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Parikh PJ, Chuong MD, Lee P. In Reply to Cellini and Fiore. Int J Radiat Oncol Biol Phys 2024; 119:309-310. [PMID: 38631746 DOI: 10.1016/j.ijrobp.2024.01.212] [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: 01/11/2024] [Accepted: 01/26/2024] [Indexed: 04/19/2024]
Affiliation(s)
| | | | - Percy Lee
- City of Hope National Medical Center
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2
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van Overeem Felter M, Møller PK, Josipovic M, Bekke SN, Bernchou U, Serup-Hansen E, Madsen K, Parikh PJ, Kim J, Geertsen P, Behrens CP, Vogelius IR, Pøhl M, Schytte T, Persson GF. MR-guided stereotactic radiotherapy of infra-diaphragmatic oligometastases: Evaluation of toxicity and dosimetric parameters. Radiother Oncol 2024; 192:110090. [PMID: 38224916 DOI: 10.1016/j.radonc.2024.110090] [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: 04/21/2023] [Revised: 11/15/2023] [Accepted: 01/08/2024] [Indexed: 01/17/2024]
Abstract
BACKGROUND AND PURPOSE The SOFT trial is a prospective, multicenter, phase 2 trial investigating magnetic resonance (MR)-guided stereotactic ablative radiotherapy (SABR) for abdominal, soft tissue metastases in patients with oligometastatic disease (OMD) (clinicaltrials.gov ID NCT04407897). We present the primary endpoint analysis of 1-year treatment-related toxicity (TRAE). MATERIALS AND METHODS Patients with up to five oligometastases from non-hematological cancers were eligible for inclusion. A risk-adapted strategy prioritized fixed organs at risk (OAR) constraints over target coverage. Fractionation schemes were 45-67.5 Gy in 3-8 fractions. The primary endpoint was grade ≥ 4 TRAE within 12 months post-SABR. The association between the risk of gastrointestinal (GI) toxicity and clinical and dosimetric parameters was tested using a normal tissue complication probability model. RESULTS We included 121 patients with 147 oligometastatic targets, mainly located in the liver (41 %), lymph nodes (35 %), or adrenal glands (14 %). Nearly half of all targets (48 %, n = 71) were within 10 mm of a radiosensitive OAR. No grade 4 or 5 TRAEs, 3.5 % grade 3 TRAEs, and 43.7 % grade 2 TRAEs were reported within the first year of follow-up. We found a significant association between grade ≥ 2 GI toxicity and the parameters GI OAR D0.1cc, D1cc, and D20cc. CONCLUSION In this phase II study of MR-guided SABR of oligometastases in the infra-diaphragmatic region, we found a low incidence of toxicity despite half of the lesions being within 10 mm of a radiosensitive OAR. GI OAR D0.1cc, D1cc, and D20cc were associated with grade ≥ 2 GI toxicity.
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Affiliation(s)
- Mette van Overeem Felter
- Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark.
| | - Pia Krause Møller
- Department of Oncology, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense C, Denmark; OPEN, Open Patient data Explorative Network at Odense University Hospital, J.B. Winsløws Vej 9a, 5000 Odense C, Denmark
| | - Mirjana Josipovic
- Department of Oncology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
| | - Susanne Nørring Bekke
- Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark
| | - Uffe Bernchou
- Department of Oncology, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense C, Denmark; Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19, 3. 5000 Odense C, Denmark
| | - Eva Serup-Hansen
- Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark
| | - Kasper Madsen
- Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark
| | - Parag J Parikh
- Department of Oncology, Henry Ford Hospital, 2800 W Grand Blvd, Detroit, MI 48202, United States
| | - Joshua Kim
- Department of Oncology, Henry Ford Hospital, 2800 W Grand Blvd, Detroit, MI 48202, United States
| | - Poul Geertsen
- Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark
| | - Claus P Behrens
- Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark; Department of Health Technology, Technical University of Denmark, Frederiksborgvej 399, 4000 Roskilde, Denmark
| | - Ivan R Vogelius
- Department of Oncology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
| | - Mette Pøhl
- Department of Oncology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Tine Schytte
- Department of Oncology, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense C, Denmark; Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19, 3. 5000 Odense C, Denmark
| | - Gitte Fredberg Persson
- Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
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Hoffe SE, Aguilera TA, Parikh PJ, Ghaly MM, Herman JM, Caster JM, Kim DW, Costello J, Malafa MP, Moser EC, Kennedy EP, Terry K, Kurman M. Stereotactic body radiotherapy plus rucosopasem in locally advanced or borderline resectable pancreatic cancer: GRECO-2 phase II study design. Future Oncol 2024; 20:437-446. [PMID: 38264869 PMCID: PMC10988540 DOI: 10.2217/fon-2022-1219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 08/02/2023] [Indexed: 01/25/2024] Open
Abstract
Ablative doses of stereotactic body radiotherapy (SBRT) may improve pancreatic cancer outcomes but may carry greater potential for gastrointestinal toxicity. Rucosopasem, an investigational selective dismutase mimetic that converts superoxide to hydrogen peroxide, can potentially increase tumor control of SBRT without compromising safety. GRECO-2 is a phase II, multicenter, randomized, double-blind, placebo-controlled trial of rucosopasem in combination with SBRT in locally advanced or borderline resectable pancreatic cancer. Patients will be randomized to rucosopasem 100 mg or placebo via intravenous infusion over 15 min, before each SBRT fraction (5 × 10 Gy). The primary end point is overall survival. Secondary end points include progression-free survival, locoregional control, time to metastasis, surgical resection rate, best overall response, in-field local response and acute and long-term toxicity.
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Affiliation(s)
- Sarah E Hoffe
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | | | | | - Maged M Ghaly
- Northwell Health Cancer Institute, New Hyde Park, NY 11040, USA
| | - Joseph M Herman
- Northwell Health Cancer Institute, New Hyde Park, NY 11040, USA
| | - Joseph M Caster
- Universty of Iowa Hospitals & Clinics, Iowa City, IA 52242, USA
| | - Dae Won Kim
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | - James Costello
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | - Mokenge P Malafa
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | | | | | - Kara Terry
- Galera Therapeutics, Inc., Malvern, PA 19355, USA
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Daamen LA, Parikh PJ, Hall WA. The Use of MR-Guided Radiation Therapy for Pancreatic Cancer. Semin Radiat Oncol 2024; 34:23-35. [PMID: 38105090 DOI: 10.1016/j.semradonc.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
The introduction of online adaptive magnetic resonance (MR)-guided radiation therapy (RT) has enabled safe treatment of pancreatic cancer with ablative doses. The aim of this review is to provide a comprehensive overview of the current literature on the use and clinical outcomes of MR-guided RT for treatment of pancreatic cancer. Relevant outcomes included toxicity, tumor response, survival and quality of life. The results of these studies support further investigation of the effectiveness of ablative MR-guided SBRT as a low-toxic, minimally-invasive therapy for localized pancreatic cancer in prospective clinical trials.
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Affiliation(s)
- Lois A Daamen
- Imaging & Oncology Division, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Parag J Parikh
- Department of Radiation Oncology, Henry Ford Medical Center, Henry Ford Health System, Detroit, MI
| | - William A Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI.
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Rusu DN, Cunningham JM, Arch JV, Chetty IJ, Parikh PJ, Dolan JL. Impact of intrafraction motion in pancreatic cancer treatments with MR-guided adaptive radiation therapy. Front Oncol 2023; 13:1298099. [PMID: 38162503 PMCID: PMC10756668 DOI: 10.3389/fonc.2023.1298099] [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: 09/21/2023] [Accepted: 11/27/2023] [Indexed: 01/03/2024] Open
Abstract
Purpose The total time of radiation treatment delivery for pancreatic cancer patients with daily online adaptive radiation therapy (ART) on an MR-Linac can range from 50 to 90 min. During this period, the target and normal tissues undergo changes due to respiration and physiologic organ motion. We evaluated the dosimetric impact of the intrafraction physiological organ changes. Methods Ten locally advanced pancreatic cancer patients were treated with 50 Gy in five fractions with intensity-modulated respiratory-gated radiation therapy on a 0.35-T MR-Linac. Patients received both pre- and post-treatment volumetric MRIs for each fraction. Gastrointestinal organs at risk (GI-OARs) were delineated on the pre-treatment MRI during the online ART process and retrospectively on the post-treatment MRI. The treated dose distribution for each adaptive plan was assessed on the post-treatment anatomy. Prescribed dose volume histogram metrics for the scheduled plan on the pre-treatment anatomy, the adapted plan on the pre-treatment anatomy, and the adapted plan on post-treatment anatomy were compared to the OAR-defined criteria for adaptation: the volume of the GI-OAR receiving greater than 33 Gy (V33Gy) should be ≤1 cubic centimeter. Results Across the 50 adapted plans for the 10 patients studied, 70% were adapted to meet the duodenum constraint, 74% for the stomach, 12% for the colon, and 48% for the small bowel. Owing to intrafraction organ motion, at the time of post-treatment imaging, the adaptive criteria were exceeded for the duodenum in 62% of fractions, the stomach in 36%, the colon in 10%, and the small bowel in 48%. Compared to the scheduled plan, the post-treatment plans showed a decrease in the V33Gy, demonstrating the benefit of plan adaptation for 66% of the fractions for the duodenum, 95% for the stomach, 100% for the colon, and 79% for the small bowel. Conclusion Post-treatment images demonstrated that over the course of the adaptive plan generation and delivery, the GI-OARs moved from their isotoxic low-dose region and nearer to the dose-escalated high-dose region, exceeding dose-volume constraints. Intrafraction motion can have a significant dosimetric impact; therefore, measures to mitigate this motion are needed. Despite consistent intrafraction motion, plan adaptation still provides a dosimetric benefit.
