upstaged to pathologic T3 disease and over half of patients with clinical N0 disease were upstaged to pathologic N1 disease after resection. DISCUSSION Clinical staging appears to overrepresent early T1, T2, and N0 disease, and underrepresent T3 and N1 disease.
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Affiliation(s)
- Akhil Chawla
- Division of Surgical Oncology, Department of Surgery, Northwestern Medicine Regional Medical Group, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jennifer Wo
- Department of Radiation 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
| | - David P Ryan
- Department of Medical 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; Vernon Cancer Center, Newton-Wellesley Hospital, 2014 Washington Street, Newton, MA, 02462, USA
| | - Lawrence S Blaszkowsky
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Vernon Cancer Center, Newton-Wellesley Hospital, 2014 Washington Street, Newton, MA, 02462, USA
| | - Keith D Lillemoe
- 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; Vernon Cancer Center, Newton-Wellesley Hospital, 2014 Washington Street, Newton, MA, 02462, USA.
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22
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Parikh AR, Mojtahed A, Schneider JL, Kanter K, Van Seventer EE, Fetter IJ, Thabet A, Fish MG, Teshome B, Fosbenner K, Nadres B, Shahzade HA, Allen JN, Blaszkowsky LS, Ryan DP, Giantonio B, Goyal L, Nipp RD, Roeland E, Weekes CD, Wo JY, Zhu AX, Dias-Santagata D, Iafrate AJ, Lennerz JK, Hong TS, Siravegna G, Horick N, Clark JW, Corcoran RB. Serial ctDNA Monitoring to Predict Response to Systemic Therapy in Metastatic Gastrointestinal Cancers. Clin Cancer Res 2020; 26:1877-1885. [PMID: 31941831 PMCID: PMC7165022 DOI: 10.1158/1078-0432.ccr-19-3467] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [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: 10/25/2019] [Revised: 12/09/2019] [Accepted: 01/10/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE ctDNA offers a promising, noninvasive approach to monitor therapeutic efficacy in real-time. We explored whether the quantitative percent change in ctDNA early after therapy initiation can predict treatment response and progression-free survival (PFS) in patients with metastatic gastrointestinal cancer. EXPERIMENTAL DESIGN A total of 138 patients with metastatic gastrointestinal cancers and tumor profiling by next-generation sequencing had serial blood draws pretreatment and at scheduled intervals during therapy. ctDNA was assessed using individualized droplet digital PCR measuring the mutant allele fraction in plasma of mutations identified in tumor biopsies. ctDNA changes were correlated with tumor markers and radiographic response. RESULTS A total of 138 patients enrolled. A total of 101 patients were evaluable for ctDNA and 68 for tumor markers at 4 weeks. Percent change of ctDNA by 4 weeks predicted partial response (PR, P < 0.0001) and clinical benefit [CB: PR and stable disease (SD), P < 0.0001]. ctDNA decreased by 98% (median) and >30% for all PR patients. ctDNA change at 8 weeks, but not 2 weeks, also predicted CB (P < 0.0001). Four-week change in tumor markers also predicted response (P = 0.0026) and CB (P = 0.022). However, at a clinically relevant specificity threshold of 90%, 4-week ctDNA change more effectively predicted CB versus tumor markers, with a sensitivity of 60% versus 24%, respectively (P = 0.0109). Patients whose 4-week ctDNA decreased beyond this threshold (≥30% decrease) had a median PFS of 175 days versus 59.5 days (HR, 3.29; 95% CI, 1.55-7.00; P < 0.0001). CONCLUSIONS Serial ctDNA monitoring may provide early indication of response to systemic therapy in patients with metastatic gastrointestinal cancer prior to radiographic assessments and may outperform standard tumor markers, warranting further evaluation.
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Affiliation(s)
- Aparna R Parikh
- Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Amikasra Mojtahed
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jaime L Schneider
- Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Katie Kanter
- Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Emily E Van Seventer
- Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Isobel J Fetter
- Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ashraf Thabet
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Madeleine G Fish
- Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Bezaye Teshome
- Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kathryn Fosbenner
- Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Brandon Nadres
- Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Heather A Shahzade
- Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jill N Allen
- Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lawrence S Blaszkowsky
- Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - David P Ryan
- Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Bruce Giantonio
- Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lipika Goyal
- Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ryan D Nipp
- Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Eric Roeland
- Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Colin D Weekes
- Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew X Zhu
- Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Dora Dias-Santagata
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - A John Iafrate
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jochen K Lennerz
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Giulia Siravegna
- Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nora Horick
- Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jeffrey W Clark
- Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ryan B Corcoran
- Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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Zafar A, Mosarla R, Drobni Z, Alvi R, Lei M, Lou UY, Murphy S, Jones-O'Connor M, Raghu VK, Rokicki A, Banerji D, Weekes CD, Clark JR, Clark J, Blaszkowsky LS, Tavares E, Neilan TG. THE INCIDENCE, RISK FACTORS AND OUTCOMES WITH 5-FU (FLUOROURACIL)-ASSOCIATED CORONARY VASOSPASM. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)30818-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Murphy JE, Wo JY, Ryan DP, Clark JW, Jiang W, Yeap BY, Drapek LC, Ly L, Baglini CV, Blaszkowsky LS, Ferrone CR, Parikh AR, Weekes CD, Nipp RD, Kwak EL, Allen JN, Corcoran RB, Ting DT, Faris JE, Zhu AX, Goyal L, Berger DL, Qadan M, Lillemoe KD, Talele N, Jain RK, DeLaney TF, Duda DG, Boucher Y, Fernández-Del Castillo C, Hong TS. Total Neoadjuvant Therapy With FOLFIRINOX in Combination With Losartan Followed by Chemoradiotherapy for Locally Advanced Pancreatic Cancer: A Phase 2 Clinical Trial. JAMA Oncol 2020; 5:1020-1027. [PMID: 31145418 DOI: 10.1001/jamaoncol.2019.0892] [Citation(s) in RCA: 315] [Impact Index Per Article: 78.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance Patients with locally advanced pancreatic cancer have historically poor outcomes. Evaluation of a total neoadjuvant approach is warranted. Objective To evaluate the margin-negative (R0) resection rate of neoadjuvant FOLFIRINOX (fluorouracil, leucovorin, oxaliplatin, and irinotecan) and losartan followed by chemoradiotherapy for locally advanced pancreatic cancer. Design, Setting, and Participants A single-arm phase 2 clinical trial was conducted at a large academic hospital from August 22, 2013, to May 22, 2018, among 49 patients with previously untreated locally advanced unresectable pancreatic cancer as determined by multidisciplinary review. Patients had Eastern Cooperative Oncology Group performance status 0 or 1 and adequate hematologic, renal, and hepatic function. Median follow-up for the analysis was 17.1 months (range, 5.0-53.7) among 27 patients still alive at study completion. Interventions Patients received FOLFIRINOX and losartan for 8 cycles. Patients with radiographically resectable tumor after chemotherapy received short-course chemoradiotherapy (5 GyE × 5 with protons) with capecitabine. Patients with persistent vascular involvement received long-course chemoradiotherapy (50.4 Gy with a vascular boost to 58.8 Gy) with fluorouracil or capecitabine. Main Outcomes and Measures R0 resection rate. Results Of the 49 patients (26 women and 23 men; median age 63 years [range, 42-78 years]), 39 completed 8 cycles of FOLFIRINOX and losartan; 10 patients had fewer than 8 cycles due to progression (5 patients), losartan intolerance (3 patients), and toxicity (2 patients). Seven patients (16%) had short-course chemoradiotherapy while 38 (84%) had long-course chemoradiotherapy. Forty-two (86%) patients underwent attempted surgery, with R0 resection achieved in 34 of 49 patients (69%; 95% CI, 55%-82%). Overall median progression-free survival was 17.5 months (95% CI: 13.9-22.7) and median overall survival was 31.4 months (95% CI, 18.1-38.5). Among patients who underwent resection, median progression-free survival was 21.3 months (95% CI, 16.6-28.2), and median overall survival was 33.0 months (95% CI, 31.4 to not reached). Conclusions and Relevance Total neoadjuvant therapy with FOLFIRINOX, losartan, and chemoradiotherapy provides downstaging of locally advanced pancreatic ductal adenocarcinoma and is associated with an R0 resection rate of 61%. Trial Registration ClinicalTrials.gov identifier: NCT01821729.
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Affiliation(s)
- Janet E Murphy
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - David P Ryan
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jeffrey W Clark
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Wenqing Jiang
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Beow Y Yeap
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lorraine C Drapek
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Leilana Ly
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christian V Baglini
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lawrence S Blaszkowsky
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Aparna R Parikh
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Colin D Weekes
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ryan D Nipp
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Eunice L Kwak
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jill N Allen
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ryan B Corcoran
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - David T Ting
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jason E Faris
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew X Zhu
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lipika Goyal
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - David L Berger
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nilesh Talele
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rakesh K Jain
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Thomas F DeLaney
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Dan G Duda
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Yves Boucher
- 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
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Michelakos T, Pergolini I, Castillo CFD, Honselmann KC, Cai L, Deshpande V, Wo JY, Ryan DP, Allen JN, Blaszkowsky LS, Clark JW, Murphy JE, Nipp RD, Parikh A, Qadan M, Warshaw AL, Hong TS, Lillemoe KD, Ferrone CR. Predictors of Resectability and Survival in Patients With Borderline and Locally Advanced Pancreatic Cancer who Underwent Neoadjuvant Treatment With FOLFIRINOX. Ann Surg 2020; 269:733-740. [PMID: 29227344 DOI: 10.1097/sla.0000000000002600] [Citation(s) in RCA: 205] [Impact Index Per Article: 51.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE The aim of this study was to determine (1) whether preoperative factors can predict resectability of borderline resectable (BR) and locally advanced (LA) pancreatic ductal adenocarcinoma (PDAC) after neoadjuvant FOLFIRINOX, (2) which patients might benefit from adjuvant therapy, and (3) survival differences between resected BR/LA patients who received neoadjuvant FOLFIRINOX and upfront resected patients. BACKGROUND Patients with BR/LA PDAC are often treated with FOLFIRINOX to obtain a margin-negative resection, yet selection of patients for resection remains challenging. METHODS Clinicopathologic data of PDAC patients surgically explored between 04/2011-11/2016 in a single institution were retrospectively collected. RESULTS Following neoadjuvant FOLFIRINOX, 141 patients were surgically explored (BR: 49%, LA: 51%) and 110 (78%) were resected. Resected patients had lower preoperative CA 19-9 levels (21 vs 40 U/mL, P = 0.03) and smaller tumors on preoperative computed tomography (CT) scan (2.3 vs 3.0 cm, P = 0.03), but no predictors of resectability were identified. Median overall survival (OS) was 34.2 months from diagnosis for all FOLFIRINOX patients and 37.7 months for resected patients. Among resected patients, preoperative CA 19-9 >100 U/mL and >8 months between diagnosis and surgery predicted a shorter postoperative disease-free survival (DFS); Charlson comorbidity index >1, preoperative CA 19-9 >100 U/mL and tumor size (>3.0 cm on CT or >2.5 cm on pathology) predicted decreased OS. DFS and OS were significantly better for BR/LA PDAC patients treated with neoadjuvant FOLFIRINOX compared with upfront resected patients (DFS: 29.1 vs 13.7, P < 0.001; OS: 37.7 vs 25.1 months from diagnosis, P = 0.01). CONCLUSION BR/LA PDAC patients with no progression on neoadjuvant FOLFIRINOX should be offered surgical exploration. Except size, traditional pathological parameters fail to predict survival among resected FOLFIRINOX patients. Resected FOLFIRINOX patients have survival that appears to be superior than that of resectable patients who go directly to surgery.
