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Abdou M, Bogan AW, Thangaiah JJ, Grover AC, Ahmed SK, Houdek MT, Haddock MG, Pyfferoen BA, Petersen IA. Myxofibrosarcoma: Outcomes, Prognostic Factors, and Role of Neoadjuvant Radiation Therapy. Adv Radiat Oncol 2024; 9:101485. [PMID: 38681890 PMCID: PMC11043815 DOI: 10.1016/j.adro.2024.101485] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 02/25/2024] [Indexed: 05/01/2024] Open
Abstract
Purpose Myxofibrosarcoma (MFS) is a subtype of soft tissue sarcoma with a highly infiltrative growth pattern that leads to a higher risk of inadvertent positive surgical margins and local relapse. Poorly defined tumor margins also pose a challenge for radiation therapy (RT) planning, in terms of treatment volumes and administration of pre- versus postoperative RT. This study aims to evaluate local control and patterns of recurrence in patients with MFS treated with neoadjuvant RT followed by definitive surgical excision. Methods and Materials Multiple institutional databases were retrospectively searched for patients diagnosed with MFS between 2013 and 2021 who were exclusively treated with preoperative RT followed by definitive surgery at our institution. The endpoints of the study were defined as local tumor recurrence, distant metastasis, and death after the date of definitive surgery. Results Forty-nine patients met the inclusion criteria and were included in the final study. The median age at diagnosis was 67 years, and 71% of patients were male. The tumor was superficially located in 63% of patients, and the mean tumor size at presentation was 7.8 cm. All patients received neoadjuvant RT and completed their planned course of treatment. Neoadjuvant chemotherapy was administered in 22% of patients. Inadvertent excision (IE) before definitive treatment was performed in 25 patients (51%), 84% of which had superficially located tumors. All margins were assessed using frozen section analysis at the time of definitive surgery, and 100% of patients had negative surgical margins, with 25% having no residual tumor. With a median follow-up of 4.7 years, the 5-year local control rate was 87%, and 5-year overall survival was 98%. Tumor depth was associated with distant metastasis (P < .01). Conclusions Despite the infiltrative nature of MFS, preoperative RT followed by definitive surgical excision, especially in the setting of a reliable frozen section margin analysis, was associated with excellent local control.
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Affiliation(s)
- Maya Abdou
- Mayo Clinic Alix School of Medicine, Rochester, Minnesota
| | - Aaron W. Bogan
- Department of Quantitative Health Sciences, Division of Biostatistics, Mayo Clinic, Scottsdale, Arizona
| | | | - Autumn C. Grover
- Department of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota
| | - Safia K. Ahmed
- Department of Radiation Oncology, Mayo Clinic, Scottsdale, Arizona
| | | | | | | | - Ivy A. Petersen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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Deufel C, Dodoo C, Kavanaugh J, Finley R, Lang K, Sorenson K, Spreiter S, Brooks J, Moseley D, Ahmed SK, Haddock MG, Ma D, Park SS, Petersen IA, Owen DW, Grams MP. Automated target placement for VMAT lattice radiation therapy: enhancing efficiency and consistency. Phys Med Biol 2024; 69:075010. [PMID: 38422544 DOI: 10.1088/1361-6560/ad2ee8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 02/29/2024] [Indexed: 03/02/2024]
Abstract
Objective. An algorithm was developed for automated positioning of lattice points within volumetric modulated arc lattice radiation therapy (VMAT LRT) planning. These points are strategically placed within the gross tumor volume (GTV) to receive high doses, adhering to specific separation rules from adjacent organs at risk (OARs). The study goals included enhancing planning safety, consistency, and efficiency while emulating human performance.Approach. A Monte Carlo-based algorithm was designed to optimize the number and arrangement of lattice points within the GTV while considering placement constraints and objectives. These constraints encompassed minimum spacing between points, distance from OARs, and longitudinal separation along thez-axis. Additionally, the algorithm included an objective to permit, at the user's discretion, solutions with more centrally placed lattice points within the GTV. To validate its effectiveness, the automated approach was compared with manually planned treatments for 24 previous patients. Prior to clinical implementation, a failure mode and effects analysis (FMEA) was conducted to identify potential shortcomings.Main results.The automated program successfully met all placement constraints with an average execution time (over 24 plans) of 0.29 ±0.07 min per lattice point. The average lattice point density (# points per 100 c.c. of GTV) was similar for automated (0.725) compared to manual placement (0.704). The dosimetric differences between the automated and manual plans were minimal, with statistically significant differences in certain metrics like minimum dose (1.9% versus 1.4%), D5% (52.8% versus 49.4%), D95% (7.1% versus 6.2%), and Body-GTV V30% (20.7 c.c. versus 19.7 c.c.).Significance.This study underscores the feasibility of employing a straightforward Monte Carlo-based algorithm to automate the creation of spherical target structures for VMAT LRT planning. The automated method yields similar dose metrics, enhances inter-planner consistency for larger targets, and requires fewer resources and less time compared to manual placement. This approach holds promise for standardizing treatment planning in prospective patient trials and facilitating its adoption across centers seeking to implement VMAT LRT techniques.
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Affiliation(s)
- Christopher Deufel
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Christopher Dodoo
- Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, AZ 85259, United States of America
| | - James Kavanaugh
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Randi Finley
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Karen Lang
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Kasie Sorenson
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Sheri Spreiter
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Jamison Brooks
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Douglas Moseley
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Safia K Ahmed
- Department of Radiation Oncology, Mayo Clinic, Scottsdale, AZ 85259, United States of America
| | - Michael G Haddock
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Daniel Ma
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Ivy A Petersen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Dawn W Owen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Michael P Grams
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
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Ahmed SK, Petersen IA, Grams MP, Finley RR, Haddock MG, Owen D. Spatially Fractionated Radiation Therapy in Sarcomas: A Large Single-Institution Experience. Adv Radiat Oncol 2024; 9:101401. [PMID: 38495033 PMCID: PMC10943518 DOI: 10.1016/j.adro.2023.101401] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 10/16/2023] [Indexed: 03/19/2024] Open
Abstract
Purpose Spatially fractionated radiation therapy (SFRT) is a recognized technique for enhancing tumor response in radioresistant and bulky tumors. We analyzed clinical and treatment outcomes in patients with bone and soft tissue sarcomas treated with modern SFRT techniques. Methods and Materials Patients with metastatic or unresectable sarcoma treated with brass collimator, volumetric modulated arc therapy lattice, or proton SFRT from December 2019 to June 2022 were retrospectively reviewed. Consolidative external beam radiation therapy (EBRT) was delivered at the physician's discretion. Patient and treatment characteristics, treatment response (symptom improvement, local control, and imaging response), and toxicity data were collected. Results The cohort consisted of 53 patients treated with 61 SFRT treatments. Median age at treatment was 60.0 years. The primary location was soft tissue in 46 courses (75%) and bone in 15 (25%). Fifty-three courses (87%) were treated for symptom relief. The most used SFRT technique was volumetric modulated arc therapy lattice (n = 52, 85%) to a dose of 20 Gy (n = 48, 79%; range, 16-20 Gy). EBRT was delivered post-SFRT in 55 (90%) treatment courses with a median time interval from SFRT to EBRT of 5 days (range, 0-14 days). Median physical EBRT dose and fractionation was 40 Gy (range, 9-73.5 Gy) and 10 fractions (range, 3-33 fractions). Median follow up was 7.4 months (range, 0.2-30 months). One-year overall survival and local control rates were 53% and 82%. Symptom relief was documented with 32 treatment courses (60%). Stable or partial response was observed with 47 treatment courses (90%). Four grade 3 to 4 acute and subacute toxicities were attributable to SFRT (8%). Conclusions The current series is the largest to date documenting outcomes for SFRT in sarcomas. Our results suggest combined SFRT with EBRT is associated with a favorable toxicity profile and high rates of symptomatic and radiographic responses for metastatic or unresectable sarcomas.
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Affiliation(s)
- Safia K. Ahmed
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Ivy A. Petersen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Michael P. Grams
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Randi R. Finley
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Dawn Owen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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Zaniletti I, Gunn HJ, Hallemeier CL, Laughlin BS, Leavitt TR, Haddock MG, Merrell KW, Leenstra JL, May BC, Ashman JB, DeWees TA. Determining the Minimal Clinically Important Difference of the Functional Assessment of Cancer Therapy Hepatobiliary Questionnaire to Evaluate the Change in the Quality of Life of Patients With Pancreatic Cancer During Radiation Therapy. Int J Radiat Oncol Biol Phys 2024; 118:137-141. [PMID: 37586614 DOI: 10.1016/j.ijrobp.2023.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 08/01/2023] [Accepted: 08/05/2023] [Indexed: 08/18/2023]
Affiliation(s)
| | - Heather J Gunn
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | | | | | | | | | | | - James L Leenstra
- Department of Radiation Oncology, Mayo Clinic, Northfield, Minnesota
| | - Byron C May
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - Jonathan B Ashman
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - Todd A DeWees
- Department of Computational and Quantitative Medicine, City of Hope, Duarte, California.
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Hall WA, Li J, You YN, Gollub MJ, Grajo JR, Rosen M, dePrisco G, Yothers G, Dorth JA, Rahma OE, Russell MM, Gross HM, Jacobs SA, Faller BA, George S, Al baghdadi T, Haddock MG, Valicenti R, Hong TS, George TJ. Prospective Correlation of Magnetic Resonance Tumor Regression Grade With Pathologic Outcomes in Total Neoadjuvant Therapy for Rectal Adenocarcinoma. J Clin Oncol 2023; 41:4643-4651. [PMID: 37478389 PMCID: PMC10564288 DOI: 10.1200/jco.22.02525] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 03/01/2023] [Accepted: 05/09/2023] [Indexed: 07/23/2023] Open
Abstract
PURPOSE Total neoadjuvant therapy (TNT) is a newly established standard treatment for rectal adenocarcinoma. Current methods to communicate magnitudes of regression during TNT are subjective and imprecise. Magnetic resonance tumor regression grade (MR-TRG) is an existing, but rarely used, regression grading system. Prospective validation of MR-TRG correlation with pathologic response in patients undergoing TNT is lacking. Utility of adding diffusion-weighted imaging to MR-TRG is also unknown. METHODS We conducted a multi-institutional prospective imaging substudy within NRG-GI002 (ClinicalTrials.gov identifier: NCT02921256) examining the ability of MR-based imaging to predict pathologic complete response (pCR) and correlate MR-TRG with the pathologic neoadjuvant response score (NAR). Serial MRIs were needed from 110 patients. Three radiologists independently, then collectively, reviewed each MRI for complete response (mriCR), which was tested for positive predictive value (PPV), negative predictive value (NPV), sensitivity, and specificity with pCR. MR-TRG was examined for association with the pathologic NAR score. All team members were blinded to pathologic data. RESULTS A total of 121 patients from 71 institutions met criteria: 28% were female (n = 34), 84% White (n = 101), and median age was 55 (24-78 years). Kappa scores for T- and N-stage after TNT were 0.38 and 0.88, reflecting fair agreement and near-perfect agreement, respectively. Calling an mriCR resulted in a kappa score of 0.82 after chemotherapy and 0.56 after TNT reflected near-perfect agreement and moderate agreement, respectively. MR-TRG scores were associated with pCR (P < .01) and NAR (P < .0001), PPV for pCR was 40% (95% CI, 26 to 53), and NPV was 84% (95% CI, 75 to 94). CONCLUSION MRI alone is a poor tool to distinguish pCR in rectal adenocarcinoma undergoing TNT. However, the MR-TRG score presents a now validated method, correlated with pathologic NAR, which can objectively measure regression magnitude during TNT.
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Affiliation(s)
- William A. Hall
- Froedtert and the Medical College of Wisconsin, Milwaukee, WI
| | - Jiahe Li
- The University of Pittsburgh, Pittsburgh, PA
| | - Y. Nancy You
- University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Joseph R. Grajo
- University of Florida, Gainesville, FL
- University of Florida Health Cancer Center, Gainesville, FL
| | - Mark Rosen
- Imaging and Radiation Oncology Core (IROC) Group, and the University of Pennsylvania, Philadelphia, PA
| | - Greg dePrisco
- Baylor Scott and White Health Baylor University Medical Center at Dallas, Dallas, TX
| | | | - Jennifer A. Dorth
- University Hospitals Seidman Cancer Center and Case Western Reserve University, Cleveland, OH
| | | | - Marcia M. Russell
- Department of Surgery, David Geffen School of Medicine at UCLA, and VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | | | | | - Bryan A. Faller
- Missouri Baptist Medical Center/Heartland NCORP, St Louis, MO
| | - Sagila George
- Stephenson Cancer Center University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Tareq Al baghdadi
- Trinity Health Ann Arbor Hospital, Michigan Cancer Research Consortium (NCORP), Ann Arbor, MI
| | | | - Richard Valicenti
- University of California Davis Comprehensive Cancer Center/UC Davis School of Med/UC Davis Health, Sacramento, CA
| | - Theodore S. Hong
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Thomas J. George
- University of Florida, Gainesville, FL
- University of Florida Health Cancer Center, Gainesville, FL
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Sutton EA, Doodoo C, Ebner DK, Amundson A, Wong WW, Stockham AL, Leenstra JL, Haddock MG, Merrell KW, Hallemeier CL, Jethwa KR. "Moderately Hypofractionated" Radiotherapy with a Simultaneously Integrated Boost for Synchronous Treatment of Prostate and Anorectal Cancer. Int J Radiat Oncol Biol Phys 2023; 117:e340-e341. [PMID: 37785189 DOI: 10.1016/j.ijrobp.2023.06.2402] [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) Data suggest safety and efficacy of 1.8-2.0 Gy per day radiotherapy (RT) with sequential boost regimens for patients with synchronous prostate and anorectal cancers. Emergence of 25-28 fraction (fx) prostate cancer RT regimens has enabled simultaneously integrated boost techniques to treat the prostate and anorectum (HypoRT), but limited reports exist to support the safety or efficacy of this approach. We aimed to assess oncologic outcomes and patient-reported outcomes (PRO)- and physician-reported adverse effects (AEs) of HypoRT for patients with synchronous prostate and anorectal cancers. MATERIALS/METHODS This was a retrospective cohort study of patients synchronously diagnosed with prostate and rectal cancer or anal canal squamous cell carcinoma (ASCC) treated with a HypoRT technique and concurrent chemotherapy between 2014-2022. Outcomes included prostate cancer biochemical recurrence (BCR), anorectal cancer recurrence, progression-free (PFS) and overall survival (OS). Acute and late gastrointestinal (GI) and genitourinary (GU) AEs and PRO were prospectively collected using common terminology criteria for AEs (CTCAE) and PRO-CTCAE. RESULTS Twelve patients were included. Patients had ECOG 0-1; median age was 71 years (51-82). Rectal cancer (n = 11) characteristics included T3 (91%), N1-2 (73%), M0 (73%); 3 had M1a disease suitable for curative-intent treatment. One patient had T2N1M0 ASCC. Prostate cancer risk groups included low (9%), intermediate (45%), and high/very high risk (46%). HypoRT included 45-50 and 67.5 Gy in 25 fx (33%), 46.8-52 and 70.2 Gy in 26 fx (17%), and 44.8-56 and 70 Gy in 28 fx (50%), to the pelvis-anorectum and prostate. Patients with rectal cancer received concurrent capecitabine. Nine (82%) patients with rectal cancer had surgical resection; 1 was R1. The patient with ASCC received concurrent 5-fluorouracil and mitomycin C. Six patients (50%) received androgen suppression. All patients completed treatment successfully but 1 patient with rectal cancer did require hospitalization with treatment break due to GI AEs. Median follow was 60 months (13-103). Oncologic outcomes and AEs are in the table. No patient experienced prostate cancer BCR or ASCC progression. Four of 11 patients with rectal cancer progressed including 3 distant metastases, each amongst initial M1a patients, and 1 local-regrowth in a patient managed non-operatively. CONCLUSION HypoRT can effectively be utilized for patients with synchronous prostate and anorectal cancer. Physician assessed AEs compared favorably with prior data, however, further work is needed to understand differences in physician and patient experience. HypoRT may serve as another suitable option in the management of this complex clinical scenario.