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Affiliation(s)
- Doris N. Rusu
- Department of Radiation Oncology, Wayne State University, Detroit, MI, United States
- Department of Radiation Oncology, Henry Ford Health System, Detroit, MI, United States
| | - Justine M. Cunningham
- Department of Radiation Oncology, Henry Ford Health System, Detroit, MI, United States
| | - Jacob V. Arch
- Department of Radiation Oncology, Henry Ford Health System, Detroit, MI, United States
| | - Indrin J. Chetty
- Department of Radiation Oncology, Henry Ford Health System, Detroit, MI, United States
- Department of Radiation Oncology, Cedars Sinai Medical Center, Los Angeles, CA, United States
| | - Parag J. Parikh
- Department of Radiation Oncology, Henry Ford Health System, Detroit, MI, United States
| | - Jennifer L. Dolan
- Department of Radiation Oncology, Henry Ford Health System, Detroit, MI, United States
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Chapman D, Parikh PJ, Dolan JL, Cunningham JM, Czarnecki E, Elshaikh MA, Dragovic J, Movsas B, Feldman AM. Does Stereotactic Online Adaptive MRgRT to the Prostate Preclude the Need for Rectal Spacer. Int J Radiat Oncol Biol Phys 2023; 117:e370. [PMID: 37785264 DOI: 10.1016/j.ijrobp.2023.06.2469] [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) Historical prospective trials have shown that hydrogel rectal spacers can be very effective at decreasing rectal wall dose, and in turn rectal toxicity, in patients undergoing curative intent fractionated courses of radiotherapy for prostate cancer. However, in the modern era of stereotactic online adaptive MR guided radiation (MRgRT), it's not yet determined if rectal spacers improve the potential daily need for plan adaptation. MATERIALS/METHODS A prospective database of MRgRT patients were queried for intact prostate cancer patients who received stereotactic online adaptive MR guided radiation. Patients were reviewed for the presence of a hydrogel rectal spacer present on the planning images. The number of adaptive fractions as well as the organs at risk out of tolerance were noted for each patient. Comparisons between number of fractions adapted as well as the number of fractions adapted for rectal constraints, were noted. For each case within this patient group that required plan adaptation, pre-specified dose constraints were finally met prior to treatment delivery. RESULTS A total of 27 patients were treated with stereotactic online adaptive MRgRT from 2020 to 2022. 8 patients had a hydrogel rectal spacer placed prior to treatment. Out of the 95 fractions delivered to non-hydrogel patients, 78 were adapted, with 52 for urethra, 31 for bladder, 5 for bladder neck, and 35 for rectum. Of the 40 fractions delivered to patients with a hydrogel spacer, 20 were adapted. The corresponding reasons for adaptation in this group were 14 times for the urethra, 19 times for the bladder, 8 times for the bladder neck, and 8 times for the rectum. It was common for multiple at-risk organs to require adaptation for a single fraction within both cohorts. Although the percentage of patients requiring adaptation for rectal constraints was greater in the non-hydrogel patients (36.8% vs. 20%), this was not found to be statistically significant; p value greater than 0.1. CONCLUSION The presence of a rectal spacer did not significantly reduce the need for online plan adaptation of the rectum for stereotactic online adaptive MRgRT. Furthermore, patients with a rectal spacer continued to often require adaptation to meet other prescription constraints. Further work is necessary to better select patients who would benefit from hydrogel spacers in the setting of online adaptive MRgRT. Additionally, longer follow-up of this patient population coupled with a larger patient cohort overall remains needed to increase the power of this analysis and to further explore the clinical outcomes of this patient group.
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Affiliation(s)
| | - P J Parikh
- Department of Radiation Oncology, Henry Ford Cancer Institute, Detroit, MI
| | - J L Dolan
- Department of Radiation Oncology, Henry Ford Cancer Institute, Detroit, MI
| | - J M Cunningham
- Department of Radiation Oncology, Henry Ford Cancer Institute, Detroit, MI
| | - E Czarnecki
- Henry Ford Hospital, Detroit, MI, United States
| | - M A Elshaikh
- Department of Radiation Oncology, Henry Ford Cancer Institute, Detroit, MI
| | - J Dragovic
- Henry Ford Cancer Institute, Detroit, MI
| | - B Movsas
- Department of Radiation Oncology, Henry Ford Cancer Institute, Detroit, MI
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Czarnecki E, Dolan JL, Cunningham JM, Chapman D, Elshaikh MA, Dragovic J, Parikh PJ, Movsas B, Feldman AM. Does a Dominant Intraprostatic Lesion Boost Require Daily Adaptation when Treated with Stereotactic Online Adaptive MR-Guided Therapy? Int J Radiat Oncol Biol Phys 2023; 117:e374-e375. [PMID: 37785274 DOI: 10.1016/j.ijrobp.2023.06.2479] [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) Multiple trials have demonstrated a dose-response relationship for radiation therapy in the treatment of localized prostate cancer. Recent data has also demonstrated a benefit with whole gland stereotactic radiation therapy (SBRT) in conjunction with a simultaneous integrated boost to the dominant intraprostatic lesion (DIL). SBRT with a DIL boost can often increase dose to nearby organs at risk such as the rectum and online adaptive MR guided radiation therapy (MGgRT) may offer a dosimetric and toxicity benefit. MATERIALS/METHODS A prospective database of MRgRT patients was queried for intact prostate cancer patients who received SBRT with a SIB to the DIL. The guideline for adaptation for coverage was to ensure the PTV-prostate coverage at 95% of prescribed dose was greater than 92% or by discretion of the treating physician. Adaptions for organs at risk were made to meet prescription constraints. The number of fractions requiring adaptation to meet organs at risk constraints and/or adequate coverage were reviewed. RESULTS A total of 26 patients were treated with SBRT with a DIL boost using stereotactic online adaptive MRgRT from 2020 to 2022. 10 of 26 patients were treated for re-irradiation of intact prostate. Out of the 130 fractions delivered, 107 fractions required adaptation (82.3%). 59 fractions were adapted for urethra (45.2%), 48 fractions were adapted for bladder (36.9%), 36 fractions were adapted for rectum (27.7%), 23 fractions were adapted for bladder neck (17.7%), and 19 fractions were adapted for coverage (14.6%). For 53 fractions (40.8 %), adaptation was required for more than one organ at risk. CONCLUSION A total of 82.3% of fractions required adaptation for patients treated with SBRT with a DIL boost using stereotactic online adaptive MRgRT. Adaptation occurred most frequently for urethral (45.2%), bladder (36.9%), and rectal constraints (27.7%). Further studies are needed to elucidate if daily adaptive online MRgRT translates to reduced patient toxicity and improved quality of life.
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Affiliation(s)
- E Czarnecki
- Henry Ford Hospital, Detroit, MI, United States
| | - J L Dolan
- Department of Radiation Oncology, Henry Ford Cancer Institute, Detroit, MI
| | - J M Cunningham
- Department of Radiation Oncology, Henry Ford Cancer Institute, Detroit, MI
| | | | - M A Elshaikh
- Department of Radiation Oncology, Henry Ford Cancer Institute, Detroit, MI
| | - J Dragovic
- Henry Ford Cancer Institute, Detroit, MI
| | | | - B Movsas
- Henry Ford Hospital, Detroit, MI
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Chin RI, Schiff JP, Bommireddy A, Kang KH, Andruska N, Price AT, Green OL, Huang Y, Korenblat K, Parikh PJ, Olsen J, Samson PP, Henke LE, Kim H, Badiyan SN. Clinical outcomes of patients with unresectable primary liver cancer treated with MR-guided stereotactic body radiation Therapy: A Six-Year experience. Clin Transl Radiat Oncol 2023; 41:100627. [PMID: 37441543 PMCID: PMC10334127 DOI: 10.1016/j.ctro.2023.100627] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 03/13/2023] [Accepted: 04/11/2023] [Indexed: 07/15/2023] Open
Abstract
Purpose Magnetic resonance-guided stereotactic body radiation therapy (MRgSBRT) with optional online adaptation has shown promise in delivering ablative doses to unresectable primary liver cancer. However, there remain limited data on the indications for online adaptation as well as dosimetric and longer-term clinical outcomes following MRgSBRT. Methods and Materials Patients with unresectable hepatocellular carcinoma (HCC), cholangiocarcinoma (CCA), and combined biphenotypic hepatocellular-cholangiocarcinoma (cHCC-CCA) who completed MRgSBRT to 50 Gy in 5 fractions between June of 2015 and December of 2021 were analyzed. The necessity of adaptive techniques was evaluated. The cumulative incidence of local progression was evaluated and survival and competing risk analyses were performed. Results Ninety-nine analyzable patients completed MRgSBRT during the study period and 54 % had planning target volumes (PTVs) within 1 cm of the duodenum, small bowel, or stomach at the time of simulation. Online adaptive RT was used in 53 % of patients to correct organ-at-risk constraint violation and/or to improve target coverage. In patients who underwent adaptive RT planning, online replanning resulted in superior target coverage when compared to projected, non-adaptive plans (median coverage ≥ 95 % at 47.5 Gy: 91 % [IQR: 82-96] before adaptation vs 95 % [IQR: 87-99] after adaptation, p < 0.01). The median follow-up for surviving patients was 34.2 months for patients with HCC and 10.1 months for patients with CCA/cHCC-CCA. For all patients, the 2-year cumulative incidence of local progression was 9.8 % (95 % CI: 1.5-18 %) for patients with HCC and 9.0 % (95 % CI: 0.1-18) for patients with CCA/cHCC-CCA. Grade 3 through 5 acute and late clinical gastrointestinal toxicities were observed in < 10 % of the patients. Conclusions MRgSBRT, with the option for online adaptive planning when merited, allows delivery of ablative doses to primary liver tumors with excellent local control with acceptable toxicities. Additional studies evaluating the efficacy and safety of MRgSBRT in the treatment of primary liver cancer are warranted.
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Affiliation(s)
- Re-I Chin
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis MO, USA
| | - Joshua P. Schiff
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis MO, USA
| | | | - Kylie H. Kang
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis MO, USA
| | - Neal Andruska
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis MO, USA
| | - Alexander T. Price
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis MO, USA
| | - Olga L. Green
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis MO, USA
| | - Yi Huang
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis MO, USA
| | - Kevin Korenblat
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis MO, USA
| | - Parag J Parikh
- Department of Radiation Oncology, Henry Ford Cancer Institute, Detroit, MI, USA
| | - Jefferey Olsen
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Pamela P. Samson
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis MO, USA
| | - Lauren E. Henke
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis MO, USA
| | - Hyun Kim
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis MO, USA
| | - Shahed N. Badiyan
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis MO, USA
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Kim H, Olsen JR, Green OL, Chin RI, Hawkins WG, Fields RC, Hammill C, Doyle MB, Chapman W, Suresh R, Tan B, Pedersen K, Jansen B, DeWees TA, Lu E, Henke LE, Badiyan S, Parikh PJ, Roach MC, Wang-Gillam A, Lim KH. MR-Guided Radiation Therapy With Concurrent Gemcitabine/Nab-Paclitaxel Chemotherapy in Inoperable Pancreatic Cancer: A TITE-CRM Phase I Trial. Int J Radiat Oncol Biol Phys 2023; 115:214-223. [PMID: 35878713 DOI: 10.1016/j.ijrobp.2022.07.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 07/06/2022] [Accepted: 07/13/2022] [Indexed: 02/09/2023]
Abstract
PURPOSE Ablative radiation therapy for borderline resectable or locally advanced pancreatic ductal adenocarcinoma (BR/LA-PDAC) may limit concurrent chemotherapy dosing and usually is only safely deliverable to tumors distant from gastrointestinal organs. Magnetic resonance guided radiation therapy may safely permit radiation and chemotherapy dose escalation. METHODS AND MATERIALS We conducted a single-arm phase I study to determine the maximum tolerated dose of ablative hypofractionated radiation with full-dose gemcitabine/nab-paclitaxel in patients with BR/LA-PDAC. Patients were treated with gemcitabine/nab-paclitaxel (1000/125 mg/m2) x 1c then concurrent gemcitabine/nab-paclitaxel and radiation. Gemcitabine/nab-paclitaxel and radiation doses were escalated per time-to-event continual reassessment method from 40 to 45 Gy 25 fxs with chemotherapy (600-800/75 mg/m2) to 60 to 67.5 Gy/15 fractions and concurrent gemcitabine/nab-paclitaxel (1000/100 mg/m2). The primary endpoint was maximum tolerated dose of radiation as defined by 60-day dose limiting toxicity (DLT). DLT was treatment-related G5, G4 hematologic, or G3 gastrointestinal requiring hospitalization >3 days. Secondary endpoints included resection rates, local progression free survival (LPFS), distant metastasis free survival (DMFS), and overall survival (OS). RESULTS Thirty patients enrolled (March 2015-February 2019), with 26 evaluable patients (2 progressed before radiation, 1 was determined ineligible for radiation during planning, 1 withdrew consent). One DLT was observed. The DLT rate was 14.1% (3.3%-24.9%) with a maximum tolerated dose of gemcitabine/nab-paclitaxel (1000/100 mg/m2) and 67.5 Gy/15 fractions. At a median follow-up of 40.6 months for living patients the median OS was 14.5 months (95% confidence interval [CI], 10.9-28.2 months). The median OS for patients with Eastern Collaborative Oncology Group 0 and carbohydrate antigen 19-9 <90 were 34.1 (95% CI, 13.6-54.1) and 43.0 (95% CI, 8.0-not reached) months, respectively. Two-year LPFS and DMFS were 85% (95% CI, 63%-94%) and 57% (95% CI, 34%-73%), respectively. CONCLUSIONS Full-dose gemcitabine/nab-paclitaxel with ablative magnetic resonance guided radiation therapy dosing is safe in patients with BR/LA-PDAC, with promising LPFS and DMFS.