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Affiliation(s)
- Theodoros Michelakos
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Ilaria Pergolini
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Kim C Honselmann
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Lei Cai
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Vikram Deshpande
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - David P Ryan
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jill N Allen
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Lawrence S Blaszkowsky
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jeffrey W Clark
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Janet E Murphy
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Ryan D Nipp
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Aparna Parikh
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Lee GC, Bordeianou LG, Francone TD, Blaszkowsky LS, Goldstone RN, Ricciardi R, Kunitake H, Qadan M. Superior pathologic and clinical outcomes after minimally invasive rectal cancer resection, compared to open resection. Surg Endosc 2019; 34:3435-3448. [PMID: 31844971 DOI: 10.1007/s00464-019-07120-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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: 02/14/2019] [Accepted: 09/13/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND While the ACOSOG and ALaCaRT trials found that laparoscopic resections for rectal cancer failed to demonstrate non-inferiority of pathologic outcomes when compared with open resections, the COLOR II and COREAN studies demonstrated non-inferiority of clinical outcomes, leading to uncertainty regarding the value of minimally invasive (MIS) techniques in rectal cancer surgery. We analyzed differences in pathologic and clinical outcomes between open versus MIS resections for rectal cancer. METHODS We identified patients who underwent resection for stage II or III rectal adenocarcinoma from the National Cancer Database (2010-2015). Surgical approach was categorized as open or MIS (laparoscopic or robotic). Logistic regression and Cox proportional hazard analysis were used to assess differences in outcomes and survival. Analysis was performed in an intention-to-treat fashion. RESULTS A total of 31,190 patients who underwent rectal adenocarcinoma resection were identified, of whom 52.8% underwent open resection and 47.2% underwent MIS resection (31.0% laparoscopic, 16.2% robotic). After adjustment for patient, tumor, and institutional characteristics, MIS approaches were associated with significantly decreased risk of positive circumferential resection margins (OR 0.82, 95% CI 0.72-0.94), increased likelihood of harvesting ≥ 12 lymph nodes (OR 1.12, 95% CI 1.04-1.21), shorter length of stay (OR 0.57, 95% CI 0.53-0.62), and improved overall survival (HR 0.90, 95% CI 0.83-0.98). CONCLUSIONS MIS approaches to rectal cancer resection were associated with improved pathologic and clinical outcomes when compared to the open approach. In this nationwide, facility-based sample of cancer cases in the United States, our data suggest superiority of MIS techniques for rectal cancer treatment.
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Affiliation(s)
- Grace C Lee
- Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
- Newton Wellesley Hospital, Newton, MA, 02462, USA
| | - Liliana G Bordeianou
- Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
- Newton Wellesley Hospital, Newton, MA, 02462, USA
| | - Todd D Francone
- Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
- Newton Wellesley Hospital, Newton, MA, 02462, USA
| | - Lawrence S Blaszkowsky
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, 02114, USA
- Newton Wellesley Hospital, Newton, MA, 02462, USA
| | - Robert N Goldstone
- Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
- Newton Wellesley Hospital, Newton, MA, 02462, USA
| | - Rocco Ricciardi
- Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, Yawkey 7B, Boston, MA, 02114, USA
- Newton Wellesley Hospital, Newton, MA, 02462, USA
| | - Hiroko Kunitake
- Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, Yawkey 7B, Boston, MA, 02114, USA.
- Newton Wellesley Hospital, Newton, MA, 02462, USA.
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, Yawkey 7B, Boston, MA, 02114, USA.
- Newton Wellesley Hospital, Newton, MA, 02462, USA.
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27
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Harrison JM, Wo JY, Ferrone CR, Horick NK, Keane FK, Qadan M, Lillemoe KD, Hong TS, Clark JW, Blaszkowsky LS, Allen JN, Castillo CFD. Intraoperative Radiation Therapy (IORT) for Borderline Resectable and Locally Advanced Pancreatic Ductal Adenocarcinoma (BR/LA PDAC) in the Era of Modern Neoadjuvant Treatment: Short-Term and Long-Term Outcomes. Ann Surg Oncol 2019; 27:1400-1406. [DOI: 10.1245/s10434-019-08084-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Indexed: 12/14/2022]
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Parikh AR, Leshchiner I, Elagina L, Goyal L, Levovitz C, Siravegna G, Livitz D, Rhrissorrakrai K, Martin EE, Van Seventer EE, Hanna M, Slowik K, Utro F, Pinto CJ, Wong A, Danysh BP, de la Cruz FF, Fetter IJ, Nadres B, Shahzade HA, Allen JN, Blaszkowsky LS, Clark JW, Giantonio B, Murphy JE, Nipp RD, Roeland E, Ryan DP, Weekes CD, Kwak EL, Faris JE, Wo JY, Aguet F, Dey-Guha I, Hazar-Rethinam M, Dias-Santagata D, Ting DT, Zhu AX, Hong TS, Golub TR, Iafrate AJ, Adalsteinsson VA, Bardelli A, Parida L, Juric D, Getz G, Corcoran RB. Author Correction: Liquid versus tissue biopsy for detecting acquired resistance and tumor heterogeneity in gastrointestinal cancers. Nat Med 2019; 25:1949. [PMID: 31745334 DOI: 10.1038/s41591-019-0698-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
An amendment to this paper has been published and can be accessed via a link at the top of the paper.
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Affiliation(s)
- Aparna R Parikh
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | | | | | - Lipika Goyal
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | | | - Giulia Siravegna
- Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy.,Department of Oncology, University of Torino, Turin, Italy
| | | | | | | | - Emily E Van Seventer
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Megan Hanna
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Kara Slowik
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | | | - Christopher J Pinto
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Alicia Wong
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | | | - Ferran Fece de la Cruz
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Isobel J Fetter
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Brandon Nadres
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Heather A Shahzade
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Jill N Allen
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Lawrence S Blaszkowsky
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Jeffrey W Clark
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Bruce Giantonio
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Janet E Murphy
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Ryan D Nipp
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Eric Roeland
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - David P Ryan
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Colin D Weekes
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Eunice L Kwak
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Jason E Faris
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Jennifer Y Wo
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | | | - Ipsita Dey-Guha
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Mehlika Hazar-Rethinam
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Dora Dias-Santagata
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - David T Ting
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Andrew X Zhu
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Theodore S Hong
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Todd R Golub
- Broad Institute of MIT and Harvard, Cambridge, MA, USA.,Dana-Farber Cancer Institute, Boston, MA, USA.,Howard Hughes Medical Institute, Boston, MA, USA
| | - A John Iafrate
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | | | - Alberto Bardelli
- Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy.,Department of Oncology, University of Torino, Turin, Italy
| | | | - Dejan Juric
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Gad Getz
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA. .,Department of Medicine, Harvard Medical School, Boston, MA, USA. .,Broad Institute of MIT and Harvard, Cambridge, MA, USA. .,Department of Pathology, Massachusetts General Hospital, Boston, MA, USA.
| | - Ryan B Corcoran
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA. .,Department of Medicine, Harvard Medical School, Boston, MA, USA.
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Ferrone C, Goyal L, Qadan M, Gervais D, Sahani DV, Zhu AX, Hong TS, Blaszkowsky LS, Tanabe KK, Vangel M, Amorim BJ, Wo JY, Mahmood U, Pandharipande PV, Catana C, Duenas VP, Collazo YQ, Canamaque LG, Domachevsky L, Bernstine HH, Groshar D, Shih TTF, Li Y, Herrmann K, Umutlu L, Rosen BR, Catalano OA. Management implications of fluorodeoxyglucose positron emission tomography/magnetic resonance in untreated intrahepatic cholangiocarcinoma. Eur J Nucl Med Mol Imaging 2019; 47:1871-1884. [PMID: 31705172 DOI: 10.1007/s00259-019-04558-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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: 06/14/2019] [Accepted: 09/25/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Intrahepatic cholangiocarcinoma (ICC) is associated with a poor prognosis with surgical resection offering the best chance for long-term survival and potential cure. However, in up to 36% of patients who undergo surgery, more extensive disease is found at time of operation requiring cancellation of surgery. PET/MR is a novel hybrid technology that might improve local and whole-body staging in ICC patients, potentially influencing clinical management. This study was aimed to investigate the possible management implications of PET/MR, relative to conventional imaging, in patients affected by untreated intrahepatic cholangiocarcinoma. METHODS Retrospective review of the clinicopathologic features of 37 patients with iCCC, who underwent PET/MR between September 2015 and August 2018, was performed to investigate the management implications that PET/MR had exerted on the affected patients, relative to conventional imaging. RESULTS Of the 37 patients enrolled, median age 63.5 years, 20 (54%) were female. The same day PET/CT was performed in 26 patients. All patients were iCCC-treatment-naïve. Conventional imaging obtained as part of routine clinical care demonstrated early-stage resectable disease for 15 patients and advanced stage disease beyond the scope of surgical resection for 22. PET/MR modified the clinical management of 11/37 (29.7%) patients: for 5 patients (13.5%), the operation was cancelled due to identification of additional disease, while 4 "inoperable" patients (10.8%) underwent an operation. An additional 2 patients (5.4%) had a significant change in their operative plan based on PET/MR. CONCLUSIONS When compared with standard imaging, PET/MR significantly influenced the treatment plan in 29.7% of patients with iCCC. TRIAL REGISTRATION 2018P001334.
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Affiliation(s)
- Cristina Ferrone
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St., Boston, MA, 02114, USA
| | - Lipika Goyal
- Department of Oncology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St., Boston, MA, 02114, USA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St., Boston, MA, 02114, USA
| | - Debra Gervais
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, WHT 270, 55 Fruit St., Boston, MA, 02114, USA
| | - Dushyant V Sahani
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, WHT 270, 55 Fruit St., Boston, MA, 02114, USA
| | - Andrew X Zhu
- Department of Oncology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St., Boston, MA, 02114, USA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St., Boston, MA, 02114, USA
| | - Lawrence S Blaszkowsky
- Department of Oncology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St., Boston, MA, 02114, USA.,Department of Oncology, Newton-Wellesley Hospital, 2114 Washington St., Newton, MA, 02462, USA
| | - Kenneth K Tanabe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St., Boston, MA, 02114, USA
| | - Mark Vangel
- Department of Biostatics, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St., Boston, MA, 02114, USA
| | - Barbara J Amorim
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, WHT 270, 55 Fruit St., Boston, MA, 02114, USA.,Division of Nuclear Medicine, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St., Boston, MA, 02114, USA
| | - Umar Mahmood
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, WHT 270, 55 Fruit St., Boston, MA, 02114, USA.,Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, 149 13th, Charlestown, MA, 02129, USA
| | - Pari V Pandharipande
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, WHT 270, 55 Fruit St., Boston, MA, 02114, USA
| | - Ciprian Catana
- Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, 149 13th, Charlestown, MA, 02129, USA
| | - Virginia P Duenas
- Department of Nuclear Medicine and Radiology, Hospital HM Puerta del Sur, Avda Carlos V 70, 28938, Madrid, Spain
| | - Yolanda Q Collazo
- Department of Surgery, Hospital HM Sanchinarro, Avda Carlos V 70, 28938, Madrid, Spain
| | - Lina G Canamaque
- Department of Nuclear Medicine and Radiology, Hospital HM Puerta del Sur, Avda Carlos V 70, 28938, Madrid, Spain
| | - Liran Domachevsky
- Department of Radiology and Nuclear Medicine, Assuta Medical Center, HaBarzel St. 20, Tel Aviv-Yafo, Israel
| | - Hanna H Bernstine
- Department of Radiology and Nuclear Medicine, Assuta Medical Center, HaBarzel St. 20, Tel Aviv-Yafo, Israel
| | - David Groshar
- Department of Radiology and Nuclear Medicine, Assuta Medical Center, HaBarzel St. 20, Tel Aviv-Yafo, Israel
| | - Tiffany Tsing-Fang Shih
- Department of Medical Imaging and Radiology, National Taiwan University College of Medicine and Hospital, No. 7, Chung-Shan South Rd., Taipei, 10016, Taiwan
| | - Yan Li
- Department of Radiology, Universitatsklinikum, Essen University, Hufelandstraße 55, 45147, Essen, Germany
| | - Ken Herrmann
- Department of Nuclear Medicine, Universitatsklinikum, Essen University, Hufelandstraße 55, 45147, Essen, Germany
| | - Lale Umutlu
- Department of Radiology, Universitatsklinikum, Essen University, Hufelandstraße 55, 45147, Essen, Germany
| | - Bruce R Rosen
- Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, 149 13th, Charlestown, MA, 02129, USA
| | - Onofrio A Catalano
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, WHT 270, 55 Fruit St., Boston, MA, 02114, USA. .,Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, 149 13th, Charlestown, MA, 02129, USA. .,Department of Radiology, University of Naples "Parthenope", Via Acton 38, 80131, Naples, Italy.