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Affiliation(s)
- E A Sutton
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - C Doodoo
- Mayo Clinic Arizona, Phoenix, AZ
| | - D K Ebner
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - A Amundson
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - W W Wong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
| | | | | | - M G Haddock
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - K W Merrell
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | | | - K R Jethwa
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
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Rummel KA, Sutton EA, Hallemeier CL, Merrell KW, Callaghan CM, Haddock MG, Waddle MR, Jethwa KR. Non-Operative Management of Rectal or Anal Canal Adenocarcinoma: National Cancer Database Analysis of the Impact of Disease, Treatment, and Social Determinants of Health on Overall Survival. Int J Radiat Oncol Biol Phys 2023; 117:e336. [PMID: 37785179 DOI: 10.1016/j.ijrobp.2023.06.2392] [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) For select patients with rectal or anal canal adenocarcinoma (RA-ACA), a non-operative management (NOM) strategy utilizing definitive radiotherapy (RT) has emerged as an option with the goal to improve quality of life compared with surgical management while maintaining similar oncologic outcomes. Disease and treatment characteristics as well as social determinants of health have been associated with access to care and health outcomes, and we hypothesized that such factors would impact overall survival (OS) amongst patients who received a NOM approach. The purpose of this study was to explore the influence of patient demographics, disease characteristics, and social determinants of health on OS amongst those receiving NOM utilizing the National Cancer Database (NCDB). MATERIALS/METHODS We identified patients at least 18 of years of age diagnosed with clinical stage 1-3 RA-ACA from 2004-2018. The NOM cohort included patients who received RT and either refused surgery or surgery was not recommended in their treatment. Patients were excluded if receipt of chemotherapy or RT were unknown, received RT to a site outside of the pelvis, or received palliative-intent treatment. OS was estimated using the Kaplan-Meier method. Univariable and multivariable (MVA) Cox proportional hazards model was used to assess characteristics associated with OS. Analyses were performed using STATA (version 17, College Station, TX). A p<0.05 was considered statistically significant. RESULTS A total of 12,409 patients were identified as the NOM cohort. The median OS was 48.8 months (95% CI: 46.8-50.6). On MVA, variables associated with poorer OS included age ≥ 70 vs 50-69, male sex, Charlson-Deyo Score ≥ 1 vs 0, insurance status (no insurance, Medicaid or Medicare vs. private), geographical region (South, Midwest or West vs. Northeast), rural urban density vs metro/urban, treatment in a community facility vs academic, year of diagnosis (2004-2011 vs. 2012-2018), clinical T4 vs T1, clinical N1 or N2 vs N0, and grade 3 vs 1 (all p<0.05). Treatment with a RT dose < 45 Gy vs. 45-54 Gy (HR: 2.24, 95% CI: 2.07-2.44), but not > 55 Gy vs. 45-54 Gy, and omission of chemotherapy (HR: 1.28, 95% CI: 1.16-1.43) were associated with poorer OS. CONCLUSION Patient, disease, treatment, and social determinants of health may influence OS amongst patients with RA-ACA who receive a NOM approach. Further work is needed to determine if the influence on OS can be explained, in part, by patients' lack of access to the intense surveillance necessary and/or the potential need for subsequent surgical management. Heightened awareness of these differential outcomes is needed to assist in patient selection and to successfully address barriers in access to optimize outcomes for patients who receive NOM.
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Affiliation(s)
- K A Rummel
- University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND
| | - E A Sutton
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - C L Hallemeier
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - K W Merrell
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - C M Callaghan
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - M G Haddock
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - M R Waddle
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - K R Jethwa
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
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Kowalchuk RO, Breen W, Harmsen WS, Weiskittle TM, Attia IZ, Herrmann J, Noseworthy PA, Friedman PA, Jethwa KR, Merrell KW, Haddock MG, Routman DM, Hallemeier CL. Electrocardiogram with Artificial Intelligence Assessment as a Predictor of Cardiac Events and Overall Survival in Patients Receiving Radiotherapy for Esophageal Cancer. Int J Radiat Oncol Biol Phys 2023; 117:S13-S14. [PMID: 37784334 DOI: 10.1016/j.ijrobp.2023.06.229] [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) Neoadjuvant (chemo)radiotherapy (RT) has demonstrated an overall survival (OS) benefit in esophageal cancer and constitutes part of the standard of care trimodality therapy. Unfortunately, subsequent cardiac toxicity can reduce the benefit of treatment. Our group aimed to study whether data from electrocardiograms (ECGs) could predict clinical outcomes and cardiac events after RT for esophageal cancer, allowing for identification of and early intervention for patients at high risk for cardiac toxicity. MATERIALS/METHODS Included patients received at least 41.4 Gy of pre-operative or definitive photon or proton RT for esophageal cancer from 2015 through July 2022. All ECGs were assessed using a previously validated artificial intelligence assessment for atrial fibrillation (AF) and reduced ejection fraction (rEF) (Noseworthy et al. Lancet 2022). The model determined propensities for the development of multiple cardiac events, including AF and heart failure (HF). Medical records were reviewed for cardiac events and conditions prior to and after RT. RESULTS A cohort of 491 patients was assembled, with 301, 121, and 364 patients having an ECG prior to, during, and after RT, respectively. Of these, 84% had malignancy in the lower third of the esophagus and 48% underwent esophagectomy. At last follow-up relative to baseline assessment, patients had increased propensity for rEF (median 0.013, interquartile range (IQR): 0.001-0.038 vs. median 0.022, IQR: 0.011-0.074, p < 0.0001) and AF (median 0.16, IQR: 0.04-0.40 vs. median 0.048, IQR: 0.01-0.19, p < 0.0001). Increases in AF propensity were associated with reduced OS (hazard ratio (HR) = 1.10 per 0.1 increase, 95% confidence interval (CI): 1.03-1.17, p = 0.0071). Baseline rEF propensity was predictive of future HF events (HR = 1.14, 95% CI: 1.07-1.22, p < 0.001) for all patients or after excluding the 172 (35%) patients with baseline HF (HR = 1.45, 95% CI: 1.19-1.76, p < 0.001). Among patients who did not have HF prior to radiotherapy, the development of HF was associated with reduced OS (HR = 1.60, 95% CI: 1.10-2.32, p = 0.014). Currently available cardiac dosimetric parameters, including heart mean/max doses, did not significantly correlate with cardiac outcomes. Patients who underwent esophagectomy had improved OS (HR = 0.62, 95% CI: 0.47-0.82, p = 0.0008) and were not more likely to develop cardiac toxicity. CONCLUSION This analysis suggests that chemoradiotherapy for esophageal cancer can have significant impacts on a patient's propensity for cardiac events, which are associated with reduced OS. ECGs carry the potential to identify patients at greater risk for such events, and baseline ECGs with artificial intelligence assessment could select patients for increased surveillance or early intervention to further optimize the therapeutic ratio of RT.
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Affiliation(s)
- R O Kowalchuk
- University of Virginia / Riverside Radiosurgery Center, Newport News, VA
| | - W Breen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - W S Harmsen
- Department of Biostatistics and Health Sciences Research, Mayo Clinic, Rochester, MN
| | | | | | - J Herrmann
- Department of Cardiology, Mayo Clinic, Rochester, MN
| | | | | | - K R Jethwa
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - K W Merrell
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - M G Haddock
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - D M Routman
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
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Sharifzadeh Y, Gunn HJ, Hallemeier CL, Harmsen WS, Shiraishi S, Amundson A, Callaghan CM, Rule WG, Sio TTW, Ashman JB, Haddock MG, Merrell KW, Jethwa KR. Patient-Reported Adverse Effects in 15-Fraction Pancreatic Cancer Radiation Therapy. Int J Radiat Oncol Biol Phys 2023; 117:e337-e338. [PMID: 37785182 DOI: 10.1016/j.ijrobp.2023.06.2396] [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) Fifteen-fraction radiotherapy (RT) regimens have emerged as a standard option in the treatment of patients with pancreas cancer. Patient-reported outcomes (PROs) during and after pancreas cancer RT have not been well characterized. There is an even greater paucity of data among patients treated with 15-fraction regimens. We aimed to characterize gastrointestinal (GI) PROs in a cohort of patients treated with 15-fraction pancreas RT. MATERIALS/METHODS This was an IRB-approved retrospective cohort study including patients with primary pancreas tumors treated with pre-operative or definitive 15-fraction RT from 2013 to 2022. PROs, including anorexia, nausea, diarrhea, stool incontinence, and abdominal pain, were prospectively collected and characterized per PRO-common terminology criteria for adverse events (PRO-CTCAE). Acute PROs were defined as occurring during RT through 110 days post-RT but prior to oncological surgery. Grade 3 or 4 PROs were respectively scored as "quite a bit" or "very much" in symptom interference questions, "frequently" or "almost constantly" in symptom frequency questions, and "severe" or "very severe" in symptom severity questions. RESULTS A total of 330 patients were analyzed. Patient characteristics included a median age of 67 years (IQR: 60 - 72), ECOG 0-1 (96%), and male sex (56%). Most patients had pancreatic ductal adenocarcinoma (96%). Resectability status included resectable (12%), borderline resectable (46%), and locally advanced (42%). 37% had lymph node involvement. 97% of patients received neoadjuvant chemotherapy and 98% received concurrent chemotherapy, most commonly with 5-fluorouracil or capecitabine (88%) or gemcitabine (11%). 99% were treated with intensity modulated RT. Median RT dose was 4500 cGy (IQR 4500 - 4500) to gross disease with margin and 3750 cGy (IQR 3750 - 3750) to elective nodal regions. 59% proceeded with oncologic resection. Grade 3 or higher acute PROs are demonstrated in the table. CONCLUSION Often considered more sensitive than physician assessments, PROs provide vital metrics that allow for a better understanding of the patient experience during cancer treatment. We report a comprehensive assessment of prospectively collected PROs per standardized PRO-CTCAE with the goals of raising awareness of the patient experience during 15-fraction pancreas cancer RT and helping guide future clinical trial designs focused on patient quality of life endpoints.
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Affiliation(s)
- Y Sharifzadeh
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | | | - C L Hallemeier
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - W S Harmsen
- Department of Biostatistics and Health Sciences Research, Mayo Clinic, Rochester, MN
| | - S Shiraishi
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - A Amundson
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - C M Callaghan
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - W G Rule
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
| | - T T W Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
| | - J B Ashman
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
| | - M G Haddock
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - K W Merrell
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - K R Jethwa
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
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10
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Laughlin BS, Zaniletti I, Vern-Gross T, Van Der Walt C, Allen-Rhoades W, Polites S, Rose PS, Ashman JB, Petersen IA, Haddock MG, Mahajan A, Keole SR, Laack NN, Ahmed SK. Clinical Outcomes for Chest Wall Ewing Sarcoma: A Multi-Center Single Institution Experience. Int J Radiat Oncol Biol Phys 2023; 117:e525. [PMID: 37785633 DOI: 10.1016/j.ijrobp.2023.06.1799] [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) We report tumor and treatment characteristics, oncologic outcomes, and treatment-associated toxicities in a cohort of chest wall Ewing sarcoma (cwES) patients treated at a single tertiary care institution. MATERIALS/METHODS After IRB approval, patients with cwES treated from 1997-2022 were retrospectively reviewed. Patient, tumor, treatment, outcomes, and toxicity data were abstracted. Local control (LC), progression-free survival (PFS), and overall survival (OS) were defined from end of treatment and assessed using the Kaplan-Meier method. Log-rank test and unadjusted Cox models were performed to determine factors associated with outcomes. RESULTS The cohort includes 45 patients. Median age at diagnosis was 19.8 years (range: 3.5 - 57.8 years). Five patients (11.1%) presented with pleural effusion and eight patients with lung metastases (17.8%). Two (4.4%) patients had metastatic disease outside the thorax. Median tumor volume (TV) was 138.6 mL (range: 3.0-6762.0 mL). All patients received VDC/IE chemotherapy. LC modality was surgery (S) in 21 patients (47%), radiation therapy (RT) in 5 (11%), and S+RT in 19 (42%). Median TV was larger in S+RT patients (319.4 mL, range: 5.3-6761.9 mL) compared to RT (152.3 mL, range: 20.4-366.9 mL) or S (70.4 mL, range: 3.1-1037.8 mL) (p = 0.03). R0 and R1 resections were performed in 36 (90%) and 4 (10%) patients, respectively. Proton beam therapy was used in 15 (63%) patients. Median dose was 50.40 Gy (range: 34.2 - 60 Gy) in 28 fractions to the primary tumor or post operative bed. Median dose for hemithorax (1 patient, 2.2%) and whole lung irradiation (7 patients, 15.6%) was 15.0 Gy (range: 15.0-15.0 Gy) in 10 fractions. Median follow-up was 2.38 years (range: 0 - 21.90 years). Five-year LC, PFS, and OS for all patients was 77.9% (95% CI, 65.3 - 92.9%), 54.2% (95% CI, 39.9 - 73.5%), and 63.5% (95% CI, 49.3 - 81.8%), respectively. In patients with localized disease, 5-year LC, PFS, and OS were 82.4% (95% CI, 67.9-99.8%), 66.4% (95% CI, 49.7-88.8%), and 71.3% (95% CI, 54.2-93.9%), respectively. Two-year LC by modality was 100% for RT (95% CI, 100-100%), 84.2% (95% CI, 69.3- 100%) for S and 73.3% (95% CI, 54 - 99.5%) for S+RT (p = 0.51). On univariate analysis, TV ≥ 200 mL was associated with a significantly worse 5-year OS (49.5%, TV ≥ 200 mL vs. 80.8%, TV < 200 mL; HR 4.44, p = 0.032) and PFS (35.2%, TV ≥ 200 mL vs. 76%, TV < 200 mL; HR 3.55, p = 0.025). TV ≥ 200 mL trended towards worse 5-year LC: 69.2% for TV ≥ 200 mL versus 81.5% for TV <200 mL [HR 2.26(95% CI 0.49 - 10.47), p = 0.287]. Overall, low rates of grade ≥2 toxicity were observed: 4 (8.9%) fatigue, 4 (8.9%) radiation dermatitis, 1 (2.2%) chyle leak, 3 (6.6%) scoliosis, 4 (8.9%) infection, 1 (2.2%) pneumonia, and 1 (2.2%) chest wall deformity. CONCLUSION RT is a safe, effective local therapy for small to moderate cwES tumors. Patients with TV ≥ 200 mL had significantly worse survival outcomes and an inferior LC rate. This suggests large cwES tumors may benefit from an aggressive multi-modality approach.
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Affiliation(s)
- B S Laughlin
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
| | - I Zaniletti
- Department of Quantitative Health Sciences, Section of Biostatistics, Mayo Clinic, Scottsdale, AZ
| | - T Vern-Gross
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
| | - C Van Der Walt
- Department of Quantitative Health Sciences, Section of Biostatistics, Mayo Clinic, Scottsdale, AZ
| | - W Allen-Rhoades
- Department of Pediatric Hematology/Oncology, Mayo Clinic, Rochester, MN
| | - S Polites
- Department of Pediatric Surgery, Mayo Clinic, Rochester, MN
| | - P S Rose
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - J B Ashman
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
| | - I A Petersen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - M G Haddock
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - A Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - S R Keole
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
| | - N N Laack
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - S K Ahmed
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
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11
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Zaniletti I, Laughlin B, Gunn HJ, Haddock MG, Ashman JB, Wittich MN, Jethwa KR, Sio TTW, DeWees TA. Determining the Minimal Clinically Important Difference of the FACT-E to Evaluate the Change in the Quality of Life of Patients with Esophageal Cancer Treated with Curative Radiotherapy. Int J Radiat Oncol Biol Phys 2023; 117:e275-e276. [PMID: 37785036 DOI: 10.1016/j.ijrobp.2023.06.1249] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Patients with esophageal cancer (EC) are often treated with radiotherapy (RT). The Functional Assessment of Cancer Therapy-Esophageal (FACT-E) is a health-related quality of life (QOL) instrument validated in patients with EC. The aim of this study was to determine the minimal clinically important difference (MCID) for FACT-E subscales, to allow for meaningful evaluation of the effect of RT on EC patient's QOL. MATERIALS/METHODS We evaluated patients with EC, treated with curative intent RT, who completed the FACT-E at baseline and end of treatment (EOT). We calculated the MCID for the FACT-E subscales using anchor-based and distribution-based approaches. In the anchor-based approach we determined improvement and deterioration based on the overall health assessment from the PROMIS-10 as the anchor. We modeled the change in domain scores with age-adjusted regressions to determine the difference in classifications. For distribution-based analysis, we considered 0.3 and 0.5 standard deviation (SD). We averaged MCID for improvement and deterioration separately across timepoints, by approach, and we report MCID ranges as the minimum and maximum values across methods. RESULTS Our cohort included 210 patients with EC, 96.7% white, 85.7% males, and 32.9% treated with photon with a median dose of 50 Gy (IQR 50-50) and a median fraction number of 25(IQR 25,25). The median age at RT was 67.6 years (IQR 60.9,73.7). The social domain had the lowest MCID (deterioration and improvement 0.9-1.9), while the widest MCID range, proportionally to the measure, was associated with the Fact-E total score (2.1-5.6 for improvement, and 3.7-5.6 for deterioration). MCID estimates from 0.3 SD were in exact agreement with the anchor-based deterioration estimates for the physical domain (2.3), and improvement estimates for the Trial Outcome Index (6.1). CONCLUSION We determined the MCID for the FACT-E domains, using a combination of anchor- and distribution-based approaches. These findings are critical to determine whether there is meaningful change in the QOL of individuals with EC treated with curative RT.