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Affiliation(s)
- Hyun Kim
- Washington University School of Medicine, Department of Radiation Oncology, St. Louis, Missouri.
| | - Jeffrey R Olsen
- University of Colorado School of Medicine, Department of Radiation Oncology, Denver, Colorado
| | - Olga L Green
- Washington University School of Medicine, Department of Radiation Oncology, St. Louis, Missouri
| | - Re-I Chin
- Washington University School of Medicine, Department of Radiation Oncology, St. Louis, Missouri
| | - William G Hawkins
- Washington University School of Medicine, Department of Surgery, Division of General Surgery, Section of Pancreatic, Hepatobiliary and Gastrointestinal Surgery, St. Louis, Missouri
| | - Ryan C Fields
- Washington University School of Medicine, Department of Surgery, Division of General Surgery, Section of Pancreatic, Hepatobiliary and Gastrointestinal Surgery, St. Louis, Missouri
| | - Chet Hammill
- Washington University School of Medicine, Department of Surgery, Division of General Surgery, Section of Pancreatic, Hepatobiliary and Gastrointestinal Surgery, St. Louis, Missouri
| | - Majella B Doyle
- Washington University School of Medicine, Department of Surgery, Division of General Surgery, Section of Pancreatic, Hepatobiliary and Gastrointestinal Surgery, St. Louis, Missouri
| | - William Chapman
- Washington University School of Medicine, Department of Surgery, Division of General Surgery, Section of Pancreatic, Hepatobiliary and Gastrointestinal Surgery, St. Louis, Missouri
| | - Rama Suresh
- Washington University School of Medicine, Department of Medicine, Division of Oncology, Section of Medical Oncology, St. Louis, Missouri
| | - Benjamin Tan
- Washington University School of Medicine, Department of Medicine, Division of Oncology, Section of Medical Oncology, St. Louis, Missouri
| | - Katrina Pedersen
- Washington University School of Medicine, Department of Medicine, Division of Oncology, Section of Medical Oncology, St. Louis, Missouri
| | - Brandi Jansen
- Washington University School of Medicine, Department of Radiation Oncology, St. Louis, Missouri
| | - Todd A DeWees
- Mayo Clinic, Scottsdale, Division of Biomedical Statistics and Informatics, Scottsdale, Arizona
| | - Esther Lu
- Washington University School of Medicine, Division of Public Health Sciences, Department of Surgery, St. Louis, Missouri
| | - Lauren E Henke
- Washington University School of Medicine, Department of Radiation Oncology, St. Louis, Missouri
| | - Shahed Badiyan
- Washington University School of Medicine, Department of Radiation Oncology, St. Louis, Missouri
| | - Parag J Parikh
- Henry Ford Health System, Department of Radiation Oncology, Detroit, Michigan
| | - Michael C Roach
- Hawai'i Pacific Health, Department of Radiation Oncology, Honolulu, Hawaii
| | - Andrea Wang-Gillam
- Washington University School of Medicine, Department of Medicine, Division of Oncology, Section of Medical Oncology, St. Louis, Missouri
| | - Kian-Huat Lim
- Washington University School of Medicine, Department of Medicine, Division of Oncology, Section of Medical Oncology, St. Louis, Missouri
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Chuong MD, Ann Clark M, Henke LE, Kishan AU, Portelance L, Parikh PJ, Bassetti MF, Nagar H, Rosenberg SA, Mehta MP, Refaat T, Rineer JM, Smith A, Seung S, Zaki BI, Fuss M, Mak RH. Patterns of Utilization and Clinical Adoption of 0.35 Tesla MR-guided Radiation Therapy in the United States - Understanding the Transition to Adaptive, Ultra-Hypofractionated Treatments. Clin Transl Radiat Oncol 2022; 38:161-168. [DOI: 10.1016/j.ctro.2022.11.013] [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: 08/19/2022] [Revised: 11/18/2022] [Accepted: 11/20/2022] [Indexed: 11/23/2022] Open
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Chapman WC, Kim H, Bauer P, Makhdoom BA, Trikalinos NA, Pedersen KS, Glasgow SC, Mutch MG, Silviera ML, Roy A, Parikh PJ, Hunt SR. Total Neoadjuvant Therapy With Short-Course Radiation: US Experience of a Neoadjuvant Rectal Cancer Therapy. Dis Colon Rectum 2022; 65:198-206. [PMID: 34990423 DOI: 10.1097/dcr.0000000000001997] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Short-course radiation followed by chemotherapy as total neoadjuvant therapy has been investigated primarily in Europe and Australia with increasing global acceptance. There are limited data on this regimen's use in the United States, however, potentially delaying implementation. OBJECTIVE This study aimed to compare clinical performance and oncologic outcomes of 2 rectal cancer neoadjuvant treatment modalities: short-course total neoadjuvant therapy versus standard chemoradiation. DESIGN This is a retrospective cohort study. SETTING This study was performed at a National Cancer Institute-designated cancer center. PATIENTS A total of 413 patients had locally advanced rectal cancers diagnosed from June 2009 to May 2018 and received either short-course total neoadjuvant therapy or standard chemoradiation. INTERVENTIONS There were 187 patients treated with short-course total neoadjuvant therapy (5 × 5 Gy radiation followed by consolidation oxaliplatin-based chemotherapy) compared with 226 chemoradiation recipients (approximately 50.4 Gy radiation in 28 fractions with concurrent fluorouracil equivalent). MAIN OUTCOME MEASURES Primary end points were tumor downstaging, measured by complete response and "low" neoadjuvant rectal score rates, and progression-free survival. Secondary analyses included treatment characteristics and completion, sphincter preservation, and recurrence rates. RESULTS Short-course total neoadjuvant therapy was associated with higher rates of complete response (26.2% vs 17.3%; p = 0.03) and "low" neoadjuvant rectal scores (40.1% vs 25.7%; p < 0.01) despite a higher burden of node-positive disease (78.6% vs 68.9%; p = 0.03). Short-course recipients also completed trimodal treatment more frequently (88.4% vs 50.4%; p < 0.01) and had fewer months with temporary stomas (4.8 vs 7.0; p < 0.01). Both regimens achieved comparable local control (local recurrence: 2.7% short-course total neoadjuvant therapy vs 2.2% chemoradiation, p = 0.76) and 2-year progression-free survival (88.2% short-course total neoadjuvant therapy (95% CI, 82.9-93.5) vs 85.6% chemoradiation (95% CI, 80.5-90.7)). LIMITATIONS Retrospective design, unbalanced disease severity, and variable dosing of neoadjuvant consolidation chemotherapy were limitations of this study. CONCLUSIONS Short-course total neoadjuvant therapy was associated with improved downstaging and similar progression-free survival compared with chemoradiation. These results were achieved with shortened radiation courses, improved treatment completion, and less time with diverting ostomies. Short-course total neoadjuvant therapy is an optimal regimen for locally advanced rectal cancer. See Video Abstract at http://links.lww.com/DCR/B724.TERAPIA NEOADYUVANTE TOTAL CON RADIACIÓN DE CORTA DURACIÓN: EXPERIENCIA ESTADOUNIDENSE DE UNA TERAPIA NEOADYUVANTE CONTRA EL CÁNCER DE RECTO. ANTECEDENTES La radiación de corta duración seguida de quimioterapia como terapia neoadyuvante total se ha investigado principalmente en Europa y Australia con una aceptación mundial cada vez mayor. Sin embargo, datos limitados sobre el uso de este régimen en los Estados Unidos, han potencialmente retrasando su implementación. OBJETIVO Comparar el desempeño clínico y los resultados oncológicos de dos modalidades de tratamiento neoadyuvante del cáncer de recto: terapia neoadyuvante total de corta duración versus quimioradiación. estándar. DISEO Cohorte retrospectivo. AJUSTE Centro oncológico designado por el NCI. PACIENTES Un total de 413 cánceres rectales localmente avanzados diagnosticados entre junio de 2009 y mayo de 2018 que recibieron cualquiera de los regímenes neoadyuvantes. INTERVENCIONES Hubo 187 pacientes tratados con terapia neoadyuvante total de ciclo corto (radiación 5 × 5 Gy seguida de quimioterapia de consolidación basada en oxaliplatino) en comparación con 226 pacientes de quimiorradiación (aproximadamente 50,4 Gy de radiación en 28 fracciones con equivalente de fluorouracilo concurrente). PRINCIPALES MEDIDAS DE RESULTADO Los criterios primarios de valoración fueron la disminución del estadio del tumor, medido por la respuesta completa y las tasas de puntuación rectal neoadyuvante "baja", y la supervivencia libre de progresión. Los análisis secundarios incluyeron las características del tratamiento y las tasas de finalización, conservación del esfínter y recurrencia. RESULTADOS La terapia neoadyuvante total de corta duración, se asoció con tasas más altas de respuesta completa (26,2% versus 17,3%, p = 0,03) y puntuaciones rectales neoadyuvantes "bajas" (40,1% versus 25,7%, p < 0,01) a pesar de una mayor carga de enfermedad con ganglios positivos (78,6% versus 68,9%, p = 0,03). Los pacientes de ciclo corto también completaron el tratamiento trimodal con mayor frecuencia (88,4% versus 50,4%, p < 0,01) y tuvieron menos meses con estomas temporales (4,8 versus 7,0, p < 0,01). Ambos regímenes lograron un control local comparable (recidiva local: 2,7% de SC-TNT versus 2,2% de TRC, p = 0,76) y supervivencia libre de progresión a 2 años (88,2% de SC-TNT [IC: 82,9 - 93,5] versus 85,6% CRT [CI: 80,5 - 90,7]). LIMITACIONES Diseño retrospectivo, gravedad de la enfermedad desequilibrada y dosificación variable de quimioterapia neoadyuvante de consolidación. CONCLUSIONES La terapia neoadyuvante total de ciclo corto se asoció con una mejora en la reducción del estadio y una supervivencia libre de progresión similar en comparación con la quimioradiación. Estos resultados se lograron con ciclos de radiación más cortos, tratamientos mejor finalizados y menos tiempo en ostomías de derivación. La terapia neoadyuvante total de corta duración es un régimen óptimo para el cáncer de recto localmente avanzado. Consulte Video Resumen en http://links.lww.com/DCR/B724. (Traducción- Dr. Fidel Ruiz Healy).