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30
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Shah MH, Goldner WS, Halfdanarson TR, Bergsland E, Berlin JD, Halperin D, Chan J, Kulke MH, Benson AB, Blaszkowsky LS, Eads J, Engstrom PF, Fanta P, Giordano T, He J, Heslin MJ, Kalemkerian GP, Kandeel F, Khan SA, Kidwai WZ, Kunz PL, Kuvshinoff BW, Lieu C, Pillarisetty VG, Saltz L, Sosa JA, Strosberg JR, Sussman CA, Trikalinos NA, Uboha NA, Whisenant J, Wong T, Yao JC, Burns JL, Ogba N, Zuccarino-Catania G. NCCN Guidelines Insights: Neuroendocrine and Adrenal Tumors, Version 2.2018. J Natl Compr Canc Netw 2019; 16:693-702. [PMID: 29891520 DOI: 10.6004/jnccn.2018.0056] [Citation(s) in RCA: 241] [Impact Index Per Article: 48.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The NCCN Guidelines for Neuroendocrine and Adrenal Tumors provide recommendations for the management of adult patients with neuroendocrine tumors (NETs), adrenal gland tumors, pheochromocytomas, and paragangliomas. Management of NETs relies heavily on the site of the primary NET. These NCCN Guidelines Insights summarize the management options and the 2018 updates to the guidelines for locoregional advanced disease, and/or distant metastasis originating from gastrointestinal tract, bronchopulmonary, and thymus primary NETs.
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31
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Murphy JE, Wo JY, Ryan DP, Jiang W, Yeap BY, Drapek LC, Blaszkowsky LS, Kwak EL, Allen JN, Clark JW, Faris JE, Zhu AX, Goyal L, Lillemoe KD, DeLaney TF, Fernández-Del Castillo C, Ferrone CR, Hong TS. Total Neoadjuvant Therapy With FOLFIRINOX Followed by Individualized Chemoradiotherapy for Borderline Resectable Pancreatic Adenocarcinoma: A Phase 2 Clinical Trial. JAMA Oncol 2019; 4:963-969. [PMID: 29800971 DOI: 10.1001/jamaoncol.2018.0329] [Citation(s) in RCA: 379] [Impact Index Per Article: 75.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Patients with borderline-resectable pancreatic ductal adenocarcinoma have historically poor outcomes with surgery followed by adjuvant chemotherapy. Evaluation of a total neoadjuvant approach with highly active therapy is warranted. Objective To evaluate the margin-negative (R0) resection rate in borderline-resectable pancreatic ductal adenocarcinoma after neoadjuvant FOLFIRINOX (fluorouracil, irinotecan, and oxaliplatin) therapy and individualized chemoradiotherapy. Design, Setting, and Participants A single-arm, phase 2 clinical trial was conducted at a large academic hospital with expertise in pancreatic surgery from August 3, 2012, through August 31, 2016, among 48 patients with newly diagnosed, previously untreated, localized pancreatic cancer determined to be borderline resectable by multidisciplinary review, who had Eastern Cooperative Oncology Group performance status 0 or 1 and adequate hematologic, renal, and hepatic function. Median follow-up for the analysis was 18.0 months among the 30 patients still alive at study completion. Interventions Patients received FOLFIRINOX for 8 cycles. Upon restaging, patients with resolution of vascular involvement received short-course chemoradiotherapy (5 Gy × 5 with protons) with capecitabine. Patients with persistent vascular involvement received long-course chemoradiotherapy with fluorouracil or capecitabine. Main Outcomes and Measures The primary outcome was R0 resection rate; secondary outcomes were median progression-free survival (PFS) and median overall survival (OS). Results Of the 48 eligible patients, 27 were men and 21 were women, with a median age of 62 years (range, 46-74 years). Of the 43 patients who planned to receive 8 preoperative cycles of chemotherapy, 34 (79%) were able to complete all cycles. Twenty-seven patients (56%) had short-course chemoradiotherapy, while 17 patients (35%) had long-course chemoradiotherapy. R0 resection was achieved in 31 of the 48 eligible patients (65%; 95% CI, 49%-78%). Among the 32 patients who underwent resection, the R0 resection rate was 97% (n = 31). Median PFS among all eligible patients was 14.7 months (95% CI, 10.5 to not reached), with 2-year PFS of 43%; median OS was 37.7 months (95% CI, 19.4 to not reached), with 2-year OS of 56%. Among patients who underwent resection, median PFS was 48.6 months (95% CI, 14.4 to not reached) and median OS has not been reached, with a 2-year PFS of 55% and a 2-year OS of 72%. Conclusions and Relevance Preoperative FOLFIRINOX followed by individualized chemoradiotherapy in borderline resectable pancreatic cancer results in high rates of R0 resection and prolonged median PFS and median OS, supporting ongoing phase 3 trials. Trial Registration ClinicalTrials.gov Identifier: NCT01591733.
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Affiliation(s)
- Janet E Murphy
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - David P Ryan
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Wenqing Jiang
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Beow Y Yeap
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Lorraine C Drapek
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Lawrence S Blaszkowsky
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Eunice L Kwak
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jill N Allen
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jeffrey W Clark
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jason E Faris
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Andrew X Zhu
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Lipika Goyal
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Thomas F DeLaney
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston
| | | | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston
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Lee GC, Gamblin TC, Fong ZV, Ferrone CR, Goyal L, Lillemoe KD, Blaszkowsky LS, Tanabe KK, Qadan M. Facility Type is Associated with Margin Status and Overall Survival of Patients with Resected Intrahepatic Cholangiocarcinoma. Ann Surg Oncol 2019; 26:4091-4099. [PMID: 31368018 DOI: 10.1245/s10434-019-07657-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Many studies have demonstrated associations between surgical resections at academic centers and improved outcomes, particularly for complex operations. However, few studies have examined this relationship in intrahepatic cholangiocarcinoma (ICC). The hypothesis of this study was that facility type is associated with improved postoperative outcomes and survival for patients with ICC who undergo resection. METHODS Patients with stages 1 to 3 ICC who underwent hepatectomy were identified using the National Cancer Database (NCDB) (2004-2014). Facilities were categorized as academic or community centers per Commission on Cancer designations. High-volume hospitals were those that performed 11 or more hepatectomies per year. Multilevel logistic mixed-effects models to identify predictors of outcomes and parametric survival-time models were used to determine overall survival (OS). RESULTS The study identified 2256 patients. Of these patients, 423 (18.8%) were treated at community centers, and 1833 (81.3%) were treated at academic centers. Nearly all high-volume centers were academic facilities (98.5% academic vs. 1.5% community centers), whereas low-volume centers were mixed (65.5% academic vs. 34.5% community centers) (p < 0.001). Surgery performed at an academic center was an independent predictor of decreased positive margins (odds ratio [OR], 0.71; 95% confidence interval [CI], 0.51-0.98; p = 0.04), a lower 90-day mortality rate (OR, 0.62; 95% CI, 0.39-0.97; p = 0.03), and improved OS (hazard ratio [HR], 0.78; 95% CI, 0.63-0.96; p = 0.02). Facility hepatectomy volume was not independently associated with any short- or long-term outcomes. CONCLUSIONS Treatment at an academic center is associated with fewer positive resection margins, a decreased 90-day mortality rate, and improved OS for patients who undergo ICC resection. Facility surgical volume was not shown to be significantly associated with any postoperative outcomes after adjustment for patient and disease characteristics.
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Affiliation(s)
- Grace C Lee
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.,Newton Wellesley Hospital, Newton, MA, USA
| | - T Clark Gamblin
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Zhi Ven Fong
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.,Newton Wellesley Hospital, Newton, MA, USA
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.,Newton Wellesley Hospital, Newton, MA, USA
| | - Lipika Goyal
- Newton Wellesley Hospital, Newton, MA, USA.,Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.,Newton Wellesley Hospital, Newton, MA, USA
| | - Lawrence S Blaszkowsky
- Newton Wellesley Hospital, Newton, MA, USA.,Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kenneth K Tanabe
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.,Newton Wellesley Hospital, Newton, MA, USA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA. .,Newton Wellesley Hospital, Newton, MA, USA. .,Surgical Oncology Associates, Massachusetts General Hospital, Boston, MA, USA.
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Amorim BJ, Hong TS, Blaszkowsky LS, Ferrone CR, Berger DL, Bordeianou LG, Ricciardi R, Clark JW, Ryan DP, Wo JY, Qadan M, Vangel M, Umutlu L, Groshar D, Cañamaques LG, Gervais DA, Mahmood U, Rosen BR, Catalano OA. Clinical impact of PET/MR in treated colorectal cancer patients. Eur J Nucl Med Mol Imaging 2019; 46:2260-2269. [PMID: 31359108 DOI: 10.1007/s00259-019-04449-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [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: 04/29/2019] [Accepted: 07/16/2019] [Indexed: 12/14/2022]
Abstract
PURPOSE The primary aim of the present study was to evaluate if PET/MR induced management changes versus standard of care imaging (SCI) in treated colorectal cancer patients. The secondary aim was to assess the staging performance of PET/MR and of SCI versus the final oncologic stage. METHODS Treated CRC patients who underwent PET/MR with 18F-FDG and SCI between January 2016 and October 2018 were enrolled in this retrospective study. Their medical records were evaluated to ascertain if PET/MR had impacted on their clinical management versus SCI. The final oncologic stage, as reported in the electronic medical record, was considered the true stage of disease. RESULTS A total of 39 patients who underwent 42 PET/MR studies were included, mean age 56.7 years (range 39-75 years), 26 males, and 13 females. PET/MR changed clinical management 15/42 times (35.7%, standard error ± 7.4%); these 15 changes in management were due to upstaging in 9/42 (21.5%) and downstaging in 6/42 (14.2%). The differences in management prompted by SCI versus PET/MR were statistically significant, and PET/MR outperformed SCI (P value < 0.001; odds ratio = 2.8). In relation to the secondary outcome, PET/MR outperformed the SCI in accuracy of oncologic staging (P value = 0.016; odds ratio = 4.6). CONCLUSIONS PET/MR is a promising imaging tool in the evaluation of treated CRC and might change the management in these patients. However, multicenter prospective studies with larger patient samples are required in order to confirm these preliminary results.