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Affiliation(s)
- I Zaniletti
- Department of Quantitative Health Sciences, Section of Biostatistics, Mayo Clinic, Scottsdale, AZ
| | - B Laughlin
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
| | | | - M G Haddock
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - J B Ashman
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
| | - M Neben Wittich
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - K R Jethwa
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - T T W Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
| | - T A DeWees
- Department of Qualitative Health Sciences, Section of Biostatistics, Mayo Clinic, Scottsdale, AZ
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12
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Gunn HJ, DeWees TA, Voss MM, Corbin KS, Hallemeier CL, Stish BJ, Haddock MG, Petersen IA, Rule WG, Vallow LA, Brown PD, Olivier K, Trifiletti DM, Vargas CE, Ma DJ. Sensitivity of the PROMIS-10 for Capturing Radiation-Related Quality of Life Changes. Int J Radiat Oncol Biol Phys 2023; 117:e232-e233. [PMID: 37784929 DOI: 10.1016/j.ijrobp.2023.06.1149] [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) Patient reported outcomes (PROs) are becoming more common when assessing the effects of radiotherapy (RT). The aim of this study was to assess the sensitivity of the Mental and Physical domains of the Patient-Reported Outcomes Measurement Information System 10 (PROMIS-10) to radiotherapy and determine what predictors were associated with change in quality of life. MATERIALS/METHODS Patients, regardless of cancer type, were enrolled on a multi-site prospective registry. Inclusion criteria included curative radiotherapy and completion of the PROMIS-10 prior to treatment (Baseline) and at End of Treatment (EOT). To assess the strongest predictors of change in the T score of mental and physical health, we included 14 demographic characteristics and treatment variables in a multivariable stepwise regression. RESULTS A total of 7,586 patients were eligible for the analysis. The median age was 65 (range 18-94), 54% were males, and 94% were white. A majority received photons (62.5%) and the others received protons (37.5%) with an average dose of 52.3 Gy (range 20-80 Gy) over an average of 22.6 fractions (range 1-66). Patient disease sites were sub-grouped into 12 categories: Breast (25.5%), GU (23.0%), H&N (11.1%), CNS (8.5%), Pancreas-Biliary (6.7%), Thoracic (5.7%), Soft Tissue/Bone (5.0%), Esophagus-Gastric (4.7%), Colorectal-Anus (4.4%), Heme/Lymph (2.6%), GYN (1.8%), and Skin/Melanoma (1.0%). For both outcomes, the model selected disease group as an important predictor and it explained the most variance in the outcome compared to the rest of the predictors. When probing the effect of disease group, H&N, Esophagus-Gastric, Skin/Melanoma, and Colorectal-Anus had the largest mean decrease in quality of life for both domains. For mental health, the model also selected radiation type. Patients treated with protons indicated a bigger decrease in mental health compared to patients treated with photons (b = 0.43, 95% CI: -0.01, 0.69). For physical health, the model selected total fractions, ethnicity, and T stage. As number of fractions increased, the physical health change scores became more negative, on average (b = -0.03, 95% CI: -0.05, -0.01). Hispanic/Latino patients indicated a smaller decrease in physical health compared to White (b = -1.50, 95% CI: -2.60, -0.40) and Unknown ethnicity patients (b = -1.82, 95% CI: -3.36, -0.27). Finally, patients with a T stage of 3 or greater indicated a smaller decrease in physical health than patients with a T stage less than 3 (b = 0.76, 95% CI: 0.35, 1.16). CONCLUSION The PROMIS-10 did not capture significant change for patients undergoing curative radiotherapy except for patients with Head & Neck, Esophagus-Gastric, Skin, and Colorectal-Anus cancer. Further analyses should explore which patients experience the greatest change in quality of life within disease group.
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Affiliation(s)
| | - T A DeWees
- Department of Qualitative Health Sciences, Section of Biostatistics, Mayo Clinic, Scottsdale, AZ
| | - M M Voss
- Department of Quantitative Health Sciences, Mayo Clinic, Arizona, Phoenix, AZ
| | - K S Corbin
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | | | - B J Stish
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - M G Haddock
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - I A Petersen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - W G Rule
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
| | - L A Vallow
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL
| | - P D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - K Olivier
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - D M Trifiletti
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL
| | - C E Vargas
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
| | - D J Ma
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
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13
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Qualls KW, Schoffner J, Dodoo CA, Gunn HJ, Halfdanarson T, Merrell KW, Haddock MG, Hallemeier CL, Jethwa KR. Single Institutional Experience Using Radiation Therapy in the Treatment of Neuroendocrine Tumor Primary and Metastatic Lesions. Int J Radiat Oncol Biol Phys 2023; 117:e334. [PMID: 37785175 DOI: 10.1016/j.ijrobp.2023.06.2388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) The role of radiation therapy (RT) in the treatment of patients with neuroendocrine tumors (NETs) has not been well established. We aim to report on our experience using RT as part of curative or palliative treatment in patients with NET. MATERIALS/METHODS This was an IRB approved single-institutional retrospective cohort study including patients with NET who received curative- or palliative-intent RT from 2013-2022. Outcomes included cumulative incidence of local progression (LP) and overall survival (OS). Univariate and multivariate methods were used to assess disease and treatment characteristics associated with outcomes. RT dose was converted to biologically effective dose (BED10), assuming α/β = 10 Gy. RESULTS Sixty-six patients who received treatment to 89 total lesions were included for analysis. The median age at RT was 56 years (range: 20-95). ECOG performance status was 0-1 in 49 and 56% were male. Primary tumor origin included: 28 pancreas, 12 lung, 8 small intestine, 5 colorectal, 2 stomach, and 11 unknown/other primary cancers. Tumor grade included 1 (62%), 2 (1%), 3 (17%) or unknown (18%). 20% were functional. 43% of patients had metastatic disease at diagnosis, 24 were initially M0 and developed M1 disease in their disease course, and 12 remained M0. RT was delivered to the primary tumor (59%) or metastatic sites (41%). Treatment was either curative-intent (37%), including "curative" intent oligometastasis direct therapy, or palliative-intent (63%). For the 27 patients with M1 disease at time of RT, 1 had all sites controlled by local therapies at the time of RT. The location of the treated lesions included 17 pancreas, 13 bone, 12 thorax, 4 colorectal, 3 small bowel, and 15 other. Median RT dose and number of fractions were 30 Gy (IQR: 20-45) and 5 (IQR: 5-15). The median BED10 was 48 (IQR: 28-65) for all lesions and 60 (IQR: 58-69) for lesions treated curatively. 21 (32%) patients received concurrent systemic therapy with RT. The median follow-up per patient and per lesion were 15 months (IQR: 6-33) and 13 months (IQR: 5-28). The median OS was 34.5 months (95% confidence interval [CI]: 16.6-NE). The 3-year cumulative incidence of local progression was 15% (95% CI: 8-28%). BED10 was not associated with LP. CONCLUSION These data support the use of RT as a highly effective local treatment modality in the care of patients with either localized or metastatic NET.
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Affiliation(s)
- K W Qualls
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | | | - C A Dodoo
- Mayo Clinic Department of Statistics, Scottsdale, AZ
| | | | | | - K W Merrell
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - M G Haddock
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | | | - K R Jethwa
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
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14
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Gergelis KR, Bogan AW, DeWees TA, Haddock MG, Glaser GE, Kumar A, Petersen IA, Garda AE. Assessing the Sexual Health of Female Survivors of Pelvic Malignancies after Radiotherapy. Int J Radiat Oncol Biol Phys 2023; 117:e231. [PMID: 37784927 DOI: 10.1016/j.ijrobp.2023.06.1146] [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) To assess patient-reported sexual health outcomes of female survivors of pelvic malignancies after radiotherapy (RT). MATERIALS/METHODS Female patients treated with curative intent RT for pelvic malignancies between 2013 and 2019 were surveyed electronically post-RT using the PROMIS Sexual Function and Satisfaction Full Profile and Female Sexual Distress Scale-Revised questionnaires. Cervical and vaginal cancers were grouped together due to the similar treatment characteristics. RESULTS Surveys were sent to 544 patients, and 53 (10%) completed the questionnaires. Respondents included survivors of anal canal (N = 11), cervical or vaginal (N = 10), uterine (N = 30), and vulvar cancers (N = 2). The median age of patients at the time of treatment was 60 years (range 31,77). The median time between RT and survey completion was 6 years (range 3,9). A total of 22 (42%), 17 (32%), and 14 patients (26%) were treated with brachytherapy (BT), external beam RT (EBRT), or a combination of EBRT and BT, respectively. Of respondents, 96% were free of disease recurrence. Sexually active was defined as partaking in sexual activity within 30 days of survey response. Patients were stratified by age greater than or less than 52 at time of RT, representing the average age of menopause. A total of 30 patients (57%) had at least somewhat interest in sex. There was no difference in the proportion of patients who had at least somewhat interest in sex over 52 years compared to those 52 and (54% vs 67%, p = 0.424). A total of 39 patients (74%) were sexually active, and of those 30 (77%) were over the age of 52 at the time of RT. Of sexually active patients, 28 (72%) reported some, quite a bit, or a lot of satisfaction with their sex lives, whereas the remaining 11 (28%) reported having none or a little bit of satisfaction with their sex lives; the proportion of those with at least some satisfaction with their sex lives did not differ between those who were over or under 52 years at the time of RT (73% vs 67%, p = 0.697). Satisfaction with sex life differed by site of malignancy with 71% cervical or vaginal, 44% anal canal, 86% uterine, and 0% vulvar patients reporting at least some satisfaction (p = 0.043). Patients treated for anal canal cancer tended to have quite a bit or a lot of vaginal discomfort during sex (78%), compared to those treated for cervical/vaginal (29%), or endometrial (18%) cancers (p = 0.006). There was no difference in patients feeling frequently or always stressed about sex between those who were sexually active compared to those who were not (13% vs 14%, p = 0.890). Patients 52 or under at the time of RT were more likely to feel frequently or always stressed about sex compared to those receiving RT over the age of 52 (42% vs 5%, p<0.001). CONCLUSION In our cohort, the majority of female survivors of pelvic malignancies were sexually active post-RT, and this important topic warrants further investigation.
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Affiliation(s)
- K R Gergelis
- Department of Radiation Oncology, University of Rochester School of Medicine and Dentistry, Wilmot Cancer Institute, Rochester, NY
| | - A W Bogan
- Department of Qualitative Health Sciences, Section of Biostatistics, Mayo Clinic, Scottsdale, AZ
| | - T A DeWees
- Department of Qualitative Health Sciences, Section of Biostatistics, Mayo Clinic, Scottsdale, AZ
| | - M G Haddock
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - G E Glaser
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Rochester, MN
| | - A Kumar
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Rochester, MN
| | - I A Petersen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - A E Garda
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
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15
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Grams MP, Deufel CL, Kavanaugh JA, Corbin KS, Ahmed SK, Haddock MG, Lester SC, Ma DJ, Petersen IA, Finley RR, Lang KG, Spreiter SS, Park SS, Owen D. Clinical aspects of spatially fractionated radiation therapy treatments. Phys Med 2023; 111:102616. [PMID: 37311338 DOI: 10.1016/j.ejmp.2023.102616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/06/2023] [Accepted: 05/30/2023] [Indexed: 06/15/2023] Open
Abstract
PURPOSE To provide clinical guidance for centers wishing to implement photon spatially fractionated radiation therapy (SFRT) treatments using either a brass grid or volumetric modulated arc therapy (VMAT) lattice approach. METHODS We describe in detail processes which have been developed over the course of a 3-year period during which our institution treated over 240 SFRT cases. The importance of patient selection, along with aspects of simulation, treatment planning, quality assurance, and treatment delivery are discussed. Illustrative examples involving clinical cases are shown, and we discuss safety implications relevant to the heterogeneous dose distributions. RESULTS SFRT can be an effective modality for tumors which are otherwise challenging to manage with conventional radiation therapy techniques or for patients who have limited treatment options. However, SFRT has several aspects which differ drastically from conventional radiation therapy treatments. Therefore, the successful implementation of an SFRT treatment program requires the multidisciplinary expertise and collaboration of physicians, physicists, dosimetrists, and radiation therapists. CONCLUSIONS We have described methods for patient selection, simulation, treatment planning, quality assurance and delivery of clinical SFRT treatments which were built upon our experience treating a large patient population with both a brass grid and VMAT lattice approach. Preclinical research and patient trials aimed at understanding the mechanism of action are needed to elucidate which patients may benefit most from SFRT, and ultimately expand its use.
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Affiliation(s)
- Michael P Grams
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
| | - Christopher L Deufel
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - James A Kavanaugh
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Kimberly S Corbin
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Safia K Ahmed
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Michael G Haddock
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Scott C Lester
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Daniel J Ma
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Ivy A Petersen
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Randi R Finley
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Karen G Lang
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Sheri S Spreiter
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Dawn Owen
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
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16
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Jeans EB, Ebner DK, Takiyama H, Qualls K, Cunningham DA, Waddle MR, Jethwa KR, Harmsen WS, Hubbard JM, Dozois EJ, Mathis KL, Tsuji H, Merrell KW, Hallemeier CL, Mahajan A, Yamada S, Foote RL, Haddock MG. Comparing Oncologic Outcomes and Toxicity for Combined Modality Therapy vs. Carbon-Ion Radiotherapy for Previously Irradiated Locally Recurrent Rectal Cancer. Cancers (Basel) 2023; 15:cancers15113057. [PMID: 37297019 DOI: 10.3390/cancers15113057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/01/2023] [Accepted: 06/02/2023] [Indexed: 06/12/2023] Open
Abstract
No standard treatment paradigm exists for previously irradiated locally recurrent rectal cancer (PILRRC). Carbon-ion radiotherapy (CIRT) may improve oncologic outcomes and reduce toxicity compared with combined modality therapy (CMT). Eighty-five patients treated at Institution A with CIRT alone (70.4 Gy/16 fx) and eighty-six at Institution B with CMT (30 Gy/15 fx chemoradiation, resection, intraoperative electron radiotherapy (IOERT)) between 2006 and 2019 were retrospectively compared. Overall survival (OS), pelvic re-recurrence (PR), distant metastasis (DM), or any disease progression (DP) were analyzed with the Kaplan-Meier model, with outcomes compared using the Cox proportional hazards model. Acute and late toxicities were compared, as was the 2-year cost. The median time to follow-up or death was 6.5 years. Median OS in the CIRT and CMT cohorts were 4.5 and 2.6 years, respectively (p ≤ 0.01). No difference was seen in the cumulative incidence of PR (p = 0.17), DM (p = 0.39), or DP (p = 0.19). Lower acute grade ≥ 2 skin and GI/GU toxicity and lower late grade ≥ 2 GU toxicities were associated with CIRT. Higher 2-year cumulative costs were associated with CMT. Oncologic outcomes were similar for patients treated with CIRT or CMT, although patient morbidity and cost were lower with CIRT, and CIRT was associated with longer OS. Prospective comparative studies are needed.