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Affiliation(s)
- William C Chapman
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Hyun Kim
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Philip Bauer
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Bilal A Makhdoom
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Nikolaos A Trikalinos
- Department of Medicine, Division of Medical Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Katrina S Pedersen
- Department of Medicine, Division of Medical Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Sean C Glasgow
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Matthew G Mutch
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Matthew L Silviera
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Amit Roy
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Parag J Parikh
- Department of Radiation Oncology, Henry Ford Cancer Institute, Detroit, Michigan
| | - Steven R Hunt
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, St. Louis, Missouri
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Weiser MR, Chou JF, Keshinro A, Chapman WC, Bauer PS, Mutch MG, Parikh PJ, Cercek A, Saltz LB, Gollub MJ, Romesser PB, Crane CH, Shia J, Markowitz AJ, Garcia-Aguilar J, Gönen M. Development and Assessment of a Clinical Calculator for Estimating the Likelihood of Recurrence and Survival Among Patients With Locally Advanced Rectal Cancer Treated With Chemotherapy, Radiotherapy, and Surgery. JAMA Netw Open 2021; 4:e2133457. [PMID: 34748003 PMCID: PMC8576585 DOI: 10.1001/jamanetworkopen.2021.33457] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [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: 12/21/2022] Open
Abstract
IMPORTANCE Predicting outcomes in patients receiving neoadjuvant therapy for rectal cancer is challenging because of tumor downstaging. Validated clinical calculators that can estimate recurrence-free survival (RFS) and overall survival (OS) among patients with rectal cancer who have received multimodal therapy are needed. OBJECTIVE To develop and validate clinical calculators providing estimates of rectal cancer recurrence and survival that are better for individualized decision-making than the American Joint Committee on Cancer (AJCC) staging system or the neoadjuvant rectal (NAR) score. DESIGN, SETTING, AND PARTICIPANTS This prognostic study developed risk models, graphically represented as nomograms, for patients with incomplete pathological response using Cox proportional hazards and multivariable regression analyses with restricted cubic splines. Because patients with complete pathological response to neoadjuvant therapy had uniformly favorable outcomes, their predictions were obtained separately. The study included 1400 patients with stage II or III rectal cancer who received treatment with chemotherapy, radiotherapy, and surgery at 2 comprehensive cancer centers (Memorial Sloan Kettering [MSK] Cancer Center and Siteman Cancer Center [SCC]) between January 1, 1998, and December 31, 2017. Patients from the MSK cohort received chemoradiation, surgery, and adjuvant chemotherapy from January 1, 1998, to December 31, 2014; these patients were randomly assigned to either a model training group or an internal validation group. Models were externally validated using data from the SCC cohort, who received either chemoradiation, surgery, and adjuvant chemotherapy (chemoradiotherapy group) or short-course radiotherapy, consolidation chemotherapy, and surgery (total neoadjuvant therapy with short-course radiotherapy group) from January 1, 2009, to December 31, 2017. Data were analyzed from March 1, 2020, to January 10, 2021. EXPOSURES Chemotherapy, radiotherapy, chemoradiotherapy, and surgery. MAIN OUTCOMES AND MEASURES Recurrence-free survival and OS were the outcome measures, and the discriminatory performance of the clinical calculators was measured with concordance index and calibration plots. The ability of the clinical calculators to predict RFS and OS was compared with that of the AJCC staging system and the NAR score. The models for RFS and OS among patients with incomplete pathological response included postoperative pathological tumor category, number of positive lymph nodes, tumor distance from anal verge, and large- and small-vessel venous and perineural invasion; age was included in the risk model for OS. The final clinical calculators provided RFS and OS estimates derived from Kaplan-Meier curves for patients with complete pathological response and from risk models for patients with incomplete pathological response. RESULTS Among 1400 total patients with locally advanced rectal cancer, the median age was 57.8 years (range, 18.0-91.9 years), and 863 patients (61.6%) were male, with tumors at a median distance of 6.7 cm (range, 0-15.0 cm) from the anal verge. The MSK cohort comprised 1069 patients; of those, 710 were assigned to the model training group and 359 were assigned to the internal validation group. The SCC cohort comprised 331 patients; of those, 200 were assigned to the chemoradiotherapy group and 131 were assigned to the total neoadjuvant therapy with short-course radiotherapy group. The concordance indices in the MSK validation data set were 0.70 (95% CI, 0.65-0.76) for RFS and 0.73 (95% CI, 0.65-0.80) for OS. In the external SCC data set, the concordance indices in the chemoradiotherapy group were 0.71 (95% CI, 0.62-0.81) for RFS and 0.72 (95% CI, 0.59-0.85) for OS; the concordance indices in the total neoadjuvant therapy with short-course radiotherapy group were 0.62 (95% CI, 0.49-0.75) for RFS and 0.67 (95% CI, 0.46-0.84) for OS. Calibration plots confirmed good agreement between predicted and observed events. These results compared favorably with predictions based on the AJCC staging system (concordance indices for MSK validation: RFS = 0.69 [95% CI, 0.64-0.74]; OS = 0.67 [95% CI, 0.58-0.75]) and the NAR score (concordance indices for MSK validation: RFS = 0.56 [95% CI, 0.50-0.63]; OS = 0.56 [95% CI, 0.46-0.66]). Furthermore, the clinical calculators provided more individualized outcome estimates compared with the categorical schemas (eg, estimated RFS for patients with AJCC stage IIIB disease ranged from 7% to 68%). CONCLUSIONS AND RELEVANCE In this prognostic study, clinical calculators were developed and validated; these calculators provided more individualized estimates of the likelihood of RFS and OS than the AJCC staging system or the NAR score among patients with rectal cancer who received multimodal treatment. The calculators were easy to use and applicable to both short- and long-course radiotherapy regimens, and they may be used to inform surveillance strategies and facilitate future clinical trials and statistical power calculations.
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Affiliation(s)
- Martin R. Weiser
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joanne F. Chou
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ajaratu Keshinro
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - William C. Chapman
- Department of Surgery, Washington University in St Louis, St Louis, Missouri
| | - Philip S. Bauer
- Department of Surgery, Washington University in St Louis, St Louis, Missouri
| | - Matthew G. Mutch
- Department of Surgery, Washington University in St Louis, St Louis, Missouri
| | - Parag J. Parikh
- Department of Radiation Oncology, Washington University in St Louis, St Louis, Missouri
| | - Andrea Cercek
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Leonard B. Saltz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marc J. Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Paul B. Romesser
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Christopher H. Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jinru Shia
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York, New York
| | - Arnold J. Markowitz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mithat Gönen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
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Hall WA, Small C, Paulson E, Koay EJ, Crane C, Intven M, Daamen LA, Meijer GJ, Heerkens HD, Bassetti M, Rosenberg SA, Aitken K, Myrehaug S, Dawson LA, Lee P, Gani C, Chuong MD, Parikh PJ, Erickson BA. Magnetic Resonance Guided Radiation Therapy for Pancreatic Adenocarcinoma, Advantages, Challenges, Current Approaches, and Future Directions. Front Oncol 2021; 11:628155. [PMID: 34046339 PMCID: PMC8144850 DOI: 10.3389/fonc.2021.628155] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 03/03/2021] [Indexed: 12/15/2022] Open
Abstract
Introduction Pancreatic adenocarcinoma (PAC) has some of the worst treatment outcomes for any solid tumor. PAC creates substantial difficulty for effective treatment with traditional RT delivery strategies primarily secondary to its location and limited visualization using CT. Several of these challenges are uniquely addressed with MR-guided RT. We sought to summarize and place into context the currently available literature on MR-guided RT specifically for PAC. Methods A literature search was conducted to identify manuscript publications since September 2014 that specifically used MR-guided RT for the treatment of PAC. Clinical outcomes of these series are summarized, discussed, and placed into the context of the existing pancreatic literature. Multiple international experts were involved to optimally contextualize these publications. Results Over 300 manuscripts were reviewed. A total of 6 clinical outcomes publications were identified that have treated patients with PAC using MR guidance. Successes, challenges, and future directions for this technology are evident in these publications. MR-guided RT holds theoretical promise for the treatment of patients with PAC. As with any new technology, immediate or dramatic clinical improvements associated with its use will take time and experience. There remain no prospective trials, currently publications are limited to small retrospective experiences. The current level of evidence for MR guidance in PAC is low and requires significant expansion. Future directions and ongoing studies that are currently open and accruing are identified and reviewed. Conclusions The potential promise of MR-guided RT for PAC is highlighted, the challenges associated with this novel therapeutic intervention are also reviewed. Outcomes are very early, and will require continued and long term follow up. MR-guided RT should not be viewed in the same fashion as a novel chemotherapeutic agent for which dosing, administration, and toxicity has been established in earlier phase studies. Instead, it should be viewed as a novel procedural intervention which must be robustly tested, refined and practiced before definitive conclusions on the potential benefits or detriments can be determined. The future of MR-guided RT for PAC is highly promising and the potential implications on PAC are substantial.
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Affiliation(s)
- William A Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Christina Small
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Eric Paulson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Eugene J Koay
- Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Christopher Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Martijn Intven
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Lois A Daamen
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Gert J Meijer
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Hanne D Heerkens
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Michael Bassetti
- Department of Radiation Oncology, University of Wisconsin-Madison, Madison, WI, United States
| | - Stephen A Rosenberg
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, United States
| | - Katharine Aitken
- Department of Radiation Oncology, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Sten Myrehaug
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Laura A Dawson
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Percy Lee
- Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Cihan Gani
- Department of Radiation Oncology, Faculty of Medicine, University of Tübingen, Tübingen, Germany
| | | | - Parag J Parikh
- Henry Ford Medical Center, Henry Ford Health System, Detroit, MI, United States
| | - Beth A Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
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14
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Kim H, Pedersen K, Olsen JR, Mutch MG, Chin RI, Glasgow SC, Wise PE, Silviera ML, Tan BR, Wang-Gillam A, Lim KH, Suresh R, Amin M, Huang Y, Henke LE, Park H, Ciorba MA, Badiyan S, Parikh PJ, Roach MC, Hunt SR. Nonoperative Rectal Cancer Management With Short-Course Radiation Followed by Chemotherapy: A Nonrandomized Control Trial. Clin Colorectal Cancer 2021; 20:e185-e193. [PMID: 34001462 DOI: 10.1016/j.clcc.2021.03.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [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: 01/13/2021] [Revised: 02/19/2021] [Accepted: 03/28/2021] [Indexed: 01/18/2023]
Abstract
PURPOSE Short-course radiation therapy (SCRT) and nonoperative management are emerging paradigms for rectal cancer treatment. This clinical trial is the first to evaluate SCRT followed by chemotherapy as a nonoperative treatment modality. METHODS Patients with nonmetastatic rectal adenocarcinoma were treated on the single-arm, Nonoperative Radiation Management of Adenocarcinoma of the Lower Rectum study of SCRT followed by chemotherapy. Patients received 25 Gy in 5 fractions to the pelvis followed by FOLFOX ×8 or CAPOX ×5 cycles. Patients with clinical complete response (cCR) underwent nonoperative surveillance. The primary end point was cCR at 1 year. Secondary end points included safety profile and anorectal function. RESULTS From June 2016 to March 2019, 19 patients were treated (21% stage I, 32% stage II, and 47% stage III disease). At a median follow-up of 27.7 months for living patients, the 1-year cCR rate was 68%. Eighteen of 19 patients are alive without evidence of disease. Patients with cCR versus without had improved 2-year disease-free survival (93% vs 67%; P = .006), distant metastasis-free survival (100% vs 67%; P = .03), and overall survival (100% vs 67%; P = .03). Involved versus uninvolved circumferential resection margin on magnetic resonance imaging was associated with less initial cCR (40% vs 93%; P = .04). Anorectal function by Functional Assessment of Cancer Therapy-Colorectal cancer score at 1 year was not different than baseline. There were no severe late effects. CONCLUSIONS Treatment with SCRT and chemotherapy resulted in high cCR rate, intact anorectal function, and no severe late effects. NCT02641691.