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Affiliation(s)
- Barbara J Amorim
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, White 270, Boston, MA, 02114, USA.,Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Division of Nuclear Medicine, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lawrence S Blaszkowsky
- Department of Hematology/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
| | - David L Berger
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Liliana G Bordeianou
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Rocco Ricciardi
- Department of Surgery, 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
| | - 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
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mark Vangel
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, White 270, Boston, MA, 02114, USA.,Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Biostatistics Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lale Umutlu
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - David Groshar
- Department of Nuclear Medicine, Assuta Medical Centers, Tel Aviv, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Debra A Gervais
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, White 270, Boston, MA, 02114, USA
| | - Umar Mahmood
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, White 270, Boston, MA, 02114, USA.,Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Bruce R Rosen
- Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Onofrio A Catalano
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, White 270, Boston, MA, 02114, USA. .,Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA. .,Department of Radiology, University of Naples "Parthenope", Naples, Italy.
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Cleary JM, Horick NK, McCleary NJ, Abrams TA, Yurgelun MB, Azzoli CG, Rubinson DA, Brooks GA, Chan JA, Blaszkowsky LS, Clark JW, Goyal L, Meyerhardt JA, Ng K, Schrag D, Savarese DM, Graham C, Fitzpatrick B, Gibb KA, Boucher Y, Duda DG, Jain RK, Fuchs CS, Enzinger PC. FOLFOX plus ziv-aflibercept or placebo in first-line metastatic esophagogastric adenocarcinoma: A double-blind, randomized, multicenter phase 2 trial. Cancer 2019; 125:2213-2221. [PMID: 30913304 PMCID: PMC6763367 DOI: 10.1002/cncr.32029] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [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: 09/11/2018] [Revised: 12/06/2018] [Accepted: 01/10/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Antiangiogenic therapy is a proven therapeutic modality for refractory gastric and gastroesophageal junction adenocarcinoma. This trial assessed whether the addition of a high affinity angiogenesis inhibitor, ziv-aflibercept, could improve the efficacy of first-line mFOLFOX6 (oxaliplatin, leucovorin, and bolus plus infusional 5- fluorouracil) in metastatic esophagogastric adenocarcinoma. METHODS Patients with treatment-naive metastatic esophagogastric adenocarcinoma were randomly assigned (in a 2:1 ratio) in a multicenter, placebo-controlled, double-blind trial to receive first-line mFOLFOX6 with or without ziv-aflibercept (4 mg/kg) every 2 weeks. The primary endpoint was 6-month progression-free survival (PFS). RESULTS Sixty-four patients were randomized to receive mFOLFOX6 and ziv-aflibercept (43 patients) or mFOLFOX6 and a placebo (21 patients). There was no difference in the PFS, overall survival, or response rate. Patients treated with mFOLFOX6/ziv-aflibercept tended to be more likely to discontinue study treatment for reasons other than progressive disease (P = .06). The relative dose intensity of oxaliplatin and 5-fluorouracil was lower in the mFOLFOX6/ziv-aflibercept arm during the first 12 and 24 weeks of the trial. There were 2 treatment-related deaths due to cerebral hemorrhage and bowel perforation in the mFOLFOX6/ziv-aflibercept cohort. CONCLUSIONS Ziv-aflibercept did not increase the anti-tumor activity of first-line mFOLFOX6 in metastatic esophagogastric cancer, potentially because of decreased dose intensity of FOLFOX. Further evaluation of ziv-aflibercept in unselected, chemotherapy-naive patients with metastatic esophagogastric adenocarcinoma is not warranted.
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Affiliation(s)
- James M. Cleary
- Center for Esophageal and Gastric Cancer, Dana-Farber/Brigham and Women’s Cancer Center, Boston, Massachusetts
- Division of Gastrointestinal Cancers, Department of Medical Oncology, Dana-Farber Cancer Institute/Harvard Medical School, Boston, Massachusetts
| | - Nora K. Horick
- Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Nadine Jackson McCleary
- Center for Esophageal and Gastric Cancer, Dana-Farber/Brigham and Women’s Cancer Center, Boston, Massachusetts
- Division of Gastrointestinal Cancers, Department of Medical Oncology, Dana-Farber Cancer Institute/Harvard Medical School, Boston, Massachusetts
| | - Thomas A. Abrams
- Center for Esophageal and Gastric Cancer, Dana-Farber/Brigham and Women’s Cancer Center, Boston, Massachusetts
- Division of Gastrointestinal Cancers, Department of Medical Oncology, Dana-Farber Cancer Institute/Harvard Medical School, Boston, Massachusetts
| | - Matthew B. Yurgelun
- Center for Esophageal and Gastric Cancer, Dana-Farber/Brigham and Women’s Cancer Center, Boston, Massachusetts
- Division of Gastrointestinal Cancers, Department of Medical Oncology, Dana-Farber Cancer Institute/Harvard Medical School, Boston, Massachusetts
| | - Christopher G. Azzoli
- Steele Laboratories for Tumor Biology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - Douglas A. Rubinson
- Center for Esophageal and Gastric Cancer, Dana-Farber/Brigham and Women’s Cancer Center, Boston, Massachusetts
- Division of Gastrointestinal Cancers, Department of Medical Oncology, Dana-Farber Cancer Institute/Harvard Medical School, Boston, Massachusetts
| | - Gabriel A. Brooks
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jennifer A. Chan
- Center for Esophageal and Gastric Cancer, Dana-Farber/Brigham and Women’s Cancer Center, Boston, Massachusetts
- Division of Gastrointestinal Cancers, Department of Medical Oncology, Dana-Farber Cancer Institute/Harvard Medical School, Boston, Massachusetts
| | | | - Jeffrey W. Clark
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - Lipika Goyal
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - Jeffrey A. Meyerhardt
- Center for Esophageal and Gastric Cancer, Dana-Farber/Brigham and Women’s Cancer Center, Boston, Massachusetts
- Division of Gastrointestinal Cancers, Department of Medical Oncology, Dana-Farber Cancer Institute/Harvard Medical School, Boston, Massachusetts
| | - Kimmie Ng
- Center for Esophageal and Gastric Cancer, Dana-Farber/Brigham and Women’s Cancer Center, Boston, Massachusetts
- Division of Gastrointestinal Cancers, Department of Medical Oncology, Dana-Farber Cancer Institute/Harvard Medical School, Boston, Massachusetts
| | - Deborah Schrag
- Center for Esophageal and Gastric Cancer, Dana-Farber/Brigham and Women’s Cancer Center, Boston, Massachusetts
- Division of Gastrointestinal Cancers, Department of Medical Oncology, Dana-Farber Cancer Institute/Harvard Medical School, Boston, Massachusetts
| | - Diane M.F. Savarese
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christopher Graham
- Center for Esophageal and Gastric Cancer, Dana-Farber/Brigham and Women’s Cancer Center, Boston, Massachusetts
- Division of Gastrointestinal Cancers, Department of Medical Oncology, Dana-Farber Cancer Institute/Harvard Medical School, Boston, Massachusetts
| | - Bridget Fitzpatrick
- Center for Esophageal and Gastric Cancer, Dana-Farber/Brigham and Women’s Cancer Center, Boston, Massachusetts
- Division of Gastrointestinal Cancers, Department of Medical Oncology, Dana-Farber Cancer Institute/Harvard Medical School, Boston, Massachusetts
| | - Kathryn A. Gibb
- Center for Esophageal and Gastric Cancer, Dana-Farber/Brigham and Women’s Cancer Center, Boston, Massachusetts
- Division of Gastrointestinal Cancers, Department of Medical Oncology, Dana-Farber Cancer Institute/Harvard Medical School, Boston, Massachusetts
| | - Yves Boucher
- Steele Laboratories for Tumor Biology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - Dan G. Duda
- Steele Laboratories for Tumor Biology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - Rakesh K. Jain
- Steele Laboratories for Tumor Biology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts
| | | | - Peter C. Enzinger
- Center for Esophageal and Gastric Cancer, Dana-Farber/Brigham and Women’s Cancer Center, Boston, Massachusetts
- Division of Gastrointestinal Cancers, Department of Medical Oncology, Dana-Farber Cancer Institute/Harvard Medical School, Boston, Massachusetts
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Parikh AR, Leshchiner I, Elagina L, Goyal L, Levovitz C, Siravegna G, Livitz D, Rhrissorrakrai K, Martin L, Seventer EEV, Hanna M, Slowik K, Utro F, Pinto CJ, Wong A, Danysh BP, Cruz FFDL, Fetter IJ, Nadres B, Shahzade HA, Allen JN, Blaszkowsky LS, Clark JW, Giantonio B, Murphy JE, Nipp RD, Roeland E, Ryan DP, Weekes CD, Kwak EL, Faris JE, Aguet F, Guha I, Hazar-Rethinam M, Dias-Santagata D, Ting DT, Zhu AX, Hong TS, Golub TR, Iafrate AJ, Adalsteinsson V, Bardelli A, Parida L, Juric D, Getz G, Corcoran RB. Abstract LB-257: Liquid biopsy versus tissue biopsy to assess acquired resistance and tumor heterogeneity in gastrointestinal cancers. Cancer Res 2019. [DOI: 10.1158/1538-7445.am2019-lb-257] [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
The inevitable emergence of acquired resistance is a major limitation to the clinical benefit of precision medicine strategies. Single-lesion tumor biopsies have long been the mainstay of understanding acquired resistance, but recent data suggest tumor biopsies may under-represent the molecular heterogeneity of acquired resistance. Alternatively, studies have suggested that liquid biopsy approaches analyzing cell-free DNA (cfDNA) may offer significant advantages, but extensive prospective comparisons of matched liquid vs. tumor biopsies obtained at the time of acquired resistance are lacking. Here, we assess systematic liquid biopsy upon acquired resistance to targeted therapy in 44 patients across seven molecularly defined subtypes of gastrointestinal cancers. Liquid biopsy at disease progression identified at least one functionally validated molecular mechanism of resistance in 75% of patients, wherein 52% exhibited >1 resistance alteration (range 2-9, median 3 per patient). In 23 patients in whom a matched post-progression tumor biopsy could be obtained, tumor biopsy was less effective than liquid biopsy in identifying resistance mechanisms, with resistance alterations detected in only 48% of patients, and multiple resistance mechanisms detected in only 9% of cases. In matched cases, liquid biopsy detected at least one resistance alteration not detected in tumor biopsy in 78% of cases. Targeted analysis and whole-exome sequencing of serial cfDNA, multiple post-progression biopsies, and rapid autopsy specimens from select cases revealed key insights into the geographic and complex characteristics of heterogeneity captured by liquid biopsy in the setting of acquired resistance. These data illustrate that acquired resistance is characterized by frequent and profound tumor heterogeneity, and suggests that liquid biopsy may more effectively identify heterogeneous clinically relevant resistance alterations compared to standard tumor biopsy.