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Affiliation(s)
- Elizabeth B Jeans
- Department of Radiation Oncology, Mayo Clinic, 200 2nd Street SW, Rochester, MN 55905, USA
| | - Daniel K Ebner
- Department of Radiation Oncology, Mayo Clinic, 200 2nd Street SW, Rochester, MN 55905, USA
| | - Hirotoshi Takiyama
- QST Hospital, National Institutes for Quantum Science and Technology, 4-9-1 Anagawa, Inageku, Chiba 263-8555, Japan
| | - Kaitlin Qualls
- Department of Radiation Oncology, Mayo Clinic, 200 2nd Street SW, Rochester, MN 55905, USA
| | - Danielle A Cunningham
- Department of Radiation Oncology, Mayo Clinic, 200 2nd Street SW, Rochester, MN 55905, USA
| | - Mark R Waddle
- Department of Radiation Oncology, Mayo Clinic, 200 2nd Street SW, Rochester, MN 55905, USA
| | - Krishan R Jethwa
- Department of Radiation Oncology, Mayo Clinic, 200 2nd Street SW, Rochester, MN 55905, USA
| | - William S Harmsen
- Department of Statistics, Mayo Clinic, 200 2nd Street SW, Rochester, MN 55905, USA
| | - Joleen M Hubbard
- Division of Medical Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Eric J Dozois
- Division of Colon & Rectal Surgery, Mayo Clinic, 200 2nd Street SW, Rochester, MN 55905, USA
| | - Kellie L Mathis
- Division of Colon & Rectal Surgery, Mayo Clinic, 200 2nd Street SW, Rochester, MN 55905, USA
| | - Hiroshi Tsuji
- QST Hospital, National Institutes for Quantum Science and Technology, 4-9-1 Anagawa, Inageku, Chiba 263-8555, Japan
| | - Kenneth W Merrell
- Department of Radiation Oncology, Mayo Clinic, 200 2nd Street SW, Rochester, MN 55905, USA
| | | | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, 200 2nd Street SW, Rochester, MN 55905, USA
| | - Shigeru Yamada
- QST Hospital, National Institutes for Quantum Science and Technology, 4-9-1 Anagawa, Inageku, Chiba 263-8555, Japan
| | - Robert L Foote
- Department of Radiation Oncology, Mayo Clinic, 200 2nd Street SW, Rochester, MN 55905, USA
| | - Michael G Haddock
- Department of Radiation Oncology, Mayo Clinic, 200 2nd Street SW, Rochester, MN 55905, USA
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17
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Hallemeier CL, Moughan J, Haddock MG, Herskovic AM, Minsky BD, Suntharalingam M, Zeitzer KL, Garg MK, Greenwald BD, Komaki RU, Puckett LL, Kim H, Lloyd S, Bush DA, Kim HE, Lad TE, Meyer JE, Okawara GS, Raben A, Schefter TE, Barker JL, Falkson CI, Videtic GMM, Jacob R, Winter KA, Crane CH. Association of Radiotherapy Duration With Clinical Outcomes in Patients With Esophageal Cancer Treated in NRG Oncology Trials: A Secondary Analysis of NRG Oncology Randomized Clinical Trials. JAMA Netw Open 2023; 6:e238504. [PMID: 37083668 PMCID: PMC10122174 DOI: 10.1001/jamanetworkopen.2023.8504] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 03/02/2023] [Indexed: 04/22/2023] Open
Abstract
Importance For many types of epithelial malignant neoplasms that are treated with definitive radiotherapy (RT), treatment prolongation and interruptions have an adverse effect on outcomes. Objective To analyze the association between RT duration and outcomes in patients with esophageal cancer who were treated with definitive chemoradiotherapy (CRT). Design, Setting, and Participants This study was an unplanned, post hoc secondary analysis of 3 prospective, multi-institutional phase 3 randomized clinical trials (Radiation Therapy Oncology Group [RTOG] 8501, RTOG 9405, and RTOG 0436) of the National Cancer Institute-sponsored NRG Oncology (formerly the National Surgical Adjuvant Breast and Bowel Project, RTOG, and Gynecologic Oncology Group). Enrolled patients with nonmetastatic esophageal cancer underwent definitive CRT in the trials between 1986 and 2013, with follow-up occurring through 2014. Data analyses were conducted between March 2022 to February 2023. Exposures Treatment groups in the trials used standard-dose RT (50 Gy) and concurrent chemotherapy. Main Outcomes and Measures The outcomes were local-regional failure (LRF), distant failure, disease-free survival (DFS), and overall survival (OS). Multivariable models were used to examine the associations between these outcomes and both RT duration and interruptions. Radiotherapy duration was analyzed as a dichotomized variable using an X-Tile software to choose a cut point and its median value as a cut point, as well as a continuous variable. Results The analysis included 509 patients (median [IQR] age, 64 [57-70] years; 418 males [82%]; and 376 White individuals [74%]). The median (IQR) follow-up was 4.01 (2.93-4.92) years for surviving patients. The median cut point of RT duration was 39 days or less in 271 patients (53%) vs more than 39 days in 238 patients (47%), and the X-Tile software cut point was 45 days or less in 446 patients (88%) vs more than 45 days in 63 patients (12%). Radiotherapy interruptions occurred in 207 patients (41%). Female (vs male) sex and other (vs White) race and ethnicity were associated with longer RT duration and RT interruptions. In the multivariable models, RT duration longer than 45 days was associated with inferior DFS (hazard ratio [HR], 1.34; 95% CI, 1.01-1.77; P = .04). The HR for OS was 1.33, but the results were not statistically significant (95% CI, 0.99-1.77; P = .05). Radiotherapy duration longer than 39 days (vs ≤39 days) was associated with a higher risk of LRF (HR, 1.32; 95% CI, 1.06-1.65; P = .01). As a continuous variable, RT duration (per 1 week increase) was associated with DFS failure (HR, 1.14; 95% CI, 1.01-1.28; P = .03). The HR for LRF 1.13, but the result was not statistically significant (95% CI, 0.99-1.28; P = .07). Conclusions and Relevance Results of this study indicated that in patients with esophageal cancer receiving definitive CRT, prolonged RT duration was associated with inferior outcomes; female patients and those with other (vs White) race and ethnicity were more likely to have longer RT duration and experience RT interruptions. Radiotherapy interruptions should be minimized to optimize outcomes.
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Affiliation(s)
| | - Jennifer Moughan
- NRG Oncology Statistics and Data Management Center/American College of Radiology, Philadelphia, Pennsylvania
| | | | - Arnold M. Herskovic
- Department of Radiation Oncology, Rush University Medical Center, Chicago, Illinois
| | - Bruce D. Minsky
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston
| | - Mohan Suntharalingam
- Department of Radiation Oncology, University of Maryland and Greenebaum Comprehensive Cancer Center, Baltimore
| | - Kenneth L. Zeitzer
- Department of Radiation Oncology, Albert Einstein Medical Center, Philadelphia, Pennsylvania
| | - Madhur K. Garg
- Department of Radiation Oncology, Montefiore Medical Center–Moses Campus, Bronx, New York
| | - Bruce D. Greenwald
- Department of Gastroenterology and Hepatology, University of Maryland and Greenebaum Cancer Center, Baltimore
| | - Ritsuko U. Komaki
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston
| | - Lindsay L. Puckett
- Department of Radiation Oncology, Medical College of Wisconsin and Zablocki Veterans' Administration Medical Center, Milwaukee
| | - Hyun Kim
- Department of Radiation Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Shane Lloyd
- Department of Radiation Oncology, University of Utah Health Science Center, Salt Lake City
| | - David A. Bush
- Department of Radiation Oncology, Loma Linda University Cancer Institute, Loma Linda, California
| | - Harold E. Kim
- Department of Radiation Oncology, Wayne State University/Karmanos Cancer Institute, Detroit, Michigan
| | - Thomas E. Lad
- Department of Medical Oncology, John H. Stroger Jr Hospital of Cook County, Chicago, Illinois
| | - Joshua E. Meyer
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Gordon S. Okawara
- Department of Radiation Oncology, McMaster University, Juravinski Cancer Centre, Hamilton, Ontario, Canada
| | - Adam Raben
- Department of Radiation Oncology, Christiana Care Health Services Inc Community Clinical Oncology Program, Newark, Delaware
| | | | - Jerry L. Barker
- Department of Radiation Oncology, US Oncology Texas Oncology-Sugar Land, Fort Worth
| | - Carla I. Falkson
- Department of Medicine, Hematology/Oncology, University of Rochester, Rochester, New York
| | | | - Rojymon Jacob
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham
| | - Kathryn A. Winter
- NRG Oncology Statistics and Data Management Center/American College of Radiology, Philadelphia, Pennsylvania
| | - Christopher H. Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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18
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Hoppe BS, Petersen IA, Wilke BK, DeWees TA, Imai R, Hug EB, Fiore MR, Debus J, Fossati P, Yamada S, Orlandi E, Zhang Q, Bao C, Seidensaal K, May BC, Harrell AC, Houdek MT, Vallow LA, Rose PS, Haddock MG, Ashman JB, Goulding KA, Attia S, Krishnan S, Mahajan A, Foote RL, Laack NN, Keole SR, Beltran CJ, Welch EM, Karim M, Ahmed SK. Pragmatic, Prospective Comparative Effectiveness Trial of Carbon Ion Therapy, Surgery, and Proton Therapy for the Management of Pelvic Sarcomas (Soft Tissue/Bone) Involving the Bone: The PROSPER Study Rationale and Design. Cancers (Basel) 2023; 15:1660. [PMID: 36980545 PMCID: PMC10046156 DOI: 10.3390/cancers15061660] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/02/2023] [Accepted: 03/05/2023] [Indexed: 03/10/2023] Open
Abstract
Surgical treatment of pelvic sarcoma involving the bone is the standard of care but is associated with several sequelae and reduced functional quality of life (QOL). Treatment with photon and proton radiotherapy is associated with relapse. Carbon ion radiotherapy (CIRT) may reduce both relapse rates and treatment sequelae. The PROSPER study is a tricontinental, nonrandomized, prospective, three-arm, pragmatic trial evaluating treatments of pelvic sarcoma involving the bone. Patients aged at least 15 years are eligible for inclusion. Participants must have an Eastern Cooperative Oncology Group Performance Status score of two or less, newly diagnosed disease, and histopathologic confirmation of pelvic chordoma, chondrosarcoma, osteosarcoma, Ewing sarcoma with bone involvement, rhabdomyosarcoma (RMS) with bone involvement, or non-RMS soft tissue sarcoma with bone involvement. Treatment arms include (1) CIRT (n = 30) delivered in Europe and Asia, (2) surgical treatment with or without adjuvant radiotherapy (n = 30), and (3) proton therapy (n = 30). Arms two and three will be conducted at Mayo Clinic campuses in Arizona, Florida, and Minnesota. The primary end point is to compare the 1-year change in functional QOL between CIRT and surgical treatment. Additional comparisons among the three arms will be made between treatment sequelae, local control, and other QOL measures.
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Affiliation(s)
- Bradford S. Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Ivy A. Petersen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Benjamin K. Wilke
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Todd A. DeWees
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Phoenix, AZ 85054, USA
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Reiko Imai
- Division of Radiation Oncology, QST Hospital, National Institutes for Quantum and Radiological Science and Technology, Chiba 263-8555, Japan
| | - Eugen B. Hug
- Department of Radiation Oncology, MedAustron Ion Therapy Center, 2700 Wiener Neustadt, Austria
| | - Maria Rosaria Fiore
- Radiation Oncology Clinical Department, National Center for Oncological Hadrontherapy (CNAO), 27100 Pavia, Italy
| | - Jürgen Debus
- Department of Radiation Oncology, University Hospital Heidelberg, 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation, German Cancer Research Center, 69120 Heidelberg, Germany
| | - Piero Fossati
- Department of Radiation Oncology, MedAustron Ion Therapy Center, 2700 Wiener Neustadt, Austria
- Department for Basic and Translational Oncology and Hematology, Karl Landsteiner University of Health Sciences, 3500 Krems, Austria
| | - Shigeru Yamada
- Division of Radiation Oncology, QST Hospital, National Institutes for Quantum and Radiological Science and Technology, Chiba 263-8555, Japan
| | - Ester Orlandi
- Radiation Oncology Clinical Department, National Center for Oncological Hadrontherapy (CNAO), 27100 Pavia, Italy
| | - Qing Zhang
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Shanghai 201102, China
| | - Cihang Bao
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Shanghai 201102, China
| | - Katharina Seidensaal
- Department of Radiation Oncology, University Hospital Heidelberg, 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation, German Cancer Research Center, 69120 Heidelberg, Germany
| | - Byron C. May
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Anna C. Harrell
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Matthew T. Houdek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Laura A. Vallow
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Peter S. Rose
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | | | | | | | - Steven Attia
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Sunil Krishnan
- Department of Radiation Oncology, University of Texas Health Houston Neurosciences-Texas Medical Center, Houston, TX 77030, USA
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Robert L. Foote
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Nadia N. Laack
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Sameer R. Keole
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Chris J. Beltran
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Eric M. Welch
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Mohammed Karim
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Safia K. Ahmed
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85054, USA
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19
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Kowalchuk RO, Spears GM, Morris LK, Owen D, Yoon HH, Jethwa K, Chuong MD, Ferris MJ, Haddock MG, Hallemeier CL, Wigle D, Lin SH, Merrell KW. Risk stratification of postoperative cardiopulmonary toxicity after trimodality therapy for esophageal cancer. Front Oncol 2023; 13:1081024. [PMID: 36845682 PMCID: PMC9948243 DOI: 10.3389/fonc.2023.1081024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 01/27/2023] [Indexed: 02/11/2023] Open
Abstract
Purpose/objective Postoperative toxicity for esophageal cancer impacts patient quality of life and potentially overall survival (OS). We studied whether patient and toxicity parameters post-chemoradiation therapy predict for post-surgical cardiopulmonary total toxicity burden (CPTTB) and whether CPTTB was associated with short and long-term outcomes. Materials/methods Patients had biopsy-proven esophageal cancer treated with neoadjuvant chemoradiation and esophagectomy. CPTTB was derived from total perioperative toxicity burden (Lin et al. JCO 2020). To develop a CPTTB risk score predictive for major CPTTB, recursive partitioning analysis was used. Results From 3 institutions, 571 patients were included. Patients were treated with 3D (37%), IMRT (44%), and proton therapy (19%). 61 patients had major CPTTB (score ≥ 70). Increasing CPTTB was predictive of decreased OS (p<0.001), lengthier post-esophagectomy length of stay (LOS, p<0.001), and death or readmission within 60 days of surgery (DR60, p<0.001). Major CPTTB was also predictive of decreased OS (hazard ratio = 1.70, 95% confidence interval: 1.17-2.47, p=0.005). The RPA-based risk score included: age ≥ 65, grade ≥ 2 nausea or esophagitis attributed to chemoradiation, and grade ≥ 3 hematologic toxicity attributed to chemoradiation. Patients treated with 3D radiotherapy had inferior OS (p=0.010) and increased major CPTTB (18.5% vs. 6.1%, p<0.001). Conclusion CPTTB predicts for OS, LOS, and DR60. Patients with 3D radiotherapy or age ≥ 65 years and chemoradiation toxicity are at highest risk for major CPTTB, predicting for higher short and long-term morbidity and mortality. Strategies to optimize medical management and reduce toxicity from chemoradiation should be strongly considered.
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Affiliation(s)
- Roman O. Kowalchuk
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Grant M. Spears
- Department of Statistics, Mayo Clinic, Rochester, MN, United States
| | - Lindsay K. Morris
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Dawn Owen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Harry H. Yoon
- Department of Medical Oncology, Mayo Clinic, Rochester, MN, United States
| | - Krishan Jethwa
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Michael D. Chuong
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL, United States
| | - Matthew J. Ferris
- Department of Radiation Oncology, University of Maryland Medical System, Baltimore, MD, United States
| | - Michael G. Haddock
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | | | - Dennis Wigle
- Department of Thoracic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Steven H. Lin
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX, United States
| | - Kenneth W. Merrell
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States,*Correspondence: Kenneth W. Merrell,
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20
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Anderson JD, Voss MM, Laughlin BS, Garda AE, Aziz K, Mullikin TC, Haddock MG, Petersen IA, DeWees TA, Vora SA. Outcomes of Proton Beam Therapy Compared With Intensity-Modulated Radiation Therapy for Uterine Cancer. Int J Part Ther 2022; 9:10-17. [PMID: 36721479 PMCID: PMC9875825 DOI: 10.14338/ijpt-22-00020.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/25/2022] [Indexed: 11/16/2022] Open
Abstract
Purpose To compare Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) in patients with endometrial cancer receiving adjuvant pelvic radiation therapy with proton beam therapy (PT) versus intensity-modulated radiation therapy (IMRT). Materials and Methods Patients with uterine cancer treated with curative intent who received either adjuvant PT or IMRT between 2014 and 2020 were identified. Patients were enrolled into a prospective registry using a gynecologic-specific subset of PRO-CTCAE designed to assess symptom impact on daily living. Questions included gastrointestinal (GI) symptoms of diarrhea, flatulence, bowel incontinence, and constipation in addition to other pertinent gynecologic, urinary, and other general symptoms. Symptom-based questions were on a 0- to 4-point scale, with grade 3+ symptoms occurring frequently or almost always. Patient-reported toxicity was analyzed at baseline, end of treatment (EOT), and at 3, 6, 9, and 12 months after treatment. Unequal variance t tests were used to determine if treatment type was a significant factor in baseline-adjusted PRO-CTCAE. Results Sixty-seven patients met inclusion criteria. Twenty-two received PT and 45 patients received IMRT. Brachytherapy boost was delivered in 73% of patients. Median external beam dose was 45 Gy for both PT and IMRT (range, 45-58.8 Gy). When comparing PRO-CTCAE, PT was associated with less diarrhea at EOT (P = .01) and at 12 months (P = .24) than IMRT. Loss of bowel control at 12 months was more common in patients receiving IMRT (P = .15). Any patient reporting grade 3+ GI toxicity was noted more frequently with IMRT (31% versus 9%, P = .09). Discussion Adjuvant PT is a promising treatment for patients with uterine cancer and may reduce patient-reported GI toxicity as compared with IMRT.
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Affiliation(s)
| | - Molly M. Voss
- Department of Health Sciences Research, Division of Biostatistics, Mayo Clinic, Scottsdale, AZ, USA
| | | | - Allison E. Garda
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Khaled Aziz
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Trey C. Mullikin
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | | | - Ivy A. Petersen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Todd A. DeWees
- Department of Health Sciences Research, Division of Biostatistics, Mayo Clinic, Scottsdale, AZ, USA
| | - Sujay A. Vora
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
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21
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Morris LK, Garda AE, Cutsinger JM, Deufel CL, Haddock MG, Petersen IA. PO30 Presentation Time: 10:30 AM. Brachytherapy 2022. [DOI: 10.1016/j.brachy.2022.09.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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22
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Abdelrahman AM, Goenka AH, Alva-Ruiz R, Yonkus JA, Leiting JL, Graham RP, Merrell KW, Thiels CA, Hallemeier CL, Warner SG, Haddock MG, Grotz TE, Tran NH, Smoot RL, Ma WW, Cleary SP, McWilliams RR, Nagorney DM, Halfdanarson TR, Kendrick ML, Truty MJ. FDG-PET Predicts Neoadjuvant Therapy Response and Survival in Borderline Resectable/Locally Advanced Pancreatic Adenocarcinoma. J Natl Compr Canc Netw 2022; 20:1023-1032.e3. [PMID: 36075389 DOI: 10.6004/jnccn.2022.7041] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 06/03/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Neoadjuvant therapy (NAT) is used in borderline resectable/locally advanced (BR/LA) pancreatic ductal adenocarcinoma (PDAC). Anatomic imaging (CT/MRI) poorly predicts response, and biochemical (CA 19-9) markers are not useful (nonsecretors/nonelevated) in many patients. Pathologic response highly predicts survival post-NAT, but is only known postoperatively. Because metabolic imaging (FDG-PET) reveals primary tumor viability, this study aimed to evaluate our experience with preoperative FDG-PET in patients with BR/LA PDAC in predicting NAT response and survival. METHODS We reviewed all patients with resected BR/LA PDAC who underwent NAT with FDG-PET within 60 days of resection. Pre- and post-NAT metabolic (FDG-PET) and biochemical (CA 19-9) responses were dichotomized in addition to pathologic responses. We compared post-NAT metabolic and biochemical responses as preoperative predictors of pathologic responses and recurrence-free survival (RFS) and overall survival (OS). RESULTS We identified 202 eligible patients. Post-NAT, 58% of patients had optimization of CA 19-9 levels. Major metabolic and pathologic responses were present in 51% and 38% of patients, respectively. Median RFS and OS times were 21 and 48.7 months, respectively. Metabolic response was superior to biochemical response in predicting pathologic response (area under the curve, 0.86 vs 0.75; P<.001). Metabolic response was the only univariate preoperative predictor of OS (odds ratio, 0.25; 95% CI, 0.13-0.40), and was highly correlated (P=.001) with pathologic response as opposed to biochemical response alone. After multivariate adjustment, metabolic response was the single largest independent preoperative predictor (P<.001) for pathologic response (odds ratio, 43.2; 95% CI, 16.9-153.2), RFS (hazard ratio, 0.37; 95% CI, 0.2-0.6), and OS (hazard ratio, 0.21; 95% CI, 0.1-0.4). CONCLUSIONS Among patients with post-NAT resected BR/LA PDAC, FDG-PET highly predicts pathologic response and survival, superior to biochemical responses alone. Given the poor ability of anatomic imaging or biochemical markers to assess NAT responses in these patients, FDG-PET is a preoperative metric of NAT efficacy, thereby allowing potential therapeutic alterations and surgical treatment decisions. We suggest that FDG-PET should be an adjunct and recommended modality during the NAT phase of care for these patients.