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Affiliation(s)
- Hyun Kim
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO.
| | - Katrina Pedersen
- Department of Medicine, Division of Oncology, Section of Medical Oncology, Washington University School of Medicine, St. Louis, MO
| | - Jeffrey R Olsen
- Department of Radiation Oncology, University of Colorado School of Medicine, Denver, CO
| | - Matthew G Mutch
- Department of Surgery, Division of General Surgery, Section of Colon and Rectal Surgery
| | - Re-I Chin
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Sean C Glasgow
- Department of Surgery, Division of General Surgery, Section of Colon and Rectal Surgery
| | - Paul E Wise
- Department of Surgery, Division of General Surgery, Section of Colon and Rectal Surgery
| | - Matthew L Silviera
- Department of Surgery, Division of General Surgery, Section of Colon and Rectal Surgery
| | - Benjamin R Tan
- Department of Medicine, Division of Oncology, Section of Medical Oncology, Washington University School of Medicine, St. Louis, MO
| | - Andrea Wang-Gillam
- Department of Medicine, Division of Oncology, Section of Medical Oncology, Washington University School of Medicine, St. Louis, MO
| | - Kian-Huat Lim
- Department of Medicine, Division of Oncology, Section of Medical Oncology, Washington University School of Medicine, St. Louis, MO
| | - Rama Suresh
- Department of Medicine, Division of Oncology, Section of Medical Oncology, Washington University School of Medicine, St. Louis, MO
| | - Manik Amin
- Department of Medicine, Division of Oncology, Section of Medical Oncology, Washington University School of Medicine, St. Louis, MO
| | - Yi Huang
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Lauren E Henke
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Haeseong Park
- Department of Medicine, Division of Oncology, Section of Medical Oncology, Washington University School of Medicine, St. Louis, MO
| | - Matthew A Ciorba
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Shahed Badiyan
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Parag J Parikh
- Department of Radiation Oncology, Henry Ford Health System, Detroit, MI
| | - Michael C Roach
- Department of Radiation Oncology, Hawai'i Pacific Health, Honolulu, HI
| | - Steven R Hunt
- Department of Radiation Oncology, University of Colorado School of Medicine, Denver, CO
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15
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Keall PJ, Sawant A, Berbeco RI, Booth JT, Cho B, Cerviño LI, Cirino E, Dieterich S, Fast MF, Greer PB, Munck Af Rosenschöld P, Parikh PJ, Poulsen PR, Santanam L, Sherouse GW, Shi J, Stathakis S. AAPM Task Group 264: The safe clinical implementation of MLC tracking in radiotherapy. Med Phys 2021; 48:e44-e64. [PMID: 33260251 DOI: 10.1002/mp.14625] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 11/11/2020] [Accepted: 11/18/2020] [Indexed: 12/25/2022] Open
Abstract
The era of real-time radiotherapy is upon us. Robotic and gimbaled linac tracking are clinically established technologies with the clinical realization of couch tracking in development. Multileaf collimators (MLCs) are a standard equipment for most cancer radiotherapy systems, and therefore MLC tracking is a potentially widely available technology. MLC tracking has been the subject of theoretical and experimental research for decades and was first implemented for patient treatments in 2013. The AAPM Task Group 264 Safe Clinical Implementation of MLC Tracking in Radiotherapy Report was charged to proactively provide the broader radiation oncology community with (a) clinical implementation guidelines including hardware, software, and clinical indications for use, (b) commissioning and quality assurance recommendations based on early user experience, as well as guidelines on Failure Mode and Effects Analysis, and (c) a discussion of potential future developments. The deliverables from this report include: an explanation of MLC tracking and its historical development; terms and definitions relevant to MLC tracking; the clinical benefit of, clinical experience with and clinical implementation guidelines for MLC tracking; quality assurance guidelines, including example quality assurance worksheets; a clinical decision pathway, future outlook and overall recommendations.
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Affiliation(s)
- Paul J Keall
- ACRF Image X Institute, The University of Sydney Faculty of Medicine and Health, Sydney, NSW, 2006, Australia
| | - Amit Sawant
- Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Ross I Berbeco
- Radiation Oncology, Brigham and Women's Hospital, Boston, MA, 02115, USA
| | - Jeremy T Booth
- Radiation Oncology, Royal North Shore Hospital, St Leonards, 2065, NSW, Australia.,Institute of Medical Physics, School of Physics, University of Sydney, Sydney, NSW, 2006, Australia
| | - Byungchul Cho
- Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, 138-736, Republic of Korea
| | - Laura I Cerviño
- Radiation Medicine & Applied Sciences, Radiation Oncology PET/CT Center, UC San Diego, LA Jolla, CA, 92093-0865, USA.,Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, 10065-6007, USA
| | - Eileen Cirino
- Lahey Health and Medical Center, Burlington, MA, 01805, USA
| | - Sonja Dieterich
- Department of Radiation Oncology, UC Davis Medical Center, Sacramento, CA, 95618, USA
| | - Martin F Fast
- Department of Radiotherapy, University Medical Center Utrecht, 3584 CX, Utrecht, The Netherlands
| | - Peter B Greer
- Calvary Mater Newcastle, Newcastle, NSW, 2310, Australia
| | - Per Munck Af Rosenschöld
- Radiation Physics, Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Parag J Parikh
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, 63110, USA.,Department of Radiation Oncology, Henry Ford Hospital, Detroit, MI, 48202, USA
| | - Per Rugaard Poulsen
- Department of Oncology and Danish Center for Particle Therapy, Aarhus University Hospital, 8200, Aarhus, Denmark
| | - Lakshmi Santanam
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, 63110, USA.,Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, 10065-6007, USA
| | | | - Jie Shi
- Sun Nuclear Corp, Melbourne, FL, 32940, USA
| | - Sotirios Stathakis
- University of Texas Health San Antonio Cancer Center, San Antonio, TX, 78229, USA
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16
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Thomas MA, Olick-Gibson J, Fu Y, Parikh PJ, Green O, Yang D. Using prediction models to evaluate magnetic resonance image guided radiation therapy plans. Phys Imaging Radiat Oncol 2020; 16:99-102. [PMID: 33458351 PMCID: PMC7807572 DOI: 10.1016/j.phro.2020.10.002] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 10/01/2020] [Accepted: 10/02/2020] [Indexed: 10/26/2022]
Abstract
Comprehensive analysis of daily, online adaptive plan quality and safety in magnetic resonance imaging (MRI) guided radiation therapy is critical to its widespread use. Artificial neural network models developed with offline plans created after simulation were used to analyze and compare online plans that were adapted and reoptimized in real time prior to treatment. Roughly one third of 60Co adapted plans were of inferior quality relative to fully optimized, offline plans, but MRI-linac adapted plans were essentially equivalent to offline plans. The models also enabled clear justification that MRI-linac plans are superior to 60Co in an overwhelming majority of cases.
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Affiliation(s)
- M Allan Thomas
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO 63108, United States.,Department of Imaging Physics, UT MD Anderson Cancer Center, Houston, TX 77030, United States
| | - Joshua Olick-Gibson
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO 63108, United States
| | - Yabo Fu
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO 63108, United States.,Department of Radiation Oncology, Emory University, Atlanta, GA 30332, United States
| | - Parag J Parikh
- Department of Radiation Oncology, Henry Ford Cancer Institute, Detroit, MI 48202, United States
| | - Olga Green
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO 63108, United States
| | - Deshan Yang
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO 63108, United States
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17
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Chen B, Alvarado DM, Iticovici M, Kau NS, Park H, Parikh PJ, Thotala D, Ciorba MA. Interferon-Induced IDO1 Mediates Radiation Resistance and Is a Therapeutic Target in Colorectal Cancer. Cancer Immunol Res 2020; 8:451-464. [PMID: 32127391 PMCID: PMC7123802 DOI: 10.1158/2326-6066.cir-19-0282] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 11/08/2019] [Accepted: 02/20/2020] [Indexed: 12/13/2022]
Abstract
Colorectal cancer is a major cause of mortality worldwide. Chemotherapy and radiation remain standard treatment for locally advanced disease, with current immune-targeting therapies applying to only a small subset of patients. Expression of the immuno-oncology target indoleamine 2,3 dioxygenase 1 (IDO1) is associated with poor colorectal cancer clinical outcomes but is understudied as a potential treatment target. In this study, we examined the interaction between the IDO1 pathway and radiotherapy in colorectal cancer. We used human and mouse colorectal cancer cell lines, organoids, mouse syngeneic colorectal cancer tumor graft models, and colorectal cancer tissues from patients who received radiotherapy. IDO1 activity was blocked using the clinical IDO1 inhibitor epacadostat and by genetic disruption. We found that radiation induced IDO1 overexpression in colorectal cancer through type I and II IFN signaling. IDO1 enzymatic activity directly influenced colorectal cancer radiation sensitivity. IDO1 inhibition sensitized colorectal cancer to radiation-induced cell death, whereas the IDO1 metabolite kynurenine promoted radioprotection. IDO1 inhibition also potentiated Th1 cytokines and myeloid cell-modulating factors in the tumor microenvironment and promoted an abscopal effect on tumors outside the radiation field. Conversely, IDO1 blockade protected the normal small intestinal epithelium from radiation toxicity and accelerated recovery from radiation-induced weight loss, indicating a role in limiting side effects. These data demonstrated that IDO1 inhibition potentiates radiotherapy effectiveness in colorectal cancer. The findings also provide rationale and mechanistic insight for the study of IDO1 inhibitors as adjuvant therapy to radiation in patients with locally advanced sporadic and colitis-associated colorectal cancer.
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MESH Headings
- Animals
- Antineoplastic Agents/pharmacology
- Cell Line, Tumor
- Colorectal Neoplasms/enzymology
- Colorectal Neoplasms/immunology
- Colorectal Neoplasms/pathology
- Colorectal Neoplasms/radiotherapy
- Female
- Gene Expression Regulation, Enzymologic/drug effects
- Humans
- Indoleamine-Pyrrole 2,3,-Dioxygenase/antagonists & inhibitors
- Indoleamine-Pyrrole 2,3,-Dioxygenase/genetics
- Indoleamine-Pyrrole 2,3,-Dioxygenase/metabolism
- Interferons/pharmacology
- Intestinal Mucosa/radiation effects
- Kynurenine/metabolism
- Mice
- Mice, Inbred BALB C
- Mice, Inbred C57BL
- Mice, Knockout
- Oximes/pharmacology
- Radiation Tolerance/drug effects
- Radiation-Protective Agents/pharmacology
- Sulfonamides/pharmacology
- Tumor Microenvironment
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Affiliation(s)
- Baosheng Chen
- Inflammatory Bowel Diseases Center and the Division of Gastroenterology, Washington University in Saint Louis School of Medicine, St. Louis, Missouri.
| | - David M Alvarado
- Inflammatory Bowel Diseases Center and the Division of Gastroenterology, Washington University in Saint Louis School of Medicine, St. Louis, Missouri
| | - Micah Iticovici
- Inflammatory Bowel Diseases Center and the Division of Gastroenterology, Washington University in Saint Louis School of Medicine, St. Louis, Missouri
| | - Nathan S Kau
- Inflammatory Bowel Diseases Center and the Division of Gastroenterology, Washington University in Saint Louis School of Medicine, St. Louis, Missouri
| | - Haeseong Park
- Division of Medical Oncology, Washington University in Saint Louis School of Medicine, St. Louis, Missouri
| | - Parag J Parikh
- Department of Radiation Oncology, Washington University in Saint Louis School of Medicine, St. Louis, Missouri
| | - Dinesh Thotala
- Department of Radiation Oncology, Washington University in Saint Louis School of Medicine, St. Louis, Missouri
| | - Matthew A Ciorba
- Inflammatory Bowel Diseases Center and the Division of Gastroenterology, Washington University in Saint Louis School of Medicine, St. Louis, Missouri.