Citation Format: Aparna R. Parikh, Ignaty Leshchiner, Liudmila Elagina, Lipika Goyal, Chaya Levovitz, Giulia Siravegna, Dimitri Livitz, Kahn Rhrissorrakrai, Liz Martin, Emily E. Van Seventer, Megan Hanna, Kara Slowik, Filippo Utro, Christopher J. Pinto, Alicia Wong, Brian P. Danysh, Ferran Fece de la Cruz, Isobel J. Fetter, Brandon Nadres, Heather A. Shahzade, Jill N. Allen, Lawrence S. Blaszkowsky, Jeffrey W. Clark, Bruce Giantonio, Janet E. Murphy, Ryan D. Nipp, Eric Roeland, David P. Ryan, Colin D. Weekes, Eunice L. Kwak, Jason E. Faris, Francois Aguet, Ipsita Guha, Mehlika Hazar-Rethinam, Dora Dias-Santagata, David T. Ting, Andrew X. Zhu, Theodore S. Hong, Todd R. Golub, A J. Iafrate, Viktor Adalsteinsson, Alberto Bardelli, Laxmi Parida, Dejan Juric, Gad Getz, Ryan B. Corcoran. Liquid biopsy versus tissue biopsy to assess acquired resistance and tumor heterogeneity in gastrointestinal cancers [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr LB-257.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Gad Getz
- 1Mass. General Hospital, Charlestown, MA
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Wo JY, Plastaras JP, Metz JM, Jiang W, Yeap BY, Drapek LC, Adams J, Baglini C, Ryan DP, Murphy JE, Parikh AR, Allen JN, Clark JW, Blaszkowsky LS, DeLaney TF, Ben-Josef E, Hong TS. Pencil Beam Scanning Proton Beam Chemoradiation Therapy With 5-Fluorouracil and Mitomycin-C for Definitive Treatment of Carcinoma of the Anal Canal: A Multi-institutional Pilot Feasibility Study. Int J Radiat Oncol Biol Phys 2019; 105:90-95. [PMID: 31128146 DOI: 10.1016/j.ijrobp.2019.04.040] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 04/19/2019] [Accepted: 04/26/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Definitive chemoradiation with concurrent 5-fluorouracil (5-FU)/mitomycin C (MMC) is an effective treatment for localized anal cancer, but it is associated with significant acute long-term treatment-related toxicity. Pencil beam scanning proton beam (PBS-PT) radiation therapy may potentially reduce this toxicity. This is a multi-institutional pilot study evaluating the feasibility of definitive concurrent chemoradiation with PBS-PT in combination with 5-FU and MMC for carcinoma of the anal canal. METHODS AND MATERIALS Patients were enrolled on a National Cancer Institute-sponsored, prospective, multi-institutional, single-arm pilot study (NCT01858025). Key eligibility criteria included Eastern Cooperative Oncology Group 0 to 2, age ≥18 years, histologically confirmed invasive squamous cell carcinoma of the anal canal, and clinically staged T1-4, N0-3 disease. Patients were treated with PBS-PT per Radiation Therapy Oncology Group 0529 dose schema and concurrent 5-FU/MMC on day 1 and 29. The primary objective of this study was to determine feasibility of PBS-PT with concurrent 5-FU/MMC, defined as grade 3+ dermatologic toxicity less than 48% (reported grade 3+ dermatologic toxicity from Radiation Therapy Oncology Group 98-11). Secondary objectives were to determine the rates of overall grade 3+ toxicities, clinical complete response rate, and disease outcomes. RESULTS Between February 2014 and April 2017, we enrolled 25 patients into our study, all of whom were analyzed. Twenty-three patients (92%) completed treatment per protocol, and 2 patients died on treatment. Median time to completion of treatment was 42 days (range, 38-49). The grade 3+ radiation dermatitis rate was 24%. Median follow-up is 27 months (range, 21-50) among the 21 patients still alive. The overall rate of clinical complete response was 88%. The 2-year local failure, colostomy-free survival, progression-free survival, and overall survival are 12%, 72%, 80%, and 84%, respectively. CONCLUSIONS In our prospective, multi-institutional pilot study of PBS-PT with concurrent 5-FU/MMC, PBS-PT was found to be feasible. A phase 2 study of proton beam radiation therapy is currently underway.
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Affiliation(s)
- Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
| | - John P Plastaras
- Department of Radiation Oncology, The University of Pennsylvania Cancer Center, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - James M Metz
- Department of Radiation Oncology, The University of Pennsylvania Cancer Center, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Wenqing Jiang
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Beow Y Yeap
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lorraine C Drapek
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Judith Adams
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christian Baglini
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - David P Ryan
- 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
| | - Aparna R Parikh
- Department of Medical 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
| | - Lawrence S Blaszkowsky
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Thomas F DeLaney
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Edgar Ben-Josef
- Department of Radiation Oncology, The University of Pennsylvania Cancer Center, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Wo JY, Niemierko A, Ryan DP, Blaszkowsky LS, Clark JW, Kwak EL, Lillemoe KD, Drapek LN, Zhu AX, Allen JN, Faris JE, Murphy JE, Nipp R, Fernandez-Del Castillo C, Ferrone CR, Hong TS. Tolerability and Long-term Outcomes of Dose-Painted Neoadjuvant Chemoradiation to Regions of Vessel Involvement in Borderline or Locally Advanced Pancreatic Cancer. Am J Clin Oncol 2019; 41:656-661. [PMID: 28134673 DOI: 10.1097/coc.0000000000000349] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE We reviewed our experience involving patients with borderline resectable or locally advanced pancreatic cancer, treated with the dose-painted (DP) boost technique to regions of vessel involvement which preclude upfront surgical resection. We evaluated patient outcomes with respect to tolerability and treatment outcomes. MATERIALS AND METHODS We retrospectively reviewed 99 patients with borderline resectable (n=25) or locally advanced pancreatic cancer (n=74) treated with DP-neoadjuvant chemoradiation from 2010 to 2015. Tumor and regional lymph nodes were prescribed 50.4 Gy and the region around the involved blood vessel was boosted to 58.8 Gy in 28 fractions. The primary outcome was acute toxicity and late duodenal toxicity. Secondary outcomes included conversion to surgical resectability, local failure, disease-free survival, and overall survival (OS). Cox proportional hazards models were performed to evaluate for predictors of survival. RESULTS All but 1 patient completed chemoradiation. The rates of grade 2+ and 3+ nausea were 40% and 12%, respectively. With regards to late toxicity, 5 patients developed potential RT-related grade 3+ duodenal complications including duodenal ulceration/bleeding (n=3) and duodenal stricture (n=2). With a median follow-up of 15 months, the median OS was 18.1 months. Among 99 patients in our study, 37 patients underwent surgical resection. For patients who underwent surgical resection (n=37), the median OS was 30.9 months. On multivariate analysis, only normalization of CA 19-9 post-RT was associated with improved OS. CONCLUSIONS We found that DP-neoadjuvant chemoradiation to regions of vessel involvement is both feasible and well tolerated. In addition, we demonstrated that over one third of patients with initially deemed unresectable disease were able to undergo surgical resection after receiving neoadjuvant therapy including DP-chemoradiation.
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Lee GC, Ferrone CR, Tanabe KK, Lillemoe KD, Blaszkowsky LS, Zhu AX, Hong TS, Qadan M. Predictors of adjuvant treatment and survival in patients with intrahepatic cholangiocarcinoma who undergo resection. Am J Surg 2019; 218:959-966. [PMID: 30871788 DOI: 10.1016/j.amjsurg.2019.02.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 02/21/2019] [Accepted: 02/27/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND Administration of adjuvant therapy (AT) in patients with intrahepatic cholangiocarcinoma (ICC) remains inconsistent despite recent trial data. This study investigates predictors of receipt of AT and survival. METHODS Patients with ICC who underwent resection were identified using the NCDB (2004-2014). Logistic regression and Cox analysis were used to determine predictors of AT and survival, respectively. "High-risk" was defined as positive margins/nodes or stage III/IVa disease. RESULTS 2813 patients were identified, of whom 42.3% received AT. Patients with positive margins, positive nodes, and higher stage tended to receive AT (p < 0.001). Black patients and patients with Medicare/Medicaid were less likely to receive AT. In "high-risk" patients, AT was associated with lower mortality (HR 0.66, 95% CI 0.56-0.78, p < 0.001). CONCLUSIONS AT after ICC resection is associated with improved survival in patients with positive margins, positive nodes, and stage III/IVa disease. There are disparities and regional variations in the receipt of AT.
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Affiliation(s)
- Grace C Lee
- Department of Surgery, Massachusetts General Hospital, Boston, MA, 02114, USA; Newton Wellesley Hospital, Newton, MA 02462, USA
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Kenneth K Tanabe
- Department of Surgery, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, MA, 02114, USA; Newton Wellesley Hospital, Newton, MA 02462, USA
| | - Lawrence S Blaszkowsky
- Newton Wellesley Hospital, Newton, MA 02462, USA; Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Andrew X Zhu
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Theodore S Hong
- Newton Wellesley Hospital, Newton, MA 02462, USA; Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Boston, MA, 02114, USA; Newton Wellesley Hospital, Newton, MA 02462, USA.
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Sanford NN, Pursley J, Noe B, Yeap BY, Goyal L, Clark JW, Allen JN, Blaszkowsky LS, Ryan DP, Ferrone CR, Tanabe KK, Qadan M, Crane CH, Koay EJ, Eyler C, DeLaney TF, Zhu AX, Wo JY, Grassberger C, Hong TS. Protons versus Photons for Unresectable Hepatocellular Carcinoma: Liver Decompensation and Overall Survival. Int J Radiat Oncol Biol Phys 2019; 105:64-72. [PMID: 30684667 DOI: 10.1016/j.ijrobp.2019.01.076] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 12/29/2018] [Accepted: 01/13/2019] [Indexed: 12/23/2022]
Abstract
PURPOSE Ablative radiation therapy is increasingly being used for hepatocellular carcinoma (HCC) resulting in excellent local control rates; however, patients without evidence of disease progression often die from liver failure. The clinical benefit of proton- over photon-based radiation therapy is unclear. We therefore sought to compare clinical outcomes of proton versus photon ablative radiation therapy in patients with unresectable HCC. METHODS AND MATERIALS This is a single-institution retrospective study of patients treated during 2008 to 2017 with nonmetastatic, unresectable HCC not previously treated with liver-directed radiation therapy and who did not receive further liver-directed radiation therapy within 12 months after completion of index treatment. The primary outcome, overall survival (OS), was assessed using Cox regression. Secondary endpoints included incidence of non-classic radiation-induced liver disease (defined as increase in baseline Child-Pugh score by ≥2 points at 3 months posttreatment), assessed using logistic regression, and locoregional recurrence, assessed using Fine-Gray regression for competing risks. All outcomes were measured from radiation start date. RESULTS The median follow-up was 14 months. Of 133 patients with median age 68 years and 75% male, 49 (37%) were treated with proton radiation therapy. Proton radiation therapy was associated with improved OS (adjusted hazard ratio, 0.47; P = .008; 95% confidence interval [CI], 0.27-0.82). The median OS for proton and photon patients was 31 and 14 months, respectively, and the 24-month OS for proton and photon patients was 59.1% and 28.6%, respectively. Proton radiation therapy was also associated with a decreased risk of non-classic radiation-induced liver disease (odds ratio, 0.26; P = .03; 95% CI, 0.08-0.86). Development of nonclassic RILD at 3 months was associated with worse OS (adjusted hazard ratio, 3.83; P < .001; 95% CI, 2.12-6.92). There was no difference in locoregional recurrence, including local failure, between protons and photons. CONCLUSIONS Proton radiation therapy was associated with improved survival, which may be driven by decreased incidence of posttreatment liver decompensation. Our findings support prospective investigations comparing proton versus photon ablative radiation therapy for HCC.
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Affiliation(s)
- Nina N Sanford
- Harvard Radiation Oncology Program, Massachusetts General Hospital, Boston, Massachusetts; Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jennifer Pursley
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Bridget Noe
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Beow Y Yeap
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Lipika Goyal
- Department of Medical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jeffrey W Clark
- Department of Medical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jill N Allen
- Department of Medical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | | | - David P Ryan
- Department of Medical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Kenneth K Tanabe
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Christopher H Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Eugene J Koay
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Christine Eyler
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Thomas F DeLaney
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Andrew X Zhu
- Department of Medical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Clemens Grassberger
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts.