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Affiliation(s)
| | - Ajit H Goenka
- Division of Nuclear Medicine Radiology, Department of Radiology
| | - Roberto Alva-Ruiz
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery
| | - Jennifer A Yonkus
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery
| | | | - Rondell P Graham
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology
| | | | | | | | - Susanne G Warner
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery
| | | | - Travis E Grotz
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery
| | - Nguyen H Tran
- Division of Medical Oncology, Department of Oncology, Mayo Clinic, Rochester, Minnesota
| | - Rory L Smoot
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery
| | - Wen Wee Ma
- Division of Medical Oncology, Department of Oncology, Mayo Clinic, Rochester, Minnesota
| | - Sean P Cleary
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery
| | - Robert R McWilliams
- Division of Medical Oncology, Department of Oncology, Mayo Clinic, Rochester, Minnesota
| | - David M Nagorney
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery
| | | | | | - Mark J Truty
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery
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Halfdanarson TR, Foster NR, Kim GP, Haddock MG, Dakhil SR, Behrens RJ, Alberts SR. N064A (Alliance): Phase II Study of Panitumumab, Chemotherapy, and External Beam Radiation in Patients with Locally Advanced Pancreatic Adenocarcinoma. Oncologist 2022; 27:534-e546. [PMID: 35285484 PMCID: PMC9255975 DOI: 10.1093/oncolo/oyac002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 12/20/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND This North Central Cancer Treatment Group (NCCTG) N064A (Alliance) phase II trial evaluated upfront chemoradiotherapy incorporating the EGFR inhibitor panitumumab, followed by gemcitabine and panitumumab for unresectable, non-metastatic pancreatic cancer. METHODS The treatment consisted of fluoropyrimidine and panitumumab given concurrently with radiotherapy followed by gemcitabine and panitumumab for 3 cycles followed by maintenance panitumumab. The primary endpoint was the 12-month overall survival (OS) rate and secondary endpoints included confirmed response rate (RR), OS, progression-free survival (PFS), and adverse events. Enrollment of 50 patients was planned and the study fully accrued. RESULTS Fifty-two patients were enrolled, but only 51 were treated and included in the analysis. The median age of patients was 65 years and 54.9% were women. Twenty-two patients received at least 1 cycle of systemic therapy following radiotherapy, but 29 patients received chemoradiotherapy only without receiving subsequent chemotherapy after completion of chemoradiotherapy. The overall RR was 5.9% (95% CI: 1.2%-16.2%). The 12-month OS rate was 50% (95% CI: 38%-67%) which fell short of the per-protocol goal for success (51.1%). The median PFS was 7.4 months (95% CI: 4.5-8.6) and the median OS was 12.1 months (95% CI 7.9-15.9). Grade 3 or higher adverse events were reported by 88%. CONCLUSION The combination of panitumumab, chemotherapy, and external beam radiation therapy was associated with very high rates of grades 3-4 toxicities and survival results did not meet the trial's goal for success. This regimen is not recommended for further study (ClinicalTrials.gov Identifier NCT00601627).
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Affiliation(s)
| | - Nathan R Foster
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN, USA
| | - George P Kim
- George Washington University Cancer Center, Washington, DC, USA
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Grams MP, Tseung HSWC, Ito S, Zhang Y, Owen D, Park SS, Ahmed SK, Petersen IA, Haddock MG, Harmsen WS, Ma DJ. A Dosimetric Comparison of Lattice, Brass, and Proton Grid Therapy Treatment Plans. Pract Radiat Oncol 2022; 12:e442-e452. [DOI: 10.1016/j.prro.2022.03.005] [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] [Received: 10/09/2021] [Revised: 02/28/2022] [Accepted: 03/09/2022] [Indexed: 11/28/2022]
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Safran HP, Winter K, Ilson DH, Wigle D, DiPetrillo T, Haddock MG, Hong TS, Leichman LP, Rajdev L, Resnick M, Kachnic LA, Seaward S, Mamon H, Diaz Pardo DA, Anderson CM, Shen X, Sharma AK, Katz AW, Salo J, Leonard KL, Moughan J, Crane CH. Trastuzumab with trimodality treatment for oesophageal adenocarcinoma with HER2 overexpression (NRG Oncology/RTOG 1010): a multicentre, randomised, phase 3 trial. Lancet Oncol 2022; 23:259-269. [PMID: 35038433 PMCID: PMC8903071 DOI: 10.1016/s1470-2045(21)00718-x] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 12/06/2021] [Accepted: 12/06/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Trastuzumab is a monoclonal antibody against HER2 (also known as ERBB2). The primary objective of the NRG Oncology/RTOG-1010 trial was to establish whether trastuzumab improves disease-free survival when combined with trimodality treatment (paclitaxel plus carboplatin and radiotherapy, followed by surgery) for patients with untreated HER2-overexpressing oesophageal adenocarcinoma. METHODS NRG Oncology/RTOG-1010 was an open label, randomised, phase 3 trial for which patients were accrued from 111 NRG-affiliated institutions in the USA. Eligible patients were adults (aged ≥18 years) with newly diagnosed pathologically confirmed oesophageal adenocarcinoma, American Joint Committee on Cancer 7th edition T1N1-2 or T2-3N0-2 stage disease, and a Zubrod performance status of 0-2. Patients were stratified by adenopathy (no vs yes [coeliac absent] vs yes [coeliac present ≤2 cm]) and randomly assigned (1:1) to receive weekly intravenous paclitaxel (50 mg/m2 intravenously over 1 h) and carboplatin (area under the curve 2, intravenously over 30-60 min) for 6 weeks with radiotherapy 50·4 Gy in 28 fractions (chemoradiotherapy) followed by surgery, with or without intravenous trastuzumab (4 mg/kg in week one, 2 mg/kg per week for 5 weeks during chemoradiotherapy, 6 mg/kg once presurgery, and 6 mg/kg every 3 weeks for 13 treatments starting 21-56 days after surgery). The primary endpoint, disease-free survival, was defined as the time from randomisation to death or first of locoregional disease persistence or recurrence, distant metastases, or second primary malignancy. Analyses were done by modified intention to treat. This study is registered with Clinicaltrials.gov, NCT01196390; it is now closed and in follow-up. FINDINGS 606 patients were entered for HER2 assessment from Dec 30, 2010 to Nov 10, 2015, and 203 eligible patients who were HER2-positive were enrolled and randomly assigned to chemoradiotherapy plus trastuzumab (n=102) or chemoradiotherapy alone (n=101). Median duration of follow-up was 2·8 years (IQR 1·4-5·7). Median disease-free survival was 19·6 months (95% CI 13·5-26·2) with chemoradiotherapy plus trastuzumab compared with 14·2 months (10·5-23·0) for chemoradiotherapy alone (hazard ratio 0·99 [95% CI 0·71-1·39], log-rank p=0·97). Grade 3 treatment-related adverse events occurred in 41 (43%) of 95 patients in the chemoradiotherapy plus trastuzumab group versus 52 (54%) of 96 in the chemoradiotherapy group and grade 4 events occurred in 20 (21%) versus 21 (22%). The most common grade 3 or worse treatment-related adverse events for both groups were haematological (53 [56%] of 95 patients in the chemoradiotherapy plus trastuzumab group vs 55 [57%] of 96 patients in the chemotherapy group) or gastrointestinal disorders (28 [29%] vs 20 [21 %]). 34 (36%) of 95 patients in the chemoradiotherapy plus trastuzumab group and 27 (28%) of 96 patients in the chemoradiotherapy only group had treatment-related serious adverse events. There were eight treatment-related deaths: five (5%) of 95 patients in the chemoradiotherapy plus trastuzumab group (bronchopleural fistula, oesophageal anastomotic leak, lung infection, sudden death, and death not otherwise specified), and three (3%) of 96 in the chemoradiotherapy group (two multiorgan failure and one sepsis). INTERPRETATION The addition of trastuzumab to neoadjuvant chemoradiotherapy for HER2-overexpressing oesophageal cancer was not effective. Trastuzumab did not lead to increased toxicities, suggesting that future studies combining it with or using other agents targeting HER2 in oesophageal cancer are warranted. FUNDING National Cancer Institute and Genentech.
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Yolcu YU, Zreik J, Wahood W, Bhatti AUR, Bydon M, Houdek MT, Rose PS, Mahajan A, Petersen IA, Haddock MG, Ahmed SK, Laack NN, Jethwa K, Jeans EB, Imai R, Yamada S, Foote RL. Comparison of Oncologic Outcomes and Treatment-Related Toxicity of Carbon Ion Radiotherapy and En Bloc Resection for Sacral Chordoma. JAMA Netw Open 2022; 5:e2141927. [PMID: 34994795 PMCID: PMC8742192 DOI: 10.1001/jamanetworkopen.2021.41927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
IMPORTANCE Maximal resection is the preferred management for sacral chordomas but can be associated with unacceptable morbidity. Outcomes with radiotherapy are poor. Carbon ion radiotherapy (CIRT) is being explored as an alternative when surgery is not preferred. OBJECTIVE To compare oncologic outcomes and treatment-related toxicity of CIRT and en bloc resection for sacral chordoma. DESIGN, SETTING, AND PARTICIPANTS Univariable logistic regression was performed to evaluate the association between treatment type and oncologic and toxicity outcomes in this retrospective cohort study. Nearest-neighbor propensity score matching was used to match the CIRT cohort with the en bloc resection cohort and 10 National Cancer Database (NCDB) cohorts separately, with the objective of obtaining more homogeneous cohorts when comparing treatments. Patient- and tumor-related characteristics from 2 institutional cohorts were collected for patients diagnosed with sacral chordomas between April 1, 1994, and July 31, 2017. The NCDB was queried for data on patients with sacral chordoma from January 1, 2004, to December 31, 2016, as a comparator in overall survival (OS) analyses. Data analysis was conducted from February 24, 2020, to January 16, 2021. EXPOSURES En bloc resection, incomplete resection, photon radiotherapy, proton radiotherapy, and CIRT. MAIN OUTCOMES AND MEASURES Overall survival was estimated using the Kaplan-Meier method and compared using the Cox proportional hazards model. Peripheral motor nerve toxic effects were scored using Common Terminology Criteria for Adverse Events, version 4.03. RESULTS A total of 911 patients were included in the study (NCDB: n = 669; median age, 64 [IQR, 52-74] years; 410 [61.3%] men; CIRT: n = 188; median age, 66 [IQR, 58-71] years; 128 [68.1%] men; en bloc surgical resection: n = 54; median age, 53.5 [IQR 49-64] years, 36 [66.7%] men). Comparison of the propensity score-matched institutional en bloc resection and CIRT cohorts revealed no statistically significant difference in OS (CIRT: median OS, 68.1 [95% CI, 44.0-102.6] months; en bloc resection: median OS, 58.6 [95% CI, 25.6-123.5] months; P = .57; hazard ratio, 0.71 [95% CI, 0.25-2.06]; P = .53). The CIRT cohort experienced lower rates of peripheral motor neuropathy (odds ratio, 0.13 [95% CI, 0.04-0.40]; P < .001). On comparison of the propensity score-matched NCDB cohorts with the CIRT cohort, significantly higher OS was found for CIRT compared with margin-positive surgery without adjuvant radiotherapy (CIRT: median OS, 64.7 [95% CI, 57.8-69.7] months; margin-positive surgery without adjuvant radiotherapy: median OS, 60.6 [95% CI, 44.2-69.7] months, P = .03) and primary radiotherapy alone (CIRT: median OS, 64.9 [95% CI 57.0-70.5] months; primary radiotherapy alone: 31.8 [95% CI, 27.9-40.6] months; P < .001). CONCLUSIONS AND RELEVANCE These findings suggest that CIRT can be used as treatment for older patients with high performance status and sacral chordoma in whom surgery is not preferred. CIRT might provide additional benefit for patients who undergo margin-positive resection or who are candidates for primary photon radiotherapy.
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Affiliation(s)
- Yagiz U Yolcu
- Mayo Clinic Neuro-informatics Laboratory, Mayo Clinic, Rochester, Minnesota
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jad Zreik
- Central Michigan University College of Medicine, Mount Pleasant
| | - Waseem Wahood
- Dr Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Davie, Florida
| | | | - Mohamad Bydon
- Mayo Clinic Neuro-informatics Laboratory, Mayo Clinic, Rochester, Minnesota
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Matthew T Houdek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Peter S Rose
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Ivy A Petersen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Safia K Ahmed
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Nadia N Laack
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Krishan Jethwa
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Reiko Imai
- QST Hospital, National Institutes for Quantum and Radiological Science and Technology, Inageku, Chiba, Japan
| | - Shigeru Yamada
- QST Hospital, National Institutes for Quantum and Radiological Science and Technology, Inageku, Chiba, Japan
| | - Robert L Foote
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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Mullikin TC, Pepin KM, Evans JE, Venkatesh SK, Ehman RL, Merrell KW, Haddock MG, Harmsen WS, Herman MG, Hallemeier CL. Evaluation of Pretreatment Magnetic Resonance Elastography for the Prediction of Radiation-Induced Liver Disease. Adv Radiat Oncol 2021; 6:100793. [PMID: 34820550 PMCID: PMC8601961 DOI: 10.1016/j.adro.2021.100793] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 08/26/2021] [Indexed: 11/29/2022] Open
Abstract
Purpose Magnetic resonance (MR) elastography (E) is a noninvasive technique for quantifying liver stiffness (LS) for fibrosis. This study evaluates whether LS is associated with risk of developing radiation-induced liver disease (RILD) in patients receiving liver-directed radiation therapy (RT). Methods and Materials Based on prior studies, LS ≤3 kPa was considered normal and LS >3.0 kPa as representing fibrosis. RILD was defined as an increase in Child-Pugh (CP) score of ≥2 from baseline within 1 year of RT. Univariate and multivariate Cox models were used to assess correlation. Results One hundred two patients, 51 with primary liver tumors and 51 with liver metastases, were identified with sufficient follow-up. In univariate models, pre-RT LS >3.0 kPa (hazard ratio [HR] 4.9; 95% confidence interval [CI], 1.6-14; P = .004), body mass index (BMI), clinical cirrhosis, CP score, albumin-bilirubin (ALBI) grade 2, primary liver tumor, and mean liver dose were significantly associated with risk of post-RT RILD. In a multivariate analysis, LS >3.0 and mean liver dose both were significantly associated with RILD risk. Conclusions Elevated pre-RT LS is associated with an increased risk of RILD in patients receiving liver-directed RT.