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18
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Dobelbower MC, Popple RA, Minnich DJ, Nader DA, Zimmerman F, Paris GE, Herth FJ, Gompelmann D, Roeder FF, Parikh PJ, McDonald AM. Anchored Transponder Guided Lung Radiation Therapy. Pract Radiat Oncol 2020; 10:e37-e44. [DOI: 10.1016/j.prro.2019.08.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/30/2019] [Accepted: 08/07/2019] [Indexed: 10/26/2022]
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19
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Hall WA, Paulson ES, van der Heide UA, Fuller CD, Raaymakers BW, Lagendijk JJW, Li XA, Jaffray DA, Dawson LA, Erickson B, Verheij M, Harrington KJ, Sahgal A, Lee P, Parikh PJ, Bassetti MF, Robinson CG, Minsky BD, Choudhury A, Tersteeg RJHA, Schultz CJ. The transformation of radiation oncology using real-time magnetic resonance guidance: A review. Eur J Cancer 2019; 122:42-52. [PMID: 31614288 PMCID: PMC8447225 DOI: 10.1016/j.ejca.2019.07.021] [Citation(s) in RCA: 120] [Impact Index Per Article: 24.0] [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: 05/15/2019] [Revised: 07/11/2019] [Accepted: 07/16/2019] [Indexed: 12/11/2022]
Abstract
Radiation therapy (RT) is an essential component of effective cancer care and is used across nearly all cancer types. The delivery of RT is becoming more precise through rapid advances in both computing and imaging. The direct integration of magnetic resonance imaging (MRI) with linear accelerators represents an exciting development with the potential to dramatically impact cancer research and treatment. These impacts extend beyond improved imaging and dose deposition. Real-time MRI-guided RT is actively transforming the work flows and capabilities of virtually every aspect of RT. It has the opportunity to change entirely the delivery methods and response assessments of numerous malignancies. This review intends to approach the topic of MRI-based RT guidance from a vendor neutral and international perspective. It also aims to provide an introduction to this topic targeted towards oncologists without a speciality focus in RT. Speciality implications, areas for physician education and research opportunities are identified as they are associated with MRI-guided RT. The uniquely disruptive implications of MRI-guided RT are discussed and placed in context. We further aim to describe and outline important future changes to the speciality of radiation oncology that will occur with MRI-guided RT. The impacts on RT caused by MRI guidance include target identification, RT planning, quality assurance, treatment delivery, training, clinical workflow, tumour response assessment and treatment scheduling. In addition, entirely novel research areas that may be enabled by MRI guidance are identified for future investigation.
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Affiliation(s)
- William A Hall
- Medical College of Wisconsin, Department of Radiation Oncology, USA.
| | - Eric S Paulson
- Medical College of Wisconsin, Department of Radiation Oncology, USA
| | | | - Clifton D Fuller
- University of Texas, MD Anderson Cancer Center, USA; Netherlands Cancer Institute, the Netherlands
| | - B W Raaymakers
- UMC Utrecht, Department of Radiotherapy, the Netherlands
| | | | - X Allen Li
- Medical College of Wisconsin, Department of Radiation Oncology, USA
| | - David A Jaffray
- Princess Margaret Cancer Centre, University of Toronto, Canada
| | - Laura A Dawson
- Princess Margaret Cancer Centre, University of Toronto, Canada
| | - Beth Erickson
- Medical College of Wisconsin, Department of Radiation Oncology, USA
| | - Marcel Verheij
- Radbound University Medical Center, Nijmegen, the Netherlands
| | - Kevin J Harrington
- The Institute of Cancer Research, The Royal Marsden NHS Foundation Trust, UK
| | - Arjun Sahgal
- Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Percy Lee
- University of California, Los Angeles, USA
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20
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Janssen QP, Buettner S, Suker M, Beumer BR, Addeo P, Bachellier P, Bahary N, Bekaii-Saab T, Bali MA, Besselink MG, Boone BA, Chau I, Clarke S, Dillhoff M, El-Rayes BF, Frakes JM, Grose D, Hosein PJ, Jamieson NB, Javed AA, Khan K, Kim KP, Kim SC, Kim SS, Ko AH, Lacy J, Margonis GA, McCarter MD, McKay CJ, Mellon EA, Moorcraft SY, Okada KI, Paniccia A, Parikh PJ, Peters NA, Rabl H, Samra J, Tinchon C, van Tienhoven G, van Veldhuisen E, Wang-Gillam A, Weiss MJ, Wilmink JW, Yamaue H, Homs MYV, van Eijck CHJ, Katz MHG, Groot Koerkamp B. Neoadjuvant FOLFIRINOX in Patients With Borderline Resectable Pancreatic Cancer: A Systematic Review and Patient-Level Meta-Analysis. J Natl Cancer Inst 2019; 111:782-794. [PMID: 31086963 PMCID: PMC6695305 DOI: 10.1093/jnci/djz073] [Citation(s) in RCA: 191] [Impact Index Per Article: 38.2] [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: 12/19/2018] [Revised: 12/19/2018] [Accepted: 04/22/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND FOLFIRINOX is a standard treatment for metastatic pancreatic cancer patients. The effectiveness of neoadjuvant FOLFIRINOX in patients with borderline resectable pancreatic cancer (BRPC) remains debated. METHODS We performed a systematic review and patient-level meta-analysis on neoadjuvant FOLFIRINOX in patients with BRPC. Studies with BRPC patients who received FOLFIRINOX as first-line neoadjuvant treatment were included. The primary endpoint was overall survival (OS), and secondary endpoints were progression-free survival, resection rate, R0 resection rate, and grade III-IV adverse events. Patient-level survival outcomes were obtained from authors of the included studies and analyzed using the Kaplan-Meier method. RESULTS We included 24 studies (8 prospective, 16 retrospective), comprising 313 (38.1%) BRPC patients treated with FOLFIRINOX. Most studies (n = 20) presented intention-to-treat results. The median number of administered neoadjuvant FOLFIRINOX cycles ranged from 4 to 9. The resection rate was 67.8% (95% confidence interval [CI] = 60.1% to 74.6%), and the R0-resection rate was 83.9% (95% CI = 76.8% to 89.1%). The median OS varied from 11.0 to 34.2 months across studies. Patient-level survival data were obtained for 20 studies representing 283 BRPC patients. The patient-level median OS was 22.2 months (95% CI = 18.8 to 25.6 months), and patient-level median progression-free survival was 18.0 months (95% CI = 14.5 to 21.5 months). Pooled event rates for grade III-IV adverse events were highest for neutropenia (17.5 per 100 patients, 95% CI = 10.3% to 28.3%), diarrhea (11.1 per 100 patients, 95% CI = 8.6 to 14.3), and fatigue (10.8 per 100 patients, 95% CI = 8.1 to 14.2). No deaths were attributed to FOLFIRINOX. CONCLUSIONS This patient-level meta-analysis of BRPC patients treated with neoadjuvant FOLFIRINOX showed a favorable median OS, resection rate, and R0-resection rate. These results need to be assessed in a randomized trial.
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Affiliation(s)
| | - Stefan Buettner
- See the Notes section for the full list of authors’ affiliations
| | - Mustafa Suker
- See the Notes section for the full list of authors’ affiliations
| | - Berend R Beumer
- See the Notes section for the full list of authors’ affiliations
| | - Pietro Addeo
- See the Notes section for the full list of authors’ affiliations
| | | | - Nathan Bahary
- See the Notes section for the full list of authors’ affiliations
| | | | - Maria A Bali
- See the Notes section for the full list of authors’ affiliations
| | - Marc G Besselink
- See the Notes section for the full list of authors’ affiliations
| | - Brian A Boone
- See the Notes section for the full list of authors’ affiliations
| | - Ian Chau
- See the Notes section for the full list of authors’ affiliations
| | - Stephen Clarke
- See the Notes section for the full list of authors’ affiliations
| | - Mary Dillhoff
- See the Notes section for the full list of authors’ affiliations
| | | | - Jessica M Frakes
- See the Notes section for the full list of authors’ affiliations
| | - Derek Grose
- See the Notes section for the full list of authors’ affiliations
| | - Peter J Hosein
- See the Notes section for the full list of authors’ affiliations
| | - Nigel B Jamieson
- See the Notes section for the full list of authors’ affiliations
| | - Ammar A Javed
- See the Notes section for the full list of authors’ affiliations
| | - Khurum Khan
- See the Notes section for the full list of authors’ affiliations
| | - Kyu-Pyo Kim
- See the Notes section for the full list of authors’ affiliations
| | - Song Cheol Kim
- See the Notes section for the full list of authors’ affiliations
| | - Sunhee S Kim
- See the Notes section for the full list of authors’ affiliations
| | - Andrew H Ko
- See the Notes section for the full list of authors’ affiliations
| | - Jill Lacy
- See the Notes section for the full list of authors’ affiliations
| | | | | | - Colin J McKay
- See the Notes section for the full list of authors’ affiliations
| | - Eric A Mellon
- See the Notes section for the full list of authors’ affiliations
| | | | - Ken-Ichi Okada
- See the Notes section for the full list of authors’ affiliations
| | | | - Parag J Parikh
- See the Notes section for the full list of authors’ affiliations
| | - Niek A Peters
- See the Notes section for the full list of authors’ affiliations
| | - Hans Rabl
- See the Notes section for the full list of authors’ affiliations
| | - Jaswinder Samra
- See the Notes section for the full list of authors’ affiliations
| | | | | | | | | | - Matthew J Weiss
- See the Notes section for the full list of authors’ affiliations
| | | | - Hiroki Yamaue
- See the Notes section for the full list of authors’ affiliations
| | | | | | - Matthew H G Katz
- See the Notes section for the full list of authors’ affiliations
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21
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Rudra S, Jiang N, Rosenberg SA, Olsen JR, Roach MC, Wan L, Portelance L, Mellon EA, Bruynzeel A, Lagerwaard F, Bassetti MF, Parikh PJ, Lee PP. Cover Image. Cancer Med 2019. [DOI: 10.1002/cam4.2258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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22
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Rudra S, Jiang N, Rosenberg SA, Olsen JR, Roach MC, Wan L, Portelance L, Mellon EA, Bruynzeel A, Lagerwaard F, Bassetti MF, Parikh PJ, Lee PP. Using adaptive magnetic resonance image-guided radiation therapy for treatment of inoperable pancreatic cancer. Cancer Med 2019; 8:2123-2132. [PMID: 30932367 PMCID: PMC6536981 DOI: 10.1002/cam4.2100] [Citation(s) in RCA: 205] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 02/12/2019] [Accepted: 02/26/2019] [Indexed: 02/06/2023] Open
Abstract
Background Adaptive magnetic resonance imaging‐guided radiation therapy (MRgRT) can escalate dose to tumors while minimizing dose to normal tissue. We evaluated outcomes of inoperable pancreatic cancer patients treated using MRgRT with and without dose escalation. Methods We reviewed 44 patients with inoperable pancreatic cancer treated with MRgRT. Treatments included conventional fractionation, hypofractionation, and stereotactic body radiation therapy. Patients were stratified into high‐dose (biologically effective dose [BED10] >70) and standard‐dose groups (BED10 ≤70). Overall survival (OS), freedom from local failure (FFLF) and freedom from distant failure (FFDF) were evaluated using Kaplan‐Meier method. Cox regression was performed to identify predictors of OS. Acute gastrointestinal (GI) toxicity was assessed for 6 weeks after completion of RT. Results Median follow‐up was 17 months. High‐dose patients (n = 24, 55%) had statistically significant improvement in 2‐year OS (49% vs 30%, P = 0.03) and trended towards significance for 2‐year FFLF (77% vs 57%, P = 0.15) compared to standard‐dose patients (n = 20, 45%). FFDF at 18 months in high‐dose vs standard‐dose groups was 24% vs 48%, respectively (P = 0.92). High‐dose radiation (HR: 0.44; 95% confidence interval [CI]: 0.21‐0.94; P = 0.03) and duration of induction chemotherapy (HR: 0.84; 95% CI: 0.72‐0.98; P = 0.03) were significantly correlated with OS on univariate analysis but neither factor was independently predictive on multivariate analysis. Grade 3+ GI toxicity occurred in three patients in the standard‐dose group and did not occur in the high‐dose group. Conclusions Patients treated with dose‐escalated MRgRT demonstrated improved OS. Prospective evaluation of high‐dose RT regimens with standardized treatment parameters in inoperable pancreatic cancer patients is warranted.