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Lee GC, Ferrone CR, Vagefi PA, Uppot RN, Tanabe KK, Lillemoe KD, Blaszkowsky LS, Qadan M. Surgical resection versus ablation for early-stage hepatocellular carcinoma: A retrospective cohort analysis. Am J Surg 2019; 218:157-163. [PMID: 30635211 DOI: 10.1016/j.amjsurg.2018.12.067] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 12/18/2018] [Accepted: 12/31/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND The most appropriate treatment for early-stage hepatocellular carcinoma (HCC) remains unclear. This study compared the association of resection versus ablation with overall survival (OS) in patients with early-stage HCC. METHODS Using the National Cancer Database (NCDB), patients diagnosed with stage I/II HCC between 2004 and 2014 were identified. Cox analysis was used to determine predictors of OS. RESULTS We identified 53,161 patients, of whom 15.9% underwent ablation and 14.5% underwent resection. Patients with fewer comorbidities, larger tumors, and private insurance were more likely to undergo resection. Resection was associated with significantly improved OS compared to ablation (HR 0.58, 95% CI 0.54-0.61, p < 0.001), at all tumor sizes (p < 0.05) and any degree of liver fibrosis (p < 0.05). CONCLUSIONS Resection of HCC tumors of all sizes and any degree of underlying fibrosis was associated with significantly improved OS compared with ablation. There was pronounced variability in the use of ablation versus resection for early-stage HCC. SUMMARY This study found that patients with early-stage hepatocellular carcinoma (HCC) have improved overall survival (OS) after surgical resection, compared to ablation, at all tumor sizes and any extent of liver disease. There were also marked variations in treatment patterns for early-stage HCC.
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Affiliation(s)
- Grace C Lee
- Department of Surgery, Massachusetts General Hospital, Boston, MA, 02114, United States; Newton Wellesley Hospital, Newton, MA, 02462, United States
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Boston, MA, 02114, United States; Newton Wellesley Hospital, Newton, MA, 02462, United States
| | - Parsia A Vagefi
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, 75390, United States
| | - Raul N Uppot
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Boston, MA, 02114, United States
| | - Kenneth K Tanabe
- Department of Surgery, Massachusetts General Hospital, Boston, MA, 02114, United States; Newton Wellesley Hospital, Newton, MA, 02462, United States
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, MA, 02114, United States; Newton Wellesley Hospital, Newton, MA, 02462, United States
| | - Lawrence S Blaszkowsky
- Newton Wellesley Hospital, Newton, MA, 02462, United States; Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, 02114, United States
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Boston, MA, 02114, United States; Newton Wellesley Hospital, Newton, MA, 02462, United States.
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Lee GC, Gamblin TC, Ferrone CR, Goyal L, Lillemoe KD, Blaszkowsky LS, Tanabe KK, Qadan M. Facility Type Is Associated with Margin Status and Overall Survival in Patients with Intrahepatic Cholangiocarcinoma Who Undergo Resection. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.08.472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Kamran SC, Clark JW, Zheng H, Borger DR, Blaszkowsky LS, Allen JN, Kwak EL, Wo JY, Parikh AR, Nipp RD, Murphy JE, Goyal L, Zhu AX, Iafrate AJ, Corcoran RB, Ryan DP, Hong TS. Primary tumor sidedness is an independent prognostic marker for survival in metastatic colorectal cancer: Results from a large retrospective cohort with mutational analysis. Cancer Med 2018; 7:2934-2942. [PMID: 29771009 PMCID: PMC6051212 DOI: 10.1002/cam4.1558] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 03/28/2018] [Accepted: 04/24/2018] [Indexed: 12/14/2022] Open
Abstract
Recent reports demonstrate inferior outcomes associated with primary right‐sided vs left‐sided colorectal tumors in patients with metastatic colorectal cancer (mCRC). We sought to describe our experience with mCRC patients on whom we have molecular data to determine whether primary tumor sidedness was an independent prognostic marker for overall survival (OS). mCRC patients with documented primary tumor sidedness who received mutational profiling between 2009 and 2014 were identified (n = 367, median follow‐up 30.4 months). Mutational profiling for >150 mutations across commonly mutated cancer genes including RAS, PIK3CA, BRAF, and PTEN as well as treatment data, including receipt of a biologic agent, were collected. Univariable/multivariable models were used to analyze relationships between collected data and OS. Among 367 patients, sidedness breakdown was as follows: 234 left (64%), 133 right (36%). 56% were male, with a median age at diagnosis of 57 (range 24‐89). A total of 143 patients had RAS mutations. Five‐year OS was 41%, median OS was 54 months (range 1‐149). Five‐year OS for left‐ vs right‐sided tumors was 46% vs 24% (P < .0001). On univariable analysis, among both RAS wildtype and mutant tumors, left‐sided tumors continued to have improved OS vs right‐sided tumors (HR: 0.49, 95% CI: 0.34‐0.69 RAS wildtype; HR: 0.61, 95% CI: 0.40‐0.95 RAS mutant). Left‐sidedness was an important prognostic factor for OS among RAS wildtype patients despite treatment with or without a biologic agent (P < .05). Left‐sidedness remained significant for improved OS on multivariable analysis (P < .0001). Left‐sided primary tumor remained most important prognostic factor for OS, even when adjusting for mutational status and receipt of biologic agent.
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Affiliation(s)
- Sophia C Kamran
- Harvard Radiation Oncology Program, Boston, MA, USA.,Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Jeffrey W Clark
- Division of Hematology and Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Hui Zheng
- Biostatistics, Massachusetts General Hospital, Boston, MA, USA
| | - Darrell R Borger
- Division of Hematology and Oncology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Jill N Allen
- Division of Hematology and Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Eunice L Kwak
- Division of Hematology and Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Aparna R Parikh
- Division of Hematology and Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Ryan D Nipp
- Division of Hematology and Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Janet E Murphy
- Division of Hematology and Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Lipika Goyal
- Division of Hematology and Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Andrew X Zhu
- Division of Hematology and Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - A John Iafrate
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Ryan B Corcoran
- Division of Hematology and Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - David P Ryan
- Division of Hematology and Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
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McDuff SGR, Remillard KA, Zheng H, Raldow AC, Wo JY, Eyler CE, Drapek LC, Goyal L, Blaszkowsky LS, Clark JW, Allen JN, Parikh AR, Ryan DP, Ferrone CR, Tanabe KK, Wolfgang JA, Zhu AX, Hong TS. Liver reirradiation for patients with hepatocellular carcinoma and liver metastasis. Pract Radiat Oncol 2018; 8:414-421. [PMID: 29937235 DOI: 10.1016/j.prro.2018.04.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 03/27/2018] [Accepted: 04/18/2018] [Indexed: 01/20/2023]
Abstract
PURPOSE This study aimed to assess the safety and efficacy of administering liver reirradiation to patients with primary liver tumors or liver metastasis. METHODS AND MATERIALS A total of 49 patients (with 64 individual tumors) who received liver reirradiation at our institution between June 2008 and December 2016 were identified for retrospective review. Patients were treated to the same, different, or a combination of previously treated liver tumors for recurrent primary (53%) or metastatic (47%) disease using photons or protons. Clinical and treatment-related factors were compiled and patients were monitored for toxicity and evidence of classic or nonclassic radiation-induced liver disease. Survival was estimated with the Kaplan-Meier method and cumulative incidence of local failure (LF) was used to estimate LF using the Response Evaluation Criteria in Solid Tumors version 1.1. RESULTS The median age at the time of reirradiation was 72 years and the median interval between radiation courses was 9 months. At a median follow-up of 10.5 months, 36 patients (73%) had died, 9 patients (18%) were alive, and 4 patients (8%) were lost to follow-up. The median survival for the cohort was 14 months. The overall 1-year estimate of LF was 46.4%. The 1-year estimates of LF for liver metastases and hepatocellular carcinoma were 61.0% and 32.5%, respectively. The average prescription dose was similar between the reirradiation and initial courses (equivalent dose in 2 Gy fractions EQD2: 65.0 vs 64.3 Gyα/β = 10, respectively) but the average dose to the untreated liver was lower at the time of reirradiation (EQD2: 10.5 vs 13.9 Gyα/β = 3, respectively, P = .01). Among patients with hepatocellular carcinoma, the average normal liver dose was significantly larger for patients who exhibited a worsening of Child-Pugh score after reirradiation compared with those who did not (1210 cGy vs 759 cGy, P = .04). With regard to toxicity, 85.7% of patients experienced grade 1 to 2 toxicity, 4.1% developed grade 3, and only 2 patients (4.1%) met the criteria for radiation-induced liver disease after reirradiation. CONCLUSIONS Liver reirradiation may be an effective and safe option for select patients; however, further prospective study is necessary to establish treatment guidelines and recommended dosing.
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Affiliation(s)
- Susan G R McDuff
- Harvard Radiation Oncology Program, Massachusetts General Hospital, Boston, Massachusetts; Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts.
| | - Kyla A Remillard
- Department of Radiation Oncology, Medical Physics and Dosimetry, Massachusetts General Hospital, Boston, Massachusetts
| | - Hui Zheng
- Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Ann C Raldow
- Department of Radiation Oncology, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Christine E Eyler
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Lorraine C Drapek
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Lipika Goyal
- Department of Internal Medicine and Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Lawrence S Blaszkowsky
- Department of Internal Medicine and Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jeffrey W Clark
- Department of Internal Medicine and Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jill N Allen
- Department of Internal Medicine and Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Aparna R Parikh
- Department of Internal Medicine and Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - David P Ryan
- Department of Internal Medicine and Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Cristina R Ferrone
- Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Kenneth K Tanabe
- Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - John A Wolfgang
- Department of Radiation Oncology, Medical Physics and Dosimetry, Massachusetts General Hospital, Boston, Massachusetts
| | - Andrew X Zhu
- Department of Internal Medicine and Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
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Hong TS, Wo JY, Borger DR, Yeap BY, McDonnell EI, Willers H, Blaszkowsky LS, Kwak EL, Allen JN, Clark JW, Tanguturi S, Goyal L, Murphy JE, Wolfgang JA, Drapek LC, Arellano RS, Mamon HJ, Mullen JT, Tanabe KK, Ferrone CR, Ryan DP, Iafrate AJ, DeLaney TF, Zhu AX. Phase II Study of Proton-Based Stereotactic Body Radiation Therapy for Liver Metastases: Importance of Tumor Genotype. J Natl Cancer Inst 2017; 109:3852626. [PMID: 28954285 DOI: 10.1093/jnci/djx031] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 02/08/2017] [Indexed: 01/11/2023] Open
Abstract
Background We evaluated the efficacy and safety of risk-adapted, proton-based stereotactic body radiation therapy (SBRT) for liver metastases from solid tumors. Methods This single-arm phase II single institutional study (NCT01239381) included patients with limited extrahepatic disease, 800 mL or greater of uninvolved liver, and no cirrhosis or Child-Pugh A, who had received proton-based SBRT to one to four liver metastases from solid tumors. Treatment comprised 30 to 50 Gray equivalent (GyE) in five fractions based on the effective volume of liver irradiated. Sample size was calculated to determine if local control (LC) at one year was greater than 70%. The cumulative incidence of local failure was used to estimate LC. The association of tumor characteristics, including genetic alterations in common cancer genes such as BRAF, EGFR, HER2, KRAS, NRAS, PIK3CA, and TP53 with local tumor control, was assessed. All statistical tests were two-sided. Results Eighty-nine patients were evaluable (colorectal, n = 34; pancreatic, n = 13; esophagogastric, n = 12; other, n = 30). Median tumor size was 2.5 cm (range = 0.5-11.9 cm). Median dose was 40 GyE (range = 30-50 GyE), and median follow-up was 30.1 months (range = 14.7-53.8 months). There was no grade 3 to 5 toxicity. Median survival time was 18.1 months. The one- and three-year LC rates were 71.9% (95% confidence limit [CL] = 62.3% to 80.9%) and 61.2% (95% CL = 50.8% to 71.8%), respectively. For large tumors (≥6 cm), one-year LC remained high at 73.9% (95% CL = 54.6% to 89.8%). Mutation in the KRAS oncogene was the strongest predictor of poor LC (P = .02). Tumor with both mutant KRAS and TP53 were particularly radioresistant, with a one-year LC rate of only 20.0%, compared with 69.2% for all others (P = .001). Conclusions We report the largest prospective evaluation to date of liver SBRT for hepatic metastases, and the first with protons. Protons were remarkably well tolerated and effective even for metastases that were 6 cm or larger. KRAS mutation is a strong predictor of poor LC, stressing the need for tumor genotyping prior to SBRT and treatment intensification in this patient subset.