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Affiliation(s)
- Trey C Mullikin
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Kay M Pepin
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Jaden E Evans
- Department of Radiation Oncology, Intermountain Health Care, Ogden, Utah
| | | | | | | | | | - William S Harmsen
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Michael G Herman
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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Gits HC, Tang AH, Harmsen WS, Bamlet WR, Graham RP, Petersen GM, Smyrk TC, Mahipal A, Kowalchuk RO, Ashman JB, Rule WG, Owen D, Neben Wittich MA, McWilliams RR, Halfdanarson T, Ma WW, Sio TT, Cleary SP, Truty MJ, Haddock MG, Hallemeier CL, Merrell KW. Intact SMAD-4 is a predictor of increased locoregional recurrence in upfront resected pancreas cancer receiving adjuvant therapy. J Gastrointest Oncol 2021; 12:2275-2286. [PMID: 34790392 PMCID: PMC8576222 DOI: 10.21037/jgo-21-55] [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] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 06/08/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Previous reports suggest that intact SMAD4 expression is associated with a locally aggressive pancreas cancer phenotype. The objectives of this work were to determine the frequency of intact SMAD4 and its association with patterns of recurrence in patients with upfront resected pancreas cancer receiving adjuvant therapy. METHODS A tissue microarray was constructed using resected specimens from patients who underwent upfront surgery and adjuvant gemcitabine with no neoadjuvant treatment for pancreas cancer. SMAD4 expression was determined by immunohistochemical staining. Associations of SMAD4 expression and clinicopathologic parameters with clinical outcomes were evaluated using Cox proportional hazard models. RESULTS One hundred twenty-seven patients were included with a median follow up of 5.7 years. Most patients had stage ≥ pT3 tumors (75%) and pN1 (68%). All patients received adjuvant gemcitabine, and 79% of patients received adjuvant chemoradiotherapy. Ten (8%) patients had intact SMAD4 expression. Grade was the only clinicopathologic parameter statistically associated with SMAD4 expression (P=0.05). Median overall survival was 2.1 years. On univariate analysis, SMAD4 expression was associated with increased locoregional recurrence (hazard ratio 7.0, P<0.01, 95% confidence interval: 2.8-18.0) but not distant recurrence (P=0.06) or overall survival (P=0.73). On multivariable analysis, SMAD4 expression (hazard ratio 9.6, P<0.01, 95% confidence interval: 3.7-24.8) and adjuvant chemoradiotherapy (hazard ratio 0.3, P=0.01, 95% confidence interval: 0.1-0.8) were associated with higher and lower locoregional recurrence, respectively. CONCLUSIONS In patients with upfront resected pancreas cancer, SMAD4 expression was associated with an increased risk of locoregional recurrence. Prospective evaluation of the frequency of SMAD4 expression and validation of its predictive utility is warranted.
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Affiliation(s)
- Hunter C. Gits
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Amy H. Tang
- Leroy T. Canoles Jr. Cancer Research Center, Department of Microbiology and Molecular Cell Biology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - William S. Harmsen
- Department of Biostatistics and Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - William R. Bamlet
- Department of Biostatistics and Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Rondell P. Graham
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Gloria M. Petersen
- Department of Epidemiology and Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Thomas C. Smyrk
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Amit Mahipal
- Department of Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | | | | | - William G. Rule
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Dawn Owen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Wen Wee Ma
- Department of Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | - Terence T. Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Sean P. Cleary
- Department of Hepatobiliary & Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Mark J. Truty
- Department of Hepatobiliary & Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
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Bhangoo RS, Mullikin TC, Ashman JB, Cheng TW, Golafshar MA, DeWees TA, Johnson JE, Shiraishi S, Liu W, Hu Y, Merrell KW, Haddock MG, Krishnan S, Rule WG, Sio TT, Hallemeier CL. Intensity Modulated Proton Therapy for Hepatocellular Carcinoma: Initial Clinical Experience. Adv Radiat Oncol 2021; 6:100675. [PMID: 34409199 PMCID: PMC8361033 DOI: 10.1016/j.adro.2021.100675] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/14/2021] [Accepted: 02/10/2021] [Indexed: 02/08/2023] Open
Abstract
Purpose Our purpose was to assess the safety and efficacy of intensity modulated proton therapy (IMPT) for the treatment of hepatocellular carcinoma (HCC). Methods and Materials A retrospective review was conducted on all patients who were treated with IMPT for HCC with curative intent from June 2015 to December 2018. All patients had fiducials placed before treatment. Inverse treatment planning used robust optimization with 2 to 3 beams. The majority of patients were treated in 15 fractions (n = 30, 81%, 52.5-67.5 Gy, relative biological effectiveness), whereas the remainder were treated in 5 fractions (n = 7, 19%, 37.5-50 Gy, relative biological effectiveness). Daily image guidance consisted of orthogonal kilovoltage x-rays and use of a 6° of freedom robotic couch. Outcomes (local control, progression free survival, and overall survival) were determined using Kaplan-Meier methods. Results Thirty-seven patients were included. The median follow-up for living patients was 21 months (Q1-Q3, 17-30 months). Pretreatment Child-Pugh score was A5-6 in 70% of patients and B7-9 in 30% of patients. Nineteen patients had prior liver directed therapy for HCC before IMPT. Eight patients (22%) required a replan during treatment, most commonly due to inadequate clinical target volume coverage. One patient (3%) experienced a grade 3 acute toxicity (pain) with no recorded grade 4 or 5 toxicities. An increase in Child-Pugh score by ≥ 2 within 3 months of treatment was observed in 6 patients (16%). At 1 year, local control was 94%, intrahepatic control was 54%, progression free survival was 35%, and overall survival was 78%. Conclusions IMPT is safe and feasible for treatment of HCC.
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Affiliation(s)
- Ronik S Bhangoo
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Trey C Mullikin
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Tiffany W Cheng
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | | | - Todd A DeWees
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona.,Department of Health Sciences Research, Mayo Clinic, Scottsdale, Arizona
| | | | - Satomi Shiraishi
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Wei Liu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Yanle Hu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | | | | | - Sunil Krishnan
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - William G Rule
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Terence T Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
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Kowalchuk RO, Lester SC, Graham RP, Harmsen WS, Zhang L, Halfdanarson TR, Smoot RL, Gits HC, Ma WW, Owen D, Mahipal A, Miller RC, Wittich MAN, Cleary SP, McWilliams RR, Haddock MG, Hallemeier CL, Truty MJ, Merrell KW. Predicting Adverse Pathologic Features and Clinical Outcomes of Resectable Pancreas Cancer With Preoperative CA 19-9. Front Oncol 2021; 11:651119. [PMID: 34046346 PMCID: PMC8147692 DOI: 10.3389/fonc.2021.651119] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 04/20/2021] [Indexed: 12/15/2022] Open
Abstract
Background We evaluated preoperative CA 19-9 levels in patients with resected pancreatic cancer to analyze whether they were predictive of clinical outcomes and could help select patients for additional therapy. We hypothesized that elevated CA 19-9 would be associated with worse pathologic findings and oncologic outcomes. Methods This study assessed 509 patients with non-metastatic pancreatic adenocarcinoma who underwent resection at our institution from 1995-2011 and had preoperative CA 19-9 recorded. No patients received neoadjuvant therapy. CA 19-9 level was analyzed as a continuous and a dichotomized (> vs. ≤ 55 U/mL) variable using logistic and Cox models. Results Median follow-up was 7.8 years, and the median age was 66 years (33-90). 64% of patients had elevated preoperative CA 19-9 (median: 141 U/mL), that did not correlate with bilirubin level or tumor size. Most patients had ≥ T3 tumors (72%) and positive lymph nodes (62%). The rate of incomplete (R1 or R2) resection was 19%. Increasing preoperative CA 19-9 was associated with extra-pancreatic extension (p=0.0005), lymphovascular space invasion (p=0.0072), incomplete resection [HR (95% CI) 2.0 (1.2-3.5)], and lower OS [HR = 1.6 (1.3-2.0)]. Each doubling in preoperative CA 19-9 value was associated with an 8.3% increased risk of death [HR = 1.08 (1.02-1.15)] and a 10.0% increased risk of distant recurrence [HR = 1.10 (1.02-1.19)]. Patients classified as non-secretors had comparable outcomes to patients with normal CA 19-9. Conclusions Elevated preoperative CA 19-9 level was associated with adverse pathologic features, incomplete resection, and inferior clinical outcomes. Neither tumor size nor bilirubin confound an elevated CA 19-9 level. Preoperative CA 19-9 level may help select patients for additional therapy.
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Affiliation(s)
- Roman O Kowalchuk
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Scott C Lester
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Rondell P Graham
- Department of Pathology, Mayo Clinic, Rochester, MN, United States
| | | | - Lizhi Zhang
- Department of Pathology, Mayo Clinic, Rochester, MN, United States
| | | | - Rory L Smoot
- Department of Pancreas Surgery, Mayo Clinic, Rochester, MN, United States
| | - Hunter C Gits
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Wen Wee Ma
- Department of Medical Oncology, Mayo Clinic, Rochester, MN, United States
| | - Dawn Owen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Amit Mahipal
- Department of Medical Oncology, Mayo Clinic, Rochester, MN, United States
| | - Robert C Miller
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | | | - Sean P Cleary
- Department of Pancreas Surgery, Mayo Clinic, Rochester, MN, United States
| | | | - Michael G Haddock
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | | | - Mark J Truty
- Department of Pancreas Surgery, Mayo Clinic, Rochester, MN, United States
| | - Kenneth W Merrell
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
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Chin JYL, Martin JA, Hallemeier CL, Haddock MG, Abu Dayyeh BK, Storm AC, Topazian M, Levy MJ, Petersen BT, Chandrasekhara V. Endoscopic techniques and common pitfalls for nasobiliary catheter placement to facilitate delivery of high-dose intraductal brachytherapy in cholangiocarcinoma. VideoGIE 2021; 6:62-66. [PMID: 33884329 PMCID: PMC7859496 DOI: 10.1016/j.vgie.2020.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Jerry Yung-Lun Chin
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - John A Martin
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | | | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Andrew C Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Mark Topazian
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Michael J Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Bret T Petersen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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Jethwa KR, Day CN, Sandhyavenu H, Gonuguntla K, Harmsen WS, Breen WG, Routman DM, Garda AE, Hubbard JM, Halfdanarson TR, Neben-Wittich MA, Merrell KW, Hallemeier CL, Haddock MG. Intensity modulated radiotherapy for anal canal squamous cell carcinoma: A 16-year single institution experience. Clin Transl Radiat Oncol 2021; 28:17-23. [PMID: 33732911 PMCID: PMC7943964 DOI: 10.1016/j.ctro.2021.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 02/01/2021] [Accepted: 02/05/2021] [Indexed: 12/28/2022] Open
Abstract
Introduction To report long-term efficacy and adverse events (AEs) associated with intensity modulated radiotherapy (IMRT) for patients with anal canal squamous cell carcinoma (ASCC). Materials and methods This was a retrospective review of patients with ASCC who received curative-intent IMRT and concurrent chemotherapy (98%) between 2003 and 2019. Overall survival (OS), colostomy-free survival (CFS), and progression-free survival (PFS) were estimated using the Kaplan-Meier method. The cumulative incidence of local recurrence (LR), locoregional recurrence (LRR), and distant metastasis (DM) were reported. Acute and late AEs were recorded per National Cancer Institute Common Terminology Criteria for AEs. Results 127 patients were included. The median patient age was 63 years (interquartile range [IQR] 55-69) and 79% of patients were female. 33% of patients had T3-4 disease and 68% had clinically involved pelvic or inguinal lymph nodes (LNs).The median patient follow-up was 47 months (IQR: 28-89 months). The estimated 4-year OS, CFS, and PFS were 81% (95% confidence interval [CI]: 73%-89%), 77% (95% CI: 68%-86%), and 78% (95% CI: 70%-86%), respectively. The 4-year cumulative incidences of LR, LRR, and DM were 3% (95% CI: 1%-9%), 9% (95% CI: 5%-17%), and 10% (95% CI: 6%-18%), respectively. Overall treatment duration greater than 39 days was associated with an increased risk of LRR (Hazard Ratio [HR]: 5.2, 95% CI: 1.4-19.5, p = 0.015). The most common grade 3+ acute AEs included hematologic (31%), gastrointestinal (GI) (17%), dermatologic (16%), and pain (15%). Grade 3+ late AEs included: GI (3%), genitourinary (GU) (2%), and pain (1%). Current smokers were more likely to experience grade 3+ acute dermatologic toxicity compared to former or never smokers (34% vs. 7%, p < 0.001). Conclusions IMRT was associated with favorable toxicity rates and long-term efficacy. These data support the continued utilization of IMRT as the preferred treatment technique for patients with ASCC.
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Key Words
- 3DCRT, 3-dimensional conformal radiotherapy
- 5-FU, 5-fluorouracil
- ACT II, United Kingdom Anal Cancer Trial II
- AE, adverse events
- ASCC, anal canal squamous cell carcinoma
- Anal cancer
- BED, biologically effective dose
- CFS, colostomy-free survival
- CI, confidence interval
- CRT, chemoradiotherapy
- CTCAE v 4.0, common terminology criteria for adverse events version 4.0
- CTV, clinical target volume
- DM, distant metastasis
- DP-IMRT, dose-painted intensity modulated radiotherapy
- DVH, dose-volume histogram
- G, grade
- GI, gastrointestinal
- GU, genitourinary
- HIV, human immunodeficiency virus
- HR, hazard ratio
- IMRT
- IMRT, intensity modulated radiotherapy
- IQR, interquartile range
- LN, lymph node
- LR, local recurrence
- LRR, locoregional recurrence
- MMC, mitomycin-C
- OS, overall survival
- PFS, progression-free survival
- PTV, planning target volume
- RT, radiotherapy
- RTOG, Radiation Therapy Oncology Group
- Radiation
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Affiliation(s)
- Krishan R Jethwa
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States.,Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, United States
| | - Courtney N Day
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, United States
| | | | - Karthik Gonuguntla
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - William S Harmsen
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, United States
| | - William G Breen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - David M Routman
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Allison E Garda
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Joleen M Hubbard
- Department of Medical Oncology, Mayo Clinic, Rochester, MN, United States
| | | | | | - Kenneth W Merrell
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | | | - Michael G Haddock
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
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Jeans EB, Breen WG, Mullikin TC, Looker BA, Mariani A, Keeney GL, Haddock MG, Petersen IA. Adjuvant brachytherapy for FIGO stage I serous or clear cell endometrial cancer. Int J Gynecol Cancer 2021; 31:859-867. [PMID: 33563642 PMCID: PMC8223628 DOI: 10.1136/ijgc-2020-002217] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/15/2021] [Accepted: 01/21/2021] [Indexed: 11/17/2022] Open
Abstract
Objectives Optimal adjuvant treatment for early-stage clear cell and serous endometrial cancer remains unclear. We report outcomes for women with surgically staged International Federation of Gynecology and Obstetrics (FIGO) stage I clear cell, serous, and mixed endometrial cancers following adjuvant vaginal cuff brachytherapy with or without chemotherapy. Methods From April 1998 to January 2020, women with FIGO stage IA–IB clear cell, serous, and mixed endometrial cancer underwent surgery and adjuvant vaginal cuff brachytherapy. Seventy-six patients received chemotherapy. High-dose rate vaginal cuff brachytherapy was planned to a total dose of 21 gray in three fractions using a multichannel vaginal cylinder. The primary objective was to determine the effectiveness of adjuvant vaginal cuff brachytherapy and to identify surgicopathological risk factors that could portend towards worse oncological outcomes. Results A total of 182 patients were included in the analysis. Median follow-up was 5.3 years (2.3–12.2). Ten-year survival was 73.3%. Five-year cumulative incidence (CI) of vaginal, pelvic, and para-aortic relapse was 1.4%, 2.1%, and 0.9%, respectively. Five-year locoregional failure, any recurrence, peritoneal relapse, and other distant recurrence was 4.4%, 11.6%, 5.3%, and 6.7%, respectively. On univariate analysis, locoregional failure was worse for larger tumors (per 1 cm) (HR 1.9, 95% CI 1.2 to 3.0, p≤0.01). Any recurrence was worse for tumors of at least 3.5 cm (HR 3.8, 95% CI 1.3 to 11.7, p=0.02) and patients with positive/suspicious cytology (HR 4.4, 95% CI 1.5 to 12.4, p≤0.01). Ten-year survival for tumors of at least 3.5 cm was 56.9% versus 86.6% for those with smaller tumors (HR 2.9, 95% CI 1.4 to 5.8, p≤0.01). Ten-year survival for positive/suspicious cytology was 50.9% versus 77.4% (HR 2.2, 95% CI 0.9 to 5.4, p=0.09). Multivariate modeling demonstrated worse locoregional failure, any recurrence, and survival with larger tumors, as well as any recurrence with positive/suspicious cytology. Subgroup analysis demonstrated improved outcomes with the use of adjuvant chemotherapy in patients with large tumors or positive/suspicious cytology. Conclusion Adjuvant vaginal cuff brachytherapy alone without chemotherapy is an appropriate treatment for women with negative peritoneal cytology and small, early-stage clear cell, serous, and mixed endometrial cancer. Larger tumors or positive/suspicious cytology are at increased risk for relapse and worse survival, and should be considered for additional upfront adjuvant treatments, such as platinum-based chemotherapy.