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Affiliation(s)
- Soumon Rudra
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Naomi Jiang
- Department of Radiation Oncology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Stephen A Rosenberg
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Carbone Cancer Center, Madison, Wisconsin
| | - Jeffrey R Olsen
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Michael C Roach
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Leping Wan
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Lorraine Portelance
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida
| | - Eric A Mellon
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida
| | - Anna Bruynzeel
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, Netherlands
| | - Frank Lagerwaard
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, Netherlands
| | - Michael F Bassetti
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Carbone Cancer Center, Madison, Wisconsin
| | - Parag J Parikh
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Percy P Lee
- Department of Radiation Oncology, David Geffen School of Medicine at UCLA, Los Angeles, California
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23
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Maughan NM, Garcia-Ramirez J, Arpidone M, Swallen A, Laforest R, Goddu SM, Parikh PJ, Zoberi JE. Validation of post-treatment PET-based dosimetry software for hepatic radioembolization of Yttrium-90 microspheres. Med Phys 2019; 46:2394-2402. [PMID: 30742714 DOI: 10.1002/mp.13444] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 01/27/2019] [Accepted: 01/28/2019] [Indexed: 01/06/2023] Open
Abstract
PURPOSE Yttrium-90 (90 Y) microsphere radioembolization enables selective internal radiotherapy for hepatic malignancies. Currently, there is no standard postdelivery imaging and dosimetry of the microsphere distribution to verify treatment. Recent studies have reported utilizing the small positron yield of 90 Y (32 ppm) with positron emission tomography (PET) to perform treatment verification and dosimetry analysis. In this study, we validated a commercial dosimetry software, MIM SurePlan™ LiverY90 (MIM Software Inc., Cleveland, OH), for clinical use. METHODS A MATLAB-based algorithm for 90 Y PET-based dosimetry was developed in-house and validated for the purpose of commissioning the commercial software. The algorithm is based on voxel S values and dosimetry formalism reported in MIRD Pamphlet 17. We validated the in-house algorithm to establish it as the ground truth by comparing results from a digital point phantom and a digital uniform cylinder to manual calculations. Once we validated our in-house MATLAB-based algorithm, we used it to perform acceptance testing and commissioning of the commercial dosimetry software, MIM SurePlan, which uses the same dosimetry formalism. A 0.4 cm/5% gamma test was performed on PET-derived dose maps from each algorithm of uniform digital and nonuniform physical phantoms filled with 90 Y chloride solution. Average dose (Davg ) and minimum dose to 70% (D70 ) of a given volume of interest (VOI) were compared for the digital phantom, the physical phantom, and five patient cases (27 tumor VOIs), representing different clinical scenarios. RESULTS The gamma-pass rates were 97.26% and 97.66% for the digital and physical phantoms, respectively. The differences between Davg and D70 were 0.076% and 0.10% for the digital phantom, respectively, and <5.2% for various VOIs in the physical phantom. In the clinical cases, 96.3% of the VOIs had a difference <5% for Davg , and 88.9% of the VOIs had a difference <5% for D70 . CONCLUSIONS Dose calculation results from MIM SurePlan were found to be in good agreement with our in-house algorithm. This indicates that MIM SurePlan performs as it should and, hence, can be deemed accepted and commissioned for clinical use for post-implant PET-based dosimetry of 90 Y radioembolization.
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Affiliation(s)
- Nichole M Maughan
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Jose Garcia-Ramirez
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | | | | | - Richard Laforest
- Department of Radiology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - S Murty Goddu
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Parag J Parikh
- Department of Radiation Oncology, Henry Ford Hospital, Detroit, MI, 48202, USA
| | - Jacqueline E Zoberi
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, 63110, USA
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24
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Henke LE, Olsen JR, Contreras JA, Curcuru A, DeWees TA, Green OL, Michalski J, Mutic S, Roach MC, Bradley JD, Parikh PJ, Kashani R, Robinson CG. Stereotactic MR-Guided Online Adaptive Radiation Therapy (SMART) for Ultracentral Thorax Malignancies: Results of a Phase 1 Trial. Adv Radiat Oncol 2018; 4:201-209. [PMID: 30706029 PMCID: PMC6349650 DOI: 10.1016/j.adro.2018.10.003] [Citation(s) in RCA: 114] [Impact Index Per Article: 19.0] [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: 03/06/2018] [Accepted: 10/05/2018] [Indexed: 12/25/2022] Open
Abstract
Purpose Stereotactic body radiation therapy (SBRT) is an effective treatment for oligometastatic or unresectable primary malignancies, although target proximity to organs at risk (OARs) within the ultracentral thorax (UCT) limits safe delivery of an ablative dose. Stereotactic magnetic resonance (MR)–guided online adaptive radiation therapy (SMART) may improve the therapeutic ratio using reoptimization to account for daily variation in target and OAR anatomy. This study assessed the feasibility of UCT SMART and characterized dosimetric and clinical outcomes in patients treated for UCT lesions on a prospective phase 1 trial. Methods and Materials Five patients with oligometastatic (n = 4) or unresectable primary (n = 1) UCT malignancies underwent SMART. Initial plans prescribed 50 Gy in 5 fractions with goal 95% planning target volume (PTV) coverage by 95% of prescription, subject to strict OAR constraints. Daily real-time online adaptive plans were created as needed to preserve hard OAR constraints, escalate PTV dose, or both, based on daily setup MR image set anatomy. Treatment times, patient outcomes, and dosimetric comparisons were prospectively recorded. Results All initial and daily adaptive plans met strict OAR constraints based on simulation and daily setup MR imaging anatomy, respectively. Four of the 5 patients received ≥1 adapted fraction. Ten of the 25 total delivered fractions were adapted. A total of 30% of plan adaptations were performed to improve PTV coverage; 70% were for reversal of ≥1 OAR violation. Local control by Response Evaluation Criteria in Solid Tumors was 100% at 3 and 6 months. No grade ≥3 acute (within 6 months of radiation completion) treatment-related toxicities were identified. Conclusions SMART may allow PTV coverage improvement and/or OAR sparing compared with nonadaptive SBRT and may widen the therapeutic index of UCT SBRT. In this small prospective cohort, we found that SMART was clinically deliverable to 100% of patients, although treatment delivery times surpassed our predefined, timing-based feasibility endpoint. This technique is well tolerated, offering excellent local control with no identified acute grade ≥3 toxicity.
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Affiliation(s)
- Lauren E. Henke
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Jeffrey R. Olsen
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Jessika A. Contreras
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Austen Curcuru
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Todd A. DeWees
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Scottsdale, Arizona
| | - Olga L. Green
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Jeff Michalski
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Sasa Mutic
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Michael C. Roach
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Jeffrey D. Bradley
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Parag J. Parikh
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Rojano Kashani
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Clifford G. Robinson
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
- Corresponding author. Department of Radiation Oncology, Washington University School of Medicine, Campus Box 8224, 4921 Parkview Place, Floor LL, St Louis, MO 63110.
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Weiner AA, Gui B, Newman NB, Nosher JL, Yousseff F, Lu SE, Foltz GM, Carpizo D, Lowenthal J, Zuckerman DA, Benson B, Olsen JR, Jabbour SK, Parikh PJ. Predictors of Survival after Yttrium-90 Radioembolization for Colorectal Cancer Liver Metastases. J Vasc Interv Radiol 2018; 29:1094-1100. [PMID: 29754852 PMCID: PMC10905616 DOI: 10.1016/j.jvir.2018.02.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [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: 07/25/2017] [Revised: 02/14/2018] [Accepted: 02/17/2018] [Indexed: 02/08/2023] Open
Abstract
PURPOSE To identify clinical parameters that are prognostic for improved overall survival (OS) after yttrium-90 radioembolization (RE) in patients with liver metastases from colorectal cancer (CRC). MATERIALS AND METHODS A total of 131 patients who underwent RE for liver metastases from CRC, treated at 2 academic centers, were reviewed. Twenty-one baseline pretreatment clinical factors were analyzed in relation to OS by the Kaplan-Meier method along with log-rank tests and univariate and multivariate Cox regression analyses. RESULTS The median OS from first RE procedure was 10.7 months (95% confidence interval [CI], 9.4-12.7 months). Several pretreatment factors, including lower carcinoembryonic antigen (CEA; ≤20 ng/mL), lower aspartate transaminase (AST; ≤40 IU/L), neutrophil-lymphocyte ratio (NLR) <5, and absence of extrahepatic disease at baseline were associated with significantly improved OS after RE, compared with high CEA (>20 ng/mL), high AST (>40 IU/L), NLR ≥5, and extrahepatic metastases (P values of <.001, <.001, .0001, and .04, respectively). On multivariate analysis, higher CEA, higher AST, NLR ≥5, extrahepatic disease, and larger volume of liver metastases remained independently associated with risk of death (hazard ratios of 1.63, 2.06, 2.22, 1.48, and 1.02, respectively). CONCLUSIONS The prognosis of patients with metastases from CRC is impacted by a complex set of clinical parameters. This analysis of pretreatment factors identified lower AST, lower CEA, lower NLR, and lower tumor burden (intra- or extrahepatic) to be independently associated with higher survival after hepatic RE. Optimal selection of patients with CRC liver metastases may improve survival rates after administration of yttrium-90.