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Affiliation(s)
- Theodore S Hong
- Department of Radiation Oncology, Department of Pathology, Division of Biostatistics, Department of Medicine, Division of Medical Oncology, Department of Medicine, Department of Radiology, and Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA; Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Jennifer Y Wo
- Department of Radiation Oncology, Department of Pathology, Division of Biostatistics, Department of Medicine, Division of Medical Oncology, Department of Medicine, Department of Radiology, and Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA; Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Darrell R Borger
- Department of Radiation Oncology, Department of Pathology, Division of Biostatistics, Department of Medicine, Division of Medical Oncology, Department of Medicine, Department of Radiology, and Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA; Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Beow Y Yeap
- Department of Radiation Oncology, Department of Pathology, Division of Biostatistics, Department of Medicine, Division of Medical Oncology, Department of Medicine, Department of Radiology, and Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA; Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Erin I McDonnell
- Department of Radiation Oncology, Department of Pathology, Division of Biostatistics, Department of Medicine, Division of Medical Oncology, Department of Medicine, Department of Radiology, and Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA; Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Henning Willers
- Department of Radiation Oncology, Department of Pathology, Division of Biostatistics, Department of Medicine, Division of Medical Oncology, Department of Medicine, Department of Radiology, and Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA; Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Lawrence S Blaszkowsky
- Department of Radiation Oncology, Department of Pathology, Division of Biostatistics, Department of Medicine, Division of Medical Oncology, Department of Medicine, Department of Radiology, and Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA; Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Eunice L Kwak
- Department of Radiation Oncology, Department of Pathology, Division of Biostatistics, Department of Medicine, Division of Medical Oncology, Department of Medicine, Department of Radiology, and Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA; Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Jill N Allen
- Department of Radiation Oncology, Department of Pathology, Division of Biostatistics, Department of Medicine, Division of Medical Oncology, Department of Medicine, Department of Radiology, and Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA; Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Jeffrey W Clark
- Department of Radiation Oncology, Department of Pathology, Division of Biostatistics, Department of Medicine, Division of Medical Oncology, Department of Medicine, Department of Radiology, and Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA; Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Shyam Tanguturi
- Department of Radiation Oncology, Department of Pathology, Division of Biostatistics, Department of Medicine, Division of Medical Oncology, Department of Medicine, Department of Radiology, and Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA; Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Lipika Goyal
- Department of Radiation Oncology, Department of Pathology, Division of Biostatistics, Department of Medicine, Division of Medical Oncology, Department of Medicine, Department of Radiology, and Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA; Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Janet E Murphy
- Department of Radiation Oncology, Department of Pathology, Division of Biostatistics, Department of Medicine, Division of Medical Oncology, Department of Medicine, Department of Radiology, and Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA; Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - John A Wolfgang
- Department of Radiation Oncology, Department of Pathology, Division of Biostatistics, Department of Medicine, Division of Medical Oncology, Department of Medicine, Department of Radiology, and Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA; Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Lorraine C Drapek
- Department of Radiation Oncology, Department of Pathology, Division of Biostatistics, Department of Medicine, Division of Medical Oncology, Department of Medicine, Department of Radiology, and Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA; Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Ronald S Arellano
- Department of Radiation Oncology, Department of Pathology, Division of Biostatistics, Department of Medicine, Division of Medical Oncology, Department of Medicine, Department of Radiology, and Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA; Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Harvey J Mamon
- Department of Radiation Oncology, Department of Pathology, Division of Biostatistics, Department of Medicine, Division of Medical Oncology, Department of Medicine, Department of Radiology, and Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA; Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - John T Mullen
- Department of Radiation Oncology, Department of Pathology, Division of Biostatistics, Department of Medicine, Division of Medical Oncology, Department of Medicine, Department of Radiology, and Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA; Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Kenneth K Tanabe
- Department of Radiation Oncology, Department of Pathology, Division of Biostatistics, Department of Medicine, Division of Medical Oncology, Department of Medicine, Department of Radiology, and Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA; Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Cristina R Ferrone
- Department of Radiation Oncology, Department of Pathology, Division of Biostatistics, Department of Medicine, Division of Medical Oncology, Department of Medicine, Department of Radiology, and Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA; Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - David P Ryan
- Department of Radiation Oncology, Department of Pathology, Division of Biostatistics, Department of Medicine, Division of Medical Oncology, Department of Medicine, Department of Radiology, and Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA; Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - A John Iafrate
- Department of Radiation Oncology, Department of Pathology, Division of Biostatistics, Department of Medicine, Division of Medical Oncology, Department of Medicine, Department of Radiology, and Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA; Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Thomas F DeLaney
- Department of Radiation Oncology, Department of Pathology, Division of Biostatistics, Department of Medicine, Division of Medical Oncology, Department of Medicine, Department of Radiology, and Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA; Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Andrew X Zhu
- Department of Radiation Oncology, Department of Pathology, Division of Biostatistics, Department of Medicine, Division of Medical Oncology, Department of Medicine, Department of Radiology, and Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA; Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
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Chen Y, Deshpande V, Ferrone C, Blaszkowsky LS, Parangi S, Warshaw AL, Lillemoe KD, Fernandez-Del Castillo C. Primary lymph node gastrinoma: A single institution experience. Surgery 2017; 162:1088-1094. [PMID: 28705492 DOI: 10.1016/j.surg.2017.05.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 05/16/2017] [Accepted: 05/21/2017] [Indexed: 01/12/2023]
Abstract
BACKGROUND Gastrinomas are rare neuroendocrine tumors that ectopically secrete gastrin and classically originate within the duodenum or pancreas. The presence of primary lymph node gastrinoma is controversial. We report on a single institution's experience with gastrinoma, with focus on primary lymph node tumors. METHODS Patients who underwent operative resection of gastrinoma between 1992 and 2016 at a single institution were identified. A diagnosis of primary lymph node gastrinoma was defined as tumor confined to one or more resected peripancreatic lymph nodes, negative localization for any extra-nodal disease and normal gastrin postresection. RESULTS In the study, 39 consecutive patients underwent operative resection of gastrinoma. Mean age was 53 years and 49% were male. 93% of patients had successful preoperative localization. Furthermore, 19 patients (49%) underwent enucleation of their tumor and 14 (35.9%) a pancreatic resection. Overall 5- and 10-year survival for all patients was 80.8% and 60.7%, respectively. Primary lymph node gastrinoma was identified in 11 cases (28.2%). The presentation of primary lymph node and non-primary lymph node patients were similar. There was no significant difference in operation type, tumor size, or overall survival. At median follow-up of 59 months, patients with primary lymph node gastrinoma were less likely to have persistent or recurrent disease (9.1% vs 42.9%, P = .04). CONCLUSION This series supports the existence of primary lymph node gastrinomas, and indicates that as many as 1 in 4 patients with gastrinoma have this form of the disease. This entity should be considered when an isolated pathologic lymph node is identified, although thorough exploration is still recommended to exclude other occult disease.
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Affiliation(s)
- Yufei Chen
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Vikram Deshpande
- Department of Pathology, Massachusetts General Hospital, Boston, MA
| | - Cristina Ferrone
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | | | - Sareh Parangi
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, MA
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Dinaux AM, Amri R, Bordeianou LG, Hong TS, Wo JY, Blaszkowsky LS, Allen JN, Murphy JE, Kunitake H, Berger DL. The Impact of Pathologic Complete Response in Patients with Neoadjuvantly Treated Locally Advanced Rectal Cancer-a Large Single-Center Experience. J Gastrointest Surg 2017; 21:1153-1158. [PMID: 28386670 DOI: 10.1007/s11605-017-3408-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [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: 02/24/2017] [Accepted: 03/16/2017] [Indexed: 01/31/2023]
Abstract
Small cohort studies demonstrated better oncologic outcomes for patients with pathologic complete response (PathCR) after neoadjuvant treatment for locally advanced rectal cancer. This study reviews long-term outcomes of a large cohort of clinically stage II/III rectal cancer patients who received neoadjuvant chemoradiation and surgery. This is a retrospective analysis of a single-center cohort, including all clinical stage II/III rectal cancer patients who received neoadjuvant chemoradiation and surgery between 2004 and 2014 (n = 271). Cox regressions were done to assess the influence of PathCR on recurrence-free survival (RFS) and overall survival (OS), adjusting for postoperative chemotherapy, clinical AJCC staging, comorbidity, and age where appropriate. PathCR patients had significantly lower distant recurrence rates (4 vs. 15.8%; P = 0.028) and lower disease-specific mortality rates (0 vs. 8.1%; P = 0.052), compared to patients with residual disease. PathCR was associated with longer RFS (HR, 5.6 [95% CI 1.3-23.1] P = 0.018) and longer OS (HR, 3.4 [1.31-10.0] P = 0.014) compared to having pathological residual disease. This large single-center study shows that patients with PathCR have significant longer RFS and OS than patients with residual disease on pathology after neoadjuvant chemoradiation.
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Affiliation(s)
- A M Dinaux
- Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - R Amri
- Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - L G Bordeianou
- Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - T S Hong
- Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - J Y Wo
- Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - L S Blaszkowsky
- Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - J N Allen
- Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - J E Murphy
- Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - H Kunitake
- Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - D L Berger
- Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
- Division of General Surgery & Gastrointestinal Surgery, Massachusetts General Hospital, 15 Parkman Street, Boston, MA, 02114, USA.
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Rose B, Mitra D, Hong TS, Jee KW, Niemierko A, Drapek LN, Blaszkowsky LS, Allen JN, Murphy JE, Clark JW, Ryan DP, Wo JY. Irradiation of anatomically defined pelvic subsites and acute hematologic toxicity in anal cancer patients undergoing chemoradiation. Pract Radiat Oncol 2017; 7:e291-e297. [PMID: 28462895 DOI: 10.1016/j.prro.2017.03.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 02/03/2017] [Accepted: 03/03/2017] [Indexed: 11/17/2022]
Abstract
PURPOSE Chemoradiation for the treatment of anal cancer is known to cause significant hematologic toxicity (HT). We sought to investigate if radiation dose to specific pelvic subsites is associated with increased HT risk. METHODS AND MATERIALS Forty-five patients with nonmetastatic anal cancer who received definitive chemoradiation with intensity modulated radiation therapy and concurrent mitomycin-C and 5-fluorouracil were studied. Total pelvic bone marrow (TBM) was divided into 3 subsites: lumbosacral bone marrow (LSBM), including the entire sacrum and L5 vertebral body; iliac bone marrow (IBM) extending from the iliac crests to the superior border of the femoral head; and lower pelvic bone marrow, including the pubic bones, ischia, acetabula, and proximal femurs. The primary endpoint was absolute neutrophil count (ANC) nadir during or within 2 weeks of treatment completion. Generalized linear modeling was used to analyze the correlation between the equivalent uniform dose (with an "a" value of 0.5) to the individual pelvic subsites and the various hematologic endpoints. Age, body mass index, sex, baseline blood counts, and immunosuppression were analyzed as potential covariates. RESULTS Mean ± standard deviation ANC nadir was 0.77 × 109/L (±0.66 × 109/L). Grades 3+ and 4+ neutropenia occurred in 71.1% and 44.4% of patients, respectively. In addition to radiation dose to pelvic bone marrow, baseline ANC was the only significant predictor of hematologic toxicity on multivariable analysis and was included in all models. The equivalent uniform doses of TBM, LSBM, and IBM were each significantly associated with neutropenia. The model performance of TBM (adjusted R2 = 0.226) was similar to both LSBM (adjusted R2 = 0.206) and IBM (adjusted R2 = 0.249). CONCLUSIONS Radiation doses to TBM, LSBM, and IBM were individually associated with HT, suggesting that sparing just a portion of pelvic bone marrow is insufficient to decrease rates of clinically significant bone marrow suppression.