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Affiliation(s)
- Elizabeth B Jeans
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - William G Breen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Trey C Mullikin
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Brittany A Looker
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrea Mariani
- Department of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Gary L Keeney
- Department of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael G Haddock
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ivy A Petersen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
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Feng Y, Sanhueza Condell CT, Hallemeier CL, Blackmon SH, Hubbard JM, Halfdanarson TR, Hobday TJ, Cassivi SD, Shen R, Neben-Wittich MA, Nichols FC, Merrell K, Blanco EW, McWilliams RR, Alberts SR, Pitot HC, Jatoi A, Haddock MG, Wigle DA, Yoon HH. HER2-overexpression/amplification and survival in patients with resectable esophageal/gastroesophageal junction adenocarcinoma (E/GEJ-AC) treated with neoadjuvant carboplatin/paclitaxel-based chemoradiation. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.3_suppl.239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
239 Background: After trastuzumab (T) approval for advanced HER2-positive E/GEJ-AC, HER2 testing has increased in patients (pts) with resectable disease. Neoadjuvant carboplatin/paclitaxel chemoradiation (nCP-CRT) is a common therapy approach. We performed the largest evaluation, to our knowledge, of the prognostic impact of HER2 in E/GEJ-AC pts treated with nCP-CRT. Methods: We retrospectively reviewed medical records of all trimodality-eligible (T2+ or N+) pts with E/GEJ-AC who started nCP-CRT (usually 50.4 Gy) with planned surgery at Mayo Clinic (2014-2019). HER2 was tested using standard criteria for HER2 positivity (ie, immunohistochemistry 3+ or amplification by in situ hybridization). Clinicopathologic data and time to recurrence (TTR), disease free survival (DFS), overall survival (OS), survival after recurrence (SAR), and pathologic complete response (pCR – ie, no residual tumor in primary or nodes) were collected. Kaplan Meier and multivariate Cox analysis were used. Results: Of 161 consecutive eligible pts, HER2 status was available in 107 pts (HER2-positive n=26, HER2-negative n=81) of whom n=82 had surgery and n=19 had pCR. Most tumors were clinical T3 (80%) or N+ (81%), histologic grade 3 of 3 (62%). HER2 positivity was significantly associated with lower grade, but not with age, clinical T or N, or ECOG performance status (PS). A similar proportion of HER2-positive ( vs negative) pts had surgery. Among pts who had surgery, pCR rates were lower in HER2-positive ( vs negative) pts (11% [2/19] vs 27% [17/63]). After a median follow up of 23 mo, DFS and TTR were significantly shorter in HER2 positive ( vs negative) pts, independent of other pretreatment covariables (Table). Yet OS was comparable. Lung recurrence was enriched in HER2 positive ( vs negative) pts. Among pts with recurrence, SAR was longer in HER2-positive vs -negative pts. A total of 53% (10/19) of previously HER2-positive pts received T-based therapy after recurrence, and these pts were the drivers of favorable SAR (median 22 mo in n=10 HER2-positive pts who received T vs 11 mo in n=9 HER2-positive pts who did not receive T vs 11 mo in n=40 HER2-negative pts; P log-rank=.01). Conclusions: HER2 positivity ( vs negativity) is independently associated with shorter TTR and DFS, but more comparable OS. The adverse association of HER2 on tumor response and TTR may have been largely overcome through enhanced survival after recurrence, although OS data are maturing. These data may have implications for the design of endpoints in future curative-intent anti-HER2 trials. [Table: see text]
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Kenneth Merrell
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | | | | | | | - Henry C. Pitot
- Division of Medical Oncology, Mayo Clinic, Rochester, MN
| | - Aminah Jatoi
- Division of Medical Oncology, Mayo Clinic, Rochester, MN
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Jethwa KR, Sannapaneni S, Mullikin TC, Harmsen WS, Petersen MM, Antharam P, Laughlin B, Mahipal A, Halfdanarson TR, Merrell KW, Neben-Wittich M, Sio TT, Haddock MG, Hallemeier CL. Chemoradiotherapy for patients with locally advanced or unresectable extra-hepatic biliary cancer. J Gastrointest Oncol 2021; 11:1408-1420. [PMID: 33457010 DOI: 10.21037/jgo-20-245] [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] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Although surgical resection is the preferred curative-intent treatment option for patients with non-metastatic, extra-hepatic biliary cancer (EBC), radiotherapy (RT) or chemoradiotherapy (CRT) may be utilized in select cases when surgical resection is not feasible. The purpose of this study is to report the efficacy and adverse events (AEs) associated with CRT for patients with locally advanced and unresectable EBC. Methods This was a retrospective cohort study of patients with EBC, including extra-hepatic cholangiocarcinoma or gallbladder cancer, deemed inoperable who received RT between 1998 and 2018. The median RT dose was 50.4 Gy in 28 fractions and 94% received concurrent 5-fluorouracil. The Kaplan-Meier method was used to estimate overall survival (OS) and progression-free survival (PFS) from the start of RT. The cumulative incidence of local progression (LP), locoregional progression (LRP), and distant metastasis (DM) were reported with death as a competing risk. Cox proportional hazards regression models were used to assess for correlation between patient and treatment characteristics and outcomes. Results Forty-eight patients were included for analysis. The median OS was 12.0 months [95% confidence interval (CI): 2.3-73.2 months]. The 2-, 3-, and 5-year OS were 33% (95% CI: 22-50%), 20% (95% CI: 11-36%), and 7% (95% CI: 2-20%), respectively. The 2-year PFS, LP, LRP, and DM were 21% (95% CI: 12-36%), 27% (95% CI: 17-44%), 31% (95% CI: 20-48%), and 33% (95% CI: 22-50%), respectively. On univariate analysis, biologically effective dose (BED) >59.5 Gy10 was associated with improved OS [hazard ratio (HR): 0.40, 95% CI: 0.18-0.92, P=0.03] and PFS (HR: 0.37, 95% CI: 0.16-0.84, P=0.02) and primary tumor size (per 1 cm increase) was associated with worsened PFS (HR: 1.29, 95% CI: 1.02-1.63, P=0.04). BED >59.5 Gy10 remained associated with PFS on multivariate analysis (HR: 0.34, 95% CI: 0.15-0.78, P=0.01). Treatment-related grade 3+ acute and late gastrointestinal AEs occurred in 13% and 17% of patients, respectively. Conclusions RT is associated with 3- and 5-year survival in a subset of patients with unresectable EBC. Further exploration of the role of RT as part of a multi-modality curative treatment strategy is warranted.
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Affiliation(s)
- Krishan R Jethwa
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA.,Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Shilpa Sannapaneni
- Department of Internal Medicine, Texas Health Presbyterian Hospital, Dallas, TX, USA
| | - Trey C Mullikin
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - William S Harmsen
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Molly M Petersen
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | | | - Brady Laughlin
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Amit Mahipal
- Department of Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Terence T Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
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Abstract
The majority of esophageal cancer patients are diagnosed with locoregionally confined disease, which is often amenable to curative intent therapy. Chemoradiotherapy (CRT) improves overall survival (OS) in stage II and III esophagus cancer in the neoadjuvant and definitive settings. Due to the close proximity of organs at risk (OARs), including lungs, heart, stomach, bowel, kidneys, and spinal cord, esophageal CRT can result in profound acute and late toxicities. Acute toxicities can include esophagitis, nausea, vomiting, fatigue, and cytopenias. Late complications may also occur months or years after completion of thoracic radiotherapy, including significant cardiac, pulmonary, liver, kidney, or bowel toxicities, which can be life-threatening or fatal. Photon-based radiotherapy exposes OARs to significant doses of radiation, whereas proton beam therapy (PBT) has unique physical properties, as it lacks an exit dose. This allows PBT to deliver, a more conformal dose to the target and minimize the volume of OARs exposed to radiation. This dosimetric advantage may portend an increased therapeutic ratio of CRT for esophagus cancer. The objective of this review is to discuss the evolution of photon and proton-based radiotherapy techniques, rationale, dosimetric and clinical studies comparing outcomes of photon- and proton-based techniques, ongoing prospective trials, and future directions of PBT as a means of reducing toxicity and improving oncologic outcomes for patients with esophagus cancer.
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Affiliation(s)
| | - Krishan R Jethwa
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | | | - Jonathan B Ashman
- Department of Radiation Oncology, Mayo Clinic, Phoenix/Scottsdale, AZ, USA
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Grams MP, Owen D, Park SS, Petersen IA, Haddock MG, Jeans EB, Finley RR, Ma DJ. VMAT Grid Therapy: A Widely Applicable Planning Approach. Pract Radiat Oncol 2020; 11:e339-e347. [PMID: 33130318 DOI: 10.1016/j.prro.2020.10.007] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 09/26/2020] [Accepted: 10/01/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To describe a novel and practical volumetric modulated arc therapy (VMAT) planning approach for grid therapy. METHODS AND MATERIALS Dose is prescribed to 1.5-cm diameter spherical contours placed throughout the gross tumor volume (GTV). Placement of spheres is variable, but they must maintain at least a 3-cm (center to center) separation, and the edge of any sphere must be at least 1 cm from any organ at risk (OAR). Three concentric ring structures are used during optimization to confine the highest doses to the center of the spheres and maximize dose sparing between them. The end result is alternating regions of high and low dose throughout the GTV and minimal dose to OARs. High-intensity flattening filter-free (FFF) modes are used to efficiently deliver the plans, and entire treatments typically take only 15 to 20 minutes. RESULTS The approach is illustrated with 2 examples treated at our institution. Patient #1 had a 1703-cm3 mediastinal mass and was prescribed 20 Gray (Gy) to 24 spherical regions within the GTV. Patient #2 had a 3680-cm3 abdominal tumor and was prescribed 18 Gy to 32 spherical regions within the GTV. Both patients received additional consolidative radiation approximately 1 week after the initial VMAT grid treatment. Each patient experienced marked reduction in tumor size and symptomatic relief without treatment-related complications. CONCLUSIONS We have described in detail a planning approach for VMAT grid therapy treatments that can typically be delivered in a clinically practical time span. The VMAT approach is especially useful for tumors that are surrounded by sensitive critical structures. As many centers offer VMAT treatments, the approach is widely accessible and can be readily implemented once appropriate patient selection and delivery processes are established.
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Affiliation(s)
- Michael P Grams
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota.
| | - Dawn Owen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Ivy A Petersen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | | | - Randi R Finley
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Daniel J Ma
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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Deng W, Jethwa KR, Gonuguntla K, Liao Z, Yoon HH, Murphy MB, Haddock MG, Hallemeier CL, Lin SH. Multi-institutional Evaluation of Curative Intent Chemoradiotherapy for Patients With Clinical T1N0 Esophageal Adenocarcinoma. Adv Radiat Oncol 2020; 5:951-958. [PMID: 33083658 PMCID: PMC7557140 DOI: 10.1016/j.adro.2020.03.020] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 12/04/2019] [Accepted: 03/31/2020] [Indexed: 02/07/2023] Open
Abstract
Purpose To evaluate the safety and efficacy of definitive chemoradiotherapy (CRT) for patients with clinical T1N0M0 esophageal adenocarcinoma. Methods and Materials This was a retrospective study of patients with clinical T1N0 adenocarcinoma of the esophagus treated with curative-intent CRT between 2004 and 2017 at 2 tertiary care centers. Patients received CRT instead of esophagectomy owing to medical comorbidities or patient preference. Toxicities were evaluated according to Common Terminology Criteria for Adverse Events version 4.03. The Kaplan-Meier method was used to estimate overall, progression-free, and disease-specific survivals. Results Twenty-eight patients were included for analysis. Median age was 76 years (range 55-90). The majority of patients were male (93%) and had a history of Barrett’s esophagus (71%). Tumor characteristics included distal esophagus location (93%), clinical stage T1b (86%), and median length of 2 cm (range, 1-9). Prior endoscopic resection was performed in 57%. The median follow-up was 44 months (range, 4-146). The acute grade 3 adverse events were observed in 7 patients (25%). One patient died of complications potentially related to chemoradiation. Eight patients (29%) had disease progression at a median of 7.6 months after CRT. First site of progression was local only (14%), local and regional (11%), or distant (4%). Salvage locally directed treatment was performed in 3 of 4 patients with local-only recurrence. The 3-year overall survival, progression-free, and disease-specific rates were 78%, 62%, and 81%, respectively. Conclusion CRT is a safe and effective curative treatment strategy for select patients with clinical T1N0M0 esophageal adenocarcinoma.
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Affiliation(s)
- Wei Deng
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing, China
| | - Krishan R Jethwa
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Harry H Yoon
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota
| | - Mariela Blum Murphy
- Department of Gastrointestinal Medical Oncology, MD Anderson Cancer Center, Houston, Texas
| | | | | | - Steven H Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Garda AE, Navin PJ, Merrell KW, Martenson JA, Neben Wittich MA, Haddock MG, Sio TT, Rule WG, Ashman JB, Sheedy SP, Hallemeier CL. Patterns of inguinal lymph node metastases in anal canal cancer and recommendations for elective clinical target volume (CTV) delineation. Radiother Oncol 2020; 149:128-133. [DOI: 10.1016/j.radonc.2020.05.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 04/02/2020] [Accepted: 05/11/2020] [Indexed: 10/24/2022]
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Deisher AJ, Whitaker TJ, Beltran CJ, Foote RL, Haddock MG, Mahajan A. Technical Delivery Parameters of 2000 Proton Treatment Courses. Int J Part Ther 2020; 6:27-34. [PMID: 32582812 DOI: 10.14338/ijpt-19-00066.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 01/07/2020] [Indexed: 11/21/2022] Open
Abstract
Purpose To summarize the technical delivery parameters of proton plans delivered at the Mayo Clinic in Rochester, Minnesota. Materials and Methods The database of treated patient proton plans was queried to extract field parameters such as gantry angle, patient support angle, minimum and maximum water-equivalent depth (WED) treated, number of layers, field size, patient orientation, and monitor units. The plans were analyzed in aggregate, by disease site, and by fractionation. Results There were 2963 proton plans for 2023 distinct treatment sites delivered between June 2015 and September 2018. The mean number of fields per plan was 2.8. The mean number of energy layers per field was 51.9. The mean monitor unit per field was 117.4. The median maximum field dimension was 12.4 cm; 95% of the fields had a maximum dimension < 28.7 cm, and the maximum field dimension was 39.8 cm. The median maximum field WED was 16.4 cm; 95% of the fields reached a maximum WED of ≤ 26.4 cm, and the maximum field WED was 32.4 cm. Conclusion A large variety of disease sites were treated using the maximum field size (40 cm) and WED (32.4 cm) capabilities of our half-gantry system.
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Affiliation(s)
- Amanda J Deisher
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | | | - Chris J Beltran
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Robert L Foote
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | | | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
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Jeans EB, Jethwa KR, Harmsen WS, Neben-Wittich M, Ashman JB, Merrell KW, Giffey B, Ito S, Kazemba B, Beltran C, Haddock MG, Hallemeier CL. Clinical Implementation of Preoperative Short-Course Pencil Beam Scanning Proton Therapy for Patients With Rectal Cancer. Adv Radiat Oncol 2020; 5:865-870. [PMID: 33083648 PMCID: PMC7557137 DOI: 10.1016/j.adro.2020.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 12/19/2019] [Revised: 03/27/2020] [Accepted: 05/01/2020] [Indexed: 01/03/2023] Open
Abstract
Purpose For treatment of rectal cancer, pencil beam scanning proton therapy (PBS-PT) may reduce radiation exposure to normal tissues compared with 3-dimensional conformal photon radiation therapy (3DCRT) or volumetric modulated arc photon radiation therapy (VMAT). The purpose of this study was to report the clinical implementation and dosimetric analysis of preoperative short-course PBS-PT for rectal cancer. Methods and Materials Eleven patients with stage IIA-IVB rectal cancer received preoperative short-course (25 Gy in 5 fx) PBS-PT between 2018 and 2019 preceding curative-intent total mesorectal excision. PBS-PT plans were generated using single-field optimization with 2 posterior-oblique fields. Verification computed tomography scans were performed on the first 3 days of treatment. Each patient had a backup 3DCRT and VMAT plan. Results Clinical target volume coverage was similar between PBS-PT, 3DCRT, and VMAT. PBS-PT had statistically significant reductions in dose to the small bowel, large bowel, bladder, and femoral heads across multiple dosimetric parameters. All patients completed PBS-PT as planned without need for replanning. All computed tomography verification scans demonstrated good target coverage with clinical target volume V100 > 95%. Conclusions Preoperative short-course PBS-PT has been successfully implemented and offers a significant reduction of dose to normal tissues. Prospective studies are warranted to evaluate if dosimetric advantages translate into clinical benefit.