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Affiliation(s)
- Ashley A Weiner
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Bin Gui
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Neil B Newman
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - John L Nosher
- Department of Radiology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Fady Yousseff
- Department of Radiation Oncology, Washington University School of Medicine, 660 South Euclid Ave, St Louis, Missouri 63110
| | - Shou-En Lu
- Rutgers School of Public Health, New Brunswick, New Jersey
| | - Gretchen M Foltz
- Department of Radiology, Washington University School of Medicine, 660 South Euclid Ave, St Louis, Missouri 63110
| | - Darren Carpizo
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Jonathan Lowenthal
- Department of Radiology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Darryl A Zuckerman
- Department of Radiology, Washington University School of Medicine, 660 South Euclid Ave, St Louis, Missouri 63110
| | - Ben Benson
- Department of Radiology, Jacobi Medical Center, Bronx, New York
| | - Jeffrey R Olsen
- Department of Radiation Oncology, University of Colorado, Denver, Colorado
| | - Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Parag J Parikh
- Department of Radiation Oncology, Washington University School of Medicine, 660 South Euclid Ave, St Louis, Missouri 63110.
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Green OL, Rankine LJ, Cai B, Curcuru A, Kashani R, Rodriguez V, Li HH, Parikh PJ, Robinson CG, Olsen JR, Mutic S, Goddu SM, Santanam L. First clinical implementation of real-time, real anatomy tracking and radiation beam control. Med Phys 2018; 45:3728-3740. [PMID: 29807390 DOI: 10.1002/mp.13002] [Citation(s) in RCA: 97] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 01/05/2018] [Accepted: 01/05/2018] [Indexed: 12/25/2022] Open
Abstract
PURPOSE We describe the acceptance testing, commissioning, periodic quality assurance, and workflow procedures developed for the first clinically implemented magnetic resonance imaging-guided radiation therapy (MR-IGRT) system for real-time tracking and beam control. METHODS The system utilizes real-time cine imaging capabilities at 4 frames per second for real-time tracking and beam control. Testing of the system was performed using an in-house developed motion platform and a commercially available motion phantom. Anatomical tracking is performed by first identifying a target (a region of interest that is either tissue to be treated or a critical structure) and generating a contour around it. A boundary contour is also created to identify tracking margins. The tracking algorithm deforms the anatomical contour (target or a normal organ) on every subsequent cine frame and compares it to the static boundary contour. If the anatomy of interest moves outside the boundary, the radiation delivery is halted until the tracked anatomy returns to treatment portal. The following were performed to validate and clinically implement the system: (a) spatial integrity evaluation; (b) tracking accuracy; (c) latency; (d) relative point dose and spatial dosimetry; (e) development of clinical workflow for gating; and (f) independent verification by an outside credentialing service. RESULTS The spatial integrity of the MR system was found to be within 2 mm over a 45-cm diameter field-of-view. The tracking accuracy for geometric targets was within 1.2 mm. The average system latency was measured to be within 394 ms. The dosimetric accuracy using ionization chambers was within 1.3% ± 1.7%, and the dosimetric spatial accuracy was within 2 mm. The phantom irradiation for the outside credentialing service had satisfactory results, as well. CONCLUSIONS The first clinical MR-IGRT system was validated for real-time tracking and gating capabilities and shown to be reliable and accurate. Patient workflow methods were developed for efficient treatment. Periodic quality assurance tests can be efficiently performed with commercially available equipment to ensure accurate system performance.
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Affiliation(s)
- Olga L Green
- Washington University School of Medicine, St. Louis, MO, 63130, USA
| | - Leith J Rankine
- University of North Carolina at Chapel Hill, Chapel Hill, NC, 27713, USA
| | - Bin Cai
- Washington University School of Medicine, St. Louis, MO, 63130, USA
| | - Austen Curcuru
- Washington University School of Medicine, St. Louis, MO, 63130, USA
| | | | - Vivian Rodriguez
- Washington University School of Medicine, St. Louis, MO, 63130, USA
| | - H Harold Li
- Washington University School of Medicine, St. Louis, MO, 63130, USA
| | - Parag J Parikh
- Washington University School of Medicine, St. Louis, MO, 63130, USA
| | | | - Jeffrey R Olsen
- University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - Sasa Mutic
- Washington University School of Medicine, St. Louis, MO, 63130, USA
| | - S M Goddu
- Washington University School of Medicine, St. Louis, MO, 63130, USA
| | - Lakshmi Santanam
- Washington University School of Medicine, St. Louis, MO, 63130, USA
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Eldeniz C, Fraum T, Salter A, Chen Y, Gach HM, Parikh PJ, Fowler KJ, An H. CAPTURE: Consistently Acquired Projections for Tuned and Robust Estimation: A Self-Navigated Respiratory Motion Correction Approach. Invest Radiol 2018; 53:293-305. [PMID: 29315083 PMCID: PMC5882511 DOI: 10.1097/rli.0000000000000442] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES In this study, we present a fully automated and robust self-navigated approach to obtain 4-dimensional (4-D) motion-resolved images during free breathing. MATERIALS AND METHODS The proposed method, Consistently Acquired Projections for Tuned and Robust Estimation (CAPTURE), is a variant of the stack-of-stars gradient-echo sequence. A 1-D navigator was consistently acquired at a fixed azimuthal angle for all stacks of spokes to reduce nonphysiological signal contamination due to system imperfections. The resulting projections were then "tuned" using complex phase rotation to adapt to scan-to-scan variations, followed by the detection of the respiratory curve. Four-dimensional motion-corrected and uncorrected images were then reconstructed via respiratory and temporal binning, respectively.This Health Insurance Portability and Accountability Act-compliant study was performed with Institutional Review Board approval. A phantom experiment was performed using a custom-made deformable motion phantom with an adjustable frequency and amplitude. For in vivo experiments, 10 healthy participants and 12 liver tumor patients provided informed consent and were imaged with the CAPTURE sequence.Two radiologists, blinded to which images were motion-corrected and which were not, independently reviewed the images and scored the image quality using a 5-point Likert scale. RESULTS In the respiratory motion phantom experiment, CAPTURE reversed the effects of motion blurring and restored edge sharpness from 36% to 78% of that observed in the images from the static scan.Despite large intra- and intersubject variability in respiration patterns, CAPTURE successfully detected the respiratory motion signal in all participants and significantly improved the image quality according to the subjective radiological assessments of 2 raters (P < 0.05 for both raters) with a 1 to 2-point improvement in the median Likert scores across the whole set of participants. Small lesions (<1 cm in size) which might otherwise be missed on uncorrected images because of motion blurring were more clearly depicted on the CAPTURE images. CONCLUSIONS CAPTURE provides a robust and fully automated solution for obtaining 4-D motion-resolved images in a free-breathing setting. With its unique tuning feature, CAPTURE can adapt to large intersubject and interscan variations. CAPTURE also enables better lesion delineation because of improved image sharpness, thereby increasing the visibility of small lesions.
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Maughan NM, Eldib M, Faul D, Conti M, Elschot M, Knešaurek K, Leek F, Townsend D, DiFilippo FP, Jackson K, Nekolla SG, Lukas M, Tapner M, Parikh PJ, Laforest R. Multi institutional quantitative phantom study of yttrium-90 PET in PET/MRI: the MR-QUEST study. EJNMMI Phys 2018; 5:7. [PMID: 29616365 PMCID: PMC5882483 DOI: 10.1186/s40658-018-0206-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [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: 10/30/2017] [Accepted: 02/16/2018] [Indexed: 12/22/2022] Open
Abstract
Background Yttrium-90 (90Y) radioembolization involves the intra-arterial delivery of radioactive microspheres to treat hepatic malignancies. Though this therapy involves careful pre-treatment planning and imaging, little is known about the precise location of the microspheres once they are administered. Recently, there has been growing interest post-radioembolization imaging using positron-emission tomography (PET) for quantitative dosimetry and identifying lesions that may benefit from additional salvage therapy. In this study, we aim to measure the inter-center variability of 90Y PET measurements as measured on PET/MRI in preparation for a multi-institutional prospective phase I/II clinical trial. Eight institutions participated in this study and followed a standardized phantom filling and imaging protocol. The NEMA NU2-2012 body phantom was filled with 3 GBq of 90Y chloride solution. The phantom was imaged for 30 min in listmode on a Siemens Biograph mMR non-TOF PET/MRI scanner at five time points across 10 days (0.3–3.0 GBq). Raw PET data were sent to a central site for image reconstruction and data analysis. Images were reconstructed with optimal parameters determined from a previous study. Volumes of interest (VOIs) matching the known sphere diameters were drawn on the vendor-provided attenuation map and propagated to the PET images. Recovery coefficients (RCs) and coefficient of variation of the RCs (COV) were calculated from these VOIs for each sphere size and activity level. Results Mean RCs ranged from 14.5 to 75.4%, with the lowest mean RC coming from the smallest sphere (10 mm) on the last day of imaging (0.16 MBq/ml) and the highest mean RC coming from the largest sphere (37 mm) on the first day of imaging (2.16 MBq/ml). The smaller spheres tended to exhibit higher COVs. In contrast, the larger spheres tended to exhibit lower COVs. COVs from the 37 mm sphere were < 25.3% in all scans. For scans with ≥ 0.60 MBq/ml, COVs were ≤ 25% in spheres ≥ 22 mm. However, for all other spheres sizes and activity levels, COVs were usually > 25%. Conclusions Post-radioembolization dosimetry of lesions or other VOIs ≥ 22 mm in diameter can be consistently obtained (< 25% variability) at a multi-institutional level using PET/MRI for any clinically significant activity for 90Y radioembolization.
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Affiliation(s)
- Nichole M Maughan
- Department of Radiation Oncology, Washington University School of Medicine, 4921 Parkview Place, Campus Box 8224, St. Louis, MO, 63110, USA
| | - Mootaz Eldib
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, 1470 Madison Ave, New York, NY, 10029, USA.,Department of Biomedical Engineering, City College of New York, 160 Convent Ave, New York, NY, 10031, USA
| | - David Faul
- Siemens Healthineers, Siemens Medical Solutions USA, Inc., 40 Liberty Boulevard, Malvern, PA, 19355-9998, USA
| | - Maurizio Conti
- Molecular Imaging, Siemens Healthineers, 810 Innovation Dr, Knoxville, TN, 37932, USA
| | - Mattijs Elschot
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Postboks 8905, 7491, Trondheim, Norway
| | - Karin Knešaurek
- Department of Radiology, Icahn School of Medicine at Mt. Sinai, One G. Levy Pl., Box 1141, New York, NY, 10029, USA
| | - Francesca Leek
- Agency for Science Technology and Research, National University of Singapore Clinical Imaging Research Centre, 14 Medical Drive, #B1-01, Singapore, 117599, Singapore
| | - David Townsend
- Agency for Science Technology and Research, National University of Singapore Clinical Imaging Research Centre, 14 Medical Drive, #B1-01, Singapore, 117599, Singapore
| | - Frank P DiFilippo
- Department of Nuclear Medicine, Cleveland Clinic, Mail Code Jb3, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | | | - Stephan G Nekolla
- Klinik und Poliklinik für Nuklearmedizin, TU München, Strasse 22, 81675, Munich, Germany
| | - Mathias Lukas
- Department of