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Affiliation(s)
- Brent Rose
- Department of Radiation Oncology, University of California San Diego, San Diego, California
| | - Devarati Mitra
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Kyung-Wook Jee
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Andrzej Niemierko
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Lorraine N Drapek
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Jill N Allen
- Department of Medical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Janet E Murphy
- Department of Medical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jeffrey W Clark
- Department of Medical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - David P Ryan
- Department of Medical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts.
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Mitra D, Hong TS, Horick N, Rose B, Drapek LN, Blaszkowsky LS, Allen JN, Kwak EL, Murphy JE, Clark JW, Ryan DP, Cusack JC, Bordeianou LG, Berger DL, Wo JY. Long-term outcomes and toxicities of a large cohort of anal cancer patients treated with dose-painted IMRT per RTOG 0529. Adv Radiat Oncol 2017; 2:110-117. [PMID: 28740921 PMCID: PMC5514246 DOI: 10.1016/j.adro.2017.01.009] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 01/12/2017] [Accepted: 01/24/2017] [Indexed: 12/02/2022] Open
Abstract
Purpose To describe the outcomes and toxicities of the largest cohort to date of patients with anal squamous cell carcinoma uniformly treated with concurrent chemoradiation using dose-painted intensity modulated radiation therapy (DP-IMRT) according to RTOG 0529. Methods and materials We identified 99 eligible patients with anal cancer who were treated at our institution with definitive chemoradiation using DP-IMRT between 2005 and 2015 per RTOG 0529 dosing guidelines. Primary study endpoints included event-free survival (defined as recurrence, colostomy, or death) and overall survival. Secondary endpoints were treatment duration and acute and late toxicity. Results At a median follow-up of 49 months (range, 2-114 months), 92% of patients had a clinical complete response. Fifteen percent underwent colostomy, including 4 pretreatment colostomies, 6 planned abdominoperineal resections (APRs), 4 salvage APRs, and 1 APR for treatment-related complications. Thirteen patients developed local recurrence, of whom 6 developed synchronous metastatic disease. The 4-year overall survival was 85.8%, and 4-year event-free survival was 75.5%. Median treatment duration was 43 days (range, 10-68 days). The overall rate of non-hematologic grade 3+ acute and grade 2+ late toxicities was 20% and 15%, respectively. Conclusions Long-term outcomes and tolerability were excellent In the largest cohort to date of patients with anal cancer who received DP-IMRT prescribed per RTOG 0529.
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Affiliation(s)
- Devarati Mitra
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Nora Horick
- Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Brent Rose
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Lorraine N Drapek
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Jill N Allen
- Department of Medical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Eunice L Kwak
- Department of Medical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Janet E Murphy
- Department of Medical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jeffrey W Clark
- Department of Medical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - David P Ryan
- Department of Medical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - James C Cusack
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | | | - David L Berger
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
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Russo M, Siravegna G, Blaszkowsky LS, Corti G, Crisafulli G, Ahronian LG, Mussolin B, Kwak EL, Buscarino M, Lazzari L, Valtorta E, Truini M, Jessop NA, Robinson HE, Hong TS, Mino-Kenudson M, Di Nicolantonio F, Thabet A, Sartore-Bianchi A, Siena S, Iafrate AJ, Corcoran RB, Bardelli A. Abstract 878: Tumor heterogeneity and lesion-specific response to targeted therapy in colorectal cancer. Cancer Res 2016. [DOI: 10.1158/1538-7445.am2016-878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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
How genomic heterogeneity associated with acquired resistance to targeted agents affects response to subsequent lines of therapy is unknown. Exposure to therapy may result in selection of sub-clonal cell populations, capable of growing under drug pressures. Therefore, a single-lesion biopsy at disease progression may vastly underrepresent the molecular heterogeneity of resistant tumor clones in an individual patient and may fail to detect the existence of distinct but important resistance mechanisms that could impact clinical response.
We identified a colorectal cancer (CRC) patient in whom multiple tumor biopsies were obtained at resistance following prolonged response to with the anti-EGFR antibody cetuximab. Full-exome sequencing of 1000 cancer genes of both primary tumor and progression biopsy revealed a TP53 mutation in all samples and a novel MEK1 p.K57T mutation in one of the progressing liver biopsy. A mutation at the same MEK1 codon was identified in the cetuximab-resistant HCA46 CRC cell line. Biochemical analysis showed constitutive activation of MEK and ERK despite cetuximab treatment. However, the combination of the MEK inhibitor trametinib with either cetuximab or panitumumab restored sensitivity, suggesting a potential therapeutic strategy to overcome resistance to EGFR blockade caused by this mutation.
Accordingly, the patient was treated with the combination of panitumumab and trametinib. After 3 months, imaging demonstrated a reduction in size of the biopsied liver metastasis harboring the MEK1 mutation, but revealed that some other lesions had progressed. Plasma collected prior to therapy was analyzed by next-generation sequencing confirming the presence of both TP53 and MEK1 variants, but surprisingly unveiling a previously unrecognized KRAS mutation. ddPCR analysis of longitudinal timepoints of ctDNA unveiled that TP53 mutant levels dropped after initiation of therapy, but rose later during treatment in parallel with CEA tumor marker levels. However, MEK1 mutant levels declined sharply, indicating effective suppression of MEK1 mutant clones by panitumumab and trametinib; while KRAS mutant levels rose, indicating outgrowth of a resistant KRAS-mutant clone. Biopsy of a different liver metastasis that progressed despite panitumumab and trametinib revealed the same KRAS mutation identified in ctDNA.
In summary these findings illustrate how distinct acquired resistance mechanisms can arise concomitantly in separate metastases within the same patient, leading to mixed lesion-specific responses to subsequent targeted therapies. Liquid biopsy approaches, in association with single-tumor biopsies, have the potential to detect the presence of simultaneous resistance mechanisms residing in separate metastases in a single patient and to monitor the effects of subsequent targeted therapies.
Citation Format: Mariangela Russo, Giulia Siravegna, Lawrence S. Blaszkowsky, Giorgio Corti, Giovanni Crisafulli, Leanne G. Ahronian, Benedetta Mussolin, Eunice L. Kwak, Michela Buscarino, Luca Lazzari, Emanuele Valtorta, Mauro Truini, Nicholas A. Jessop, Hayley E. Robinson, Theodore S. Hong, Mari Mino-Kenudson, Federica Di Nicolantonio, Ashraf Thabet, Andrea Sartore-Bianchi, Salvatore Siena, A John Iafrate, Ryan B. Corcoran, Alberto Bardelli. Tumor heterogeneity and lesion-specific response to targeted therapy in colorectal cancer. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 878.
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Affiliation(s)
| | | | | | - Giorgio Corti
- 1University of Turin, Depart. of Oncology, Candiolo (TO), Italy
| | | | | | | | | | | | - Luca Lazzari
- 1University of Turin, Depart. of Oncology, Candiolo (TO), Italy
| | | | - Mauro Truini
- 3Niguarda Cancer Center, Ospedale Niguarda Ca’ Granda, Milan, Italy
| | | | | | | | | | | | - Ashraf Thabet
- 5Department of Radiology, Massachusetts General Hospital, Boston, MA
| | | | - Salvatore Siena
- 3Niguarda Cancer Center, Ospedale Niguarda Ca’ Granda, Milan, Italy
| | - A John Iafrate
- 4Department of Pathology, Massachusetts General Hospital, Boston, MA
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Hong TS, Wo JY, Yeap BY, Ben-Josef E, McDonnell EI, Blaszkowsky LS, Kwak EL, Allen JN, Clark JW, Goyal L, Murphy JE, Javle MM, Wolfgang JA, Drapek LC, Arellano RS, Mamon HJ, Mullen JT, Yoon SS, Tanabe KK, Ferrone CR, Ryan DP, DeLaney TF, Crane CH, Zhu AX. Multi-Institutional Phase II Study of High-Dose Hypofractionated Proton Beam Therapy in Patients With Localized, Unresectable Hepatocellular Carcinoma and Intrahepatic Cholangiocarcinoma. J Clin Oncol 2015; 34:460-8. [PMID: 26668346 DOI: 10.1200/jco.2015.64.2710] [Citation(s) in RCA: 302] [Impact Index Per Article: 33.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE To evaluate the efficacy and safety of high-dose, hypofractionated proton beam therapy for hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC). MATERIALS AND METHODS In this single-arm, phase II, multi-institutional study, 92 patients with biopsy-confirmed HCC or ICC, determined to be unresectable by multidisciplinary review, with a Child-Turcotte-Pugh score (CTP) of A or B, ECOG performance status of 0 to 2, no extrahepatic disease, and no prior radiation received 15 fractions of proton therapy to a maximum total dose of 67.5 Gy equivalent. Sample size was calculated to demonstrate > 80% local control (LC) defined by Response Evaluation Criteria in Solid Tumors (RECIST) 1.0 criteria at 2 years for HCC patients, with the parallel goal of obtaining acceptable precision for estimating outcomes for ICC. RESULTS Eighty-three patients were evaluable: 44 with HCC, 37 with ICC, and two with mixed HCC/ICC. The CTP score was A for 79.5% of patients and B for 15.7%; 4.8% of patients had no cirrhosis. Prior treatment had been given to 31.8% of HCC patients and 61.5% of ICC patients. The median maximum dimension was 5.0 cm (range, 1.9 to 12.0 cm) for HCC patients and 6.0 cm (range, 2.2 to 10.9 cm) for ICC patients. Multiple tumors were present in 27.3% of HCC patients and in 12.8% of ICC patients. Tumor vascular thrombosis was present in 29.5% of HCC patients and in 28.2% of ICC patients. The median dose delivered to both HCC and ICC patients was 58.0 Gy. With a median follow-up among survivors of 19.5 months, the LC rate at 2 years was 94.8% for HCC and 94.1% for ICC. The overall survival rate at 2 years was 63.2% for HCC and 46.5% ICC. CONCLUSION High-dose hypofractionated proton therapy demonstrated high LC rates for HCC and ICC safely, supporting ongoing phase III trials of radiation in HCC and ICC.
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Affiliation(s)
- Theodore S Hong
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Jennifer Y Wo
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Beow Y Yeap
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Edgar Ben-Josef
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Erin I McDonnell
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lawrence S Blaszkowsky
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Eunice L Kwak
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jill N Allen
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jeffrey W Clark
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lipika Goyal
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Janet E Murphy
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Milind M Javle
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - John A Wolfgang
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lorraine C Drapek
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ronald S Arellano
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Harvey J Mamon
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - John T Mullen
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sam S Yoon
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kenneth K Tanabe
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Cristina R Ferrone
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - David P Ryan
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Thomas F DeLaney
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Christopher H Crane
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Andrew X Zhu
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
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