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Affiliation(s)
| | - Krishan R. Jethwa
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut
| | | | | | | | | | - Broc Giffey
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Shima Ito
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Bret Kazemba
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Chris Beltran
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Christopher L. Hallemeier
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
- Corresponding author: Christopher L. Hallemeier, MD
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Safran H, Winter KA, Wigle DA, DiPetrillo TA, Haddock MG, Hong TS, Leichman LP, Rajdev L, Resnick MB, Kachnic LA, Seaward SA, Mamon HJ, Diaz Pardo DA, Anderson CM, Shen X, Sharma AK, Katz AW, Salo JC, Leonard KL, Crane CH. Trastuzumab with trimodality treatment for esophageal adenocarcinoma with HER2 overexpression: NRG Oncology/RTOG 1010. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.4500] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
4500 Background: Trastuzumab is a monoclonal antibody against human epidermal growth factor receptor 2 (HER2). The primary objective of RTOG 1010 was to determine if trastuzumab increases disease-free survival (DFS) when combined with trimodality treatment for patients with HER2 overexpressing esophageal adenocarcinoma. Methods: This open label, randomized phase III trial included patients with newly diagnosed stage T1N1-2, T2-3N0-2 adenocarcinoma of the esophagus involving the mid, distal, or esophagogastric junction and up to 5cm of the stomach. All patients received chemotherapy (C) of paclitaxel, 50mg/m2 and carboplatin AUC = 2, weekly for 6 weeks, with radiation (XRT: 3D-CRT or IMRT, 50.4 Gy in 28 fractions) followed by surgery. Patients were randomized 1:1 to receive weekly trastuzumab 4mg/kg week 1 then 2mg/kg/weekly x 5 during CXRT then 6 mg/kg for 1 dose prior to surgery and 6mg/kg every 3 weeks for 13 treatments after surgery. HER2 status was determined by IHC and gene amplification by FISH. With a 2-sided alpha of 0.05, 162 DFS events provide 90% power to detect a signal for an increase in median DFS from 15 to 25 months. DFS and overall survival (OS) were estimated by the Kaplan-Meier method. and arms were compared using the log rank test. The Cox proportional hazards model was used to analyze treatment effect. Results: 571 patients were entered for assessment of HER2 expression, 203 HER2+ patients randomized. The median follow-up for alive patients is 5.0 years. The estimated 2, 3, and 4-year DFS (95% CI) for the CXRT +trastuzumab arm were 41.8% (31.8%, 51.7%), 34.3% (24.7%, 43.9%), and 33.1% (23.6%, 42.7%), respectively, and for the CXRT arm were 40.0% (30.0%, 49.9%), 33.4% (23.8%, 43.0%), and 30.1% (20.7%, 39.4%), respectively; log-rank p = 0.85. The median DFS time is 19.6 months (13.5-26.2) for the CXRT +trastuzumab arm compared to 14.2 months (10.5-23.0) for the CXRT arm. The hazard ratio (95% CI) comparing the DFS of CXRT+trastuzumab arm to the CXRT arm was 0.97 (0.69, 1.36). The median OS time was 38.5 months (26.2-70.4) for the CXRT+trastuzumab arm compared to 38.9 months (29.0-64.5) for the CXRT arm, hazard ratio (95% CI): 1.01 (0.69, 1.47). There was no statistically significant increase in treatment-related toxicities with the addition of trastuzumab including no increase in cardiac events. Conclusions: The addition of trastuzumab to trimodality treatment did not improve DFS for patients with HER2 overexpressing esophageal adenocarcinoma. Supported by NCI grants U10CA180868, UG1CA189867, U10CA180822 and Genentech. Clinical trial information: NCT01196390 .
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Affiliation(s)
- Howard Safran
- Brown University Oncology Research Group, Providence, RI
| | - Kathryn A. Winter
- Statistical Center, Radiation Therapy Oncology Group, Philadelphia, PA
| | | | | | | | - Theodore S. Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
| | | | - Lakshmi Rajdev
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | | | | | | | | | | | | | - Xinglei Shen
- University of Kansas Cancer Center, Westwood, KS
| | | | - Alan W. Katz
- University of Rochester, James P. Wilmot Cancer Institute, Rochester, NY
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Abrams RA, Winter KA, Safran H, Goodman KA, Regine WF, Berger AC, Gillin MT, Philip PA, Lowy AM, Wu A, DiPetrillo TA, Corn BW, Seaward SA, Haddock MG, Song S, Jiang Y, Fisher BJ, Katz AW, Mehta S, Willett CG, Crane CH. Results of the NRG Oncology/RTOG 0848 Adjuvant Chemotherapy Question-Erlotinib+Gemcitabine for Resected Cancer of the Pancreatic Head: A Phase II Randomized Clinical Trial. Am J Clin Oncol 2020; 43:173-179. [PMID: 31985516 PMCID: PMC7280743 DOI: 10.1097/coc.0000000000000633] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [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] [Indexed: 01/10/2023]
Abstract
PURPOSE NRG/RTOG 0848 was designed to determine whether adjuvant radiation with fluoropyrimidine sensitization improved survival following gemcitabine-based adjuvant chemotherapy for patients with resected pancreatic head adenocarcinoma. In step 1 of this protocol, patients were randomized to adjuvant gemcitabine versus the combination of gemcitabine and erlotinib. This manuscript reports the final analysis of these step 1 data. METHODS Eligibility-within 10 weeks of curative intent pancreaticoduodenectomy with postoperative CA19-9<180. Gemcitabine arm-6 cycles of gemcitabine. Gemcitabine+erlotinib arm-gemcitabine and erlotinib 100 mg/d. Two hundred deaths provided 90% power (1-sided α=0.15) to detect the hypothesized OS signal (hazard ratio=0.72) in favor of the arm 2. RESULTS From November 17, 2009 to February 28, 2014, 163 patients were randomized and evaluable for arm 1 and 159 for arm 2. Median age was 63 (39 to 86) years. CA19-9 ≤90 in 93%. Arm 1: 32 patients (20%) grade 4 and 2 (1%) grade 5 adverse events; arm 2, 27 (17%) grade 4 and 3 (2%) grade 5. GI adverse events, arm 1: 22% grade ≥3 and arm 2: 28%, (P=0.22). The median follow-up (surviving patients) was 42.5 months (min-max: <1 to 75). With 203 deaths, the median and 3-year OS (95% confidence interval) are 29.9 months (21.7, 33.4) and 39% (30, 45) for arm 1 and 28.1 months (20.7, 30.9) and 39% (31, 47) for arm 2 (log-rank P=0.62). Hazard ratio (95% confidence interval) comparing OS of arm 2 to arm 1 is 1.04 (0.79, 1.38). CONCLUSIONS The addition of adjuvant erlotinib to gemcitabine did not provide a signal for increased OS in this trial.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Benjamin W. Corn
- Tel Aviv Sourasky Medical Center (at time work was completed); Shaare Zedek Medical Center (current)
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Jethwa KR, Jang S, Mullikin TC, Harmsen WS, Petersen MM, Olivier KR, Park SS, Neben-Wittich MA, Hubbard JM, Sandhyavenu H, Whitaker TJ, Waltman LA, Kipp BR, Merrell KW, Haddock MG, Hallemeier CL. Association of tumor genomic factors and efficacy for metastasis-directed stereotactic body radiotherapy for oligometastatic colorectal cancer. Radiother Oncol 2020; 146:29-36. [PMID: 32114263 DOI: 10.1016/j.radonc.2020.02.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 02/07/2020] [Accepted: 02/09/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE/OBJECTIVE(S) To report tumor genomic factors associated with overall survival (OS) and local failure (LF) for patients with colorectal cancer (CRC) who received metastasis-directed stereotactic body radiation therapy (SBRT). MATERIALS/METHODS This was a retrospective review of patients with CRC who received metastasis-directed SBRT. Tumor genomic alterations were identified through KRAS, BRAF, or a 50-gene next generation sequencing panel. OS and LF were estimated using Kaplan-Meier and competing-risk methods. RESULTS Eighty-five patients and 109 lesions were treated between 2008 and 2018. The median patient follow-up was 50 months (IQR: 28-107). The median and 5-year OS was 34 months and 26% (95% CI: 16-41%), respectively. The 2-year cumulative incidence of LF was 30% (95% CI: 23-41%). Univariate associates with OS included patient age ≥60 years, bone metastasis, increasing tumor size, KRAS mutation, and combined KRAS and TP53 mutation, while increasing tumor size, bone metastasis, biologically effective dose <100 Gy, and combined KRAS and TP53 mutation were associated with LF. Multivariate associates with OS included patient age ≥60 years (HR: 2.4, 95% CI: 1.2-4.8, p = 0.01), lesion size per 1 cm (HR: 1.3, 95% CI: 1.1-1.5, p < 0.01), and KRAS mutation (HR: 2.2, 95% CI: 1.2-4.3, p < 0.01), while no multivariable model for LF retained more than a single variable. CONCLUSION Genomic factors, in particular KRAS and TP53 mutation, may assist in patient selection and radiotherapeutic decision-making for patients with oligometastatic CRC. Prospective validation, ideally with genomic correlation of all irradiated metastases, is warranted.
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Affiliation(s)
- Krishan R Jethwa
- Department of Radiation Oncology, Mayo Clinic, Rochester, United States; Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, United States
| | - Samuel Jang
- Department of Radiation Oncology, Mayo Clinic, Rochester, United States
| | - Trey C Mullikin
- Department of Radiation Oncology, Mayo Clinic, Rochester, United States
| | - William S Harmsen
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, United States
| | - Molly M Petersen
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, United States
| | - Kenneth R Olivier
- Department of Radiation Oncology, Mayo Clinic, Rochester, United States
| | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, United States
| | | | - Joleen M Hubbard
- Division of Medical Oncology, Mayo Clinic, Rochester, United States
| | | | - Thomas J Whitaker
- Department of Radiation Oncology, Mayo Clinic, Rochester, United States
| | - Lindsey A Waltman
- Department of Laboratory Medicine and pathology, Mayo Clinic, Rochester, United States
| | - Benjamin R Kipp
- Department of Laboratory Medicine and pathology, Mayo Clinic, Rochester, United States
| | - Kenneth W Merrell
- Department of Radiation Oncology, Mayo Clinic, Rochester, United States
| | - Michael G Haddock
- Department of Radiation Oncology, Mayo Clinic, Rochester, United States
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Jethwa KR, Haddock MG, Tryggestad EJ, Hallemeier CL. The emerging role of proton therapy for esophagus cancer. J Gastrointest Oncol 2020; 11:144-156. [PMID: 32175118 PMCID: PMC7052753 DOI: 10.21037/jgo.2019.11.04] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 11/19/2019] [Indexed: 11/06/2022] Open
Abstract
Chemoradiotherapy (CRT) plays an essential role in the treatment of esophageal cancer as either curative or neoadjuvant therapy. When delivered with conventional photon-based techniques, multiple adjacent organs at risk including the heart, lungs, kidneys, liver, stomach, and bowel, receive considerable radiation dose which may contribute to acute and late adverse events (AEs). Proton beam therapy (PBT) offers a reduction in radiation exposure to these organs and potentially an improvement in the therapeutic ratio. Herein we discuss the emerging role of PBT for esophageal cancer, including rationale, treatment planning, early dosimetric and clinical comparisons of PBT with photon-based techniques, ongoing prospective trials, and potential areas of opportunity for the incorporation of PBT with the goal of improving outcomes for patients with esophageal cancer.
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Affiliation(s)
- Krishan R. Jethwa
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
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Hallemeier CL, Ashman JB, Haddock MG. A brief overview of the use of proton beam radiotherapy for gastrointestinal cancers. J Gastrointest Oncol 2020; 11:139-143. [DOI: 10.21037/jgo.2019.07.06] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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47
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Garda AE, Sheedy SP, Haddock MG, Hallemeier CL. Cystic Lymph Node Metastases From HPV-Associated Squamous Cell Carcinoma of the Anal Canal. Pract Radiat Oncol 2019; 10:e111-e115. [PMID: 31866578 DOI: 10.1016/j.prro.2019.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 11/20/2019] [Accepted: 12/11/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Allison E Garda
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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48
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Reyngold M, Winter KA, Regine WF, Abrams RA, Safran H, Hoffman JP, Mowat RB, Hayes JP, Kessel IL, DiPetrillo T, Narayan S, Chen Y, Ben-Josef E, Delouya G, Suh JH, Meyer J, Haddock MG, Feldman M, Gaur R, Yost K, Peterson RA, Sherr DL, Moughan J, Crane CH. Marital Status and Overall Survival in Patients with Resectable Pancreatic Cancer: Results of an Ancillary Analysis of NRG Oncology/RTOG 9704. Oncologist 2019; 25:e477-e483. [PMID: 32162826 DOI: 10.1634/theoncologist.2019-0562] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [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: 07/24/2019] [Accepted: 10/23/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Several registry-based analyses suggested a survival advantage for married versus single patients with pancreatic cancer. The mechanisms underlying the association of marital status and survival are likely multiple and complex and, therefore, may be obscured in analyses generated from large population-based databases. The goal of this research was to characterize this potential association of marital status with outcomes in patients with resected pancreatic cancer who underwent combined modality adjuvant therapy on a prospective clinical trial. MATERIALS AND METHODS This is an ancillary analysis of 367 patients with known marital status treated on NRG Oncology/RTOG 97-04. Survival analysis was performed using the Kaplan-Meier method and compared using the log-rank test. Multivariate analysis was performed using the Cox proportional hazards regression model. RESULTS Of 367 patients, 271 (74%) were married or partnered and 96 (26%) were single. Married or partnered patients were more likely to be male. There was no association between marital status and overall survival (OS) or disease-free survival (DFS) on univariate (hazard ratio [HR], 1.09 and 1.01, respectively) or multivariate analyses (HR, 1.05 and 0.98, respectively). Married or partnered male patients did not have improved survival compared with female or single patients. CONCLUSION Ancillary analysis of data from NRG Oncology/RTOG 97-04 demonstrated no association between marital and/or partner status and OS or DFS in patients with resected pancreatic cancer who received adjuvant postoperative chemotherapy followed by concurrent external beam radiation therapy and chemotherapy. Clinical trial identification number. NCT00003216. IMPLICATIONS FOR PRACTICE Several population-based studies have shown an epidemiological link between marital status and survival in patients with pancreatic cancer. A better understanding of this association could offer an opportunity to improve outcomes through psychosocial interventions designed to mitigate the negative effects of not being married. Based on the results of this analysis, patients who have undergone a resection and are receiving adjuvant therapy on a clinical trial are unlikely to benefit from such interventions. Further efforts to study the association between marital status and survival should be focused on less selected subgroups of patients with pancreatic cancer.
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Affiliation(s)
- Marsha Reyngold
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Kathryn A Winter
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania, USA
| | - William F Regine
- University of Maryland Marlene and Stewart Greenebaum Cancer Center, Baltimore, Maryland, USA
| | - Ross A Abrams
- Rush University Medical Center, Chicago, Illinois, USA
| | - Howard Safran
- Rhode Island Hospital, Providence, Rhode Island, USA
| | - John P Hoffman
- Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - Rex B Mowat
- Toledo Community Hospital Oncology Program, Community Clinical Oncology Program, Toledo, Ohio, USA
| | - John P Hayes
- Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Ivan L Kessel
- University of Texas Medical Branch, Galveston, Texas, USA
| | | | - Samir Narayan
- Michigan Cancer Research Consortium, Grand Rapid, Michigan, USA
| | | | - Edgar Ben-Josef
- University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, USA
| | - Guila Delouya
- Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - John H Suh
- Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Joshua Meyer
- Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | | | | | - Rakesh Gaur
- Kansas City Community Clinical Oncology Program, Prairie Village, Kansas, USA
| | - Kathleen Yost
- Grand Rapids Community Clinical Oncology Program, Grand Rapids, Michigan, USA
| | | | - David L Sherr
- The Brooklyn Hospital Center, New York, New York, USA
| | - Jennifer Moughan
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania, USA
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Garant A, Whitaker TJ, Spears GM, Routman DM, Harmsen WS, Wilhite TJ, Ashman JB, Sio TT, Rule WG, Neben Wittich MA, Martenson JA, Tryggestad EJ, Yoon HH, Blackmon S, Merrell KW, Haddock MG, Hallemeier CL. A Comparison of Patient-Reported Health-Related Quality of Life During Proton Versus Photon Chemoradiation Therapy for Esophageal Cancer. Pract Radiat Oncol 2019; 9:410-417. [DOI: 10.1016/j.prro.2019.07.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 07/01/2019] [Accepted: 07/02/2019] [Indexed: 12/17/2022]
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Deufel CL, Tian S, Yan BB, Vaishnav BD, Haddock MG, Petersen IA. Automated applicator digitization for high-dose-rate cervix brachytherapy using image thresholding and density-based clustering. Brachytherapy 2019; 19:111-118. [PMID: 31594729 DOI: 10.1016/j.brachy.2019.09.002] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 08/13/2019] [Accepted: 09/09/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE The purpose of the study was to develop and evaluate an automated digitization algorithm for high-dose-rate cervix brachytherapy, with the goal of reducing the duration of treatment planning, staff resources, variability, and potential for human error. METHODS An automated digitization algorithm was developed and retrospectively evaluated using treatment planning data from 10 patients with cervix cancer who were treated with a titanium tandem and ovoids applicator set. Applicators were segmented, without human interaction, by thresholding CT images to isolate high-density voxels and assigning the voxels to applicator and nonapplicator structures using HDBSCAN, a density-based linkage clustering algorithm. The applicator contours were determined from the centroid of the clustered voxels on each image slice and written to a treatment plan file. Automated contours were evaluated against manual digitization using distance and dosimetric metrics. RESULTS A close agreement between automatic and manual digitization was observed. The mean magnitude of contour disagreement for 10 patients equaled 0.3 mm. Hausdorff distances were ≤1.0 mm. The applicator tip coordinates had submillimeter agreement. The median and mean dose volume histogram parameter differences were less than or equal to 1% for high-risk clinical target volume D90, high-risk clinical target volume D95, bladder D2cc, rectum D2cc, large bowel D2cc, and small bowel D2cc. The average execution time for the automated algorithm was less than 30 s. CONCLUSION The digitization of titanium tandem and ovoids applicators for high-dose-rate brachytherapy treatment planning can be automated using straightforward thresholding and clustering algorithms. The adoption of automated digitization is expected to improve the consistency of treatment plans and reduce the duration of treatment planning.
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Affiliation(s)
| | - Shulan Tian
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Benjamin B Yan
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | | | | | - Ivy A Petersen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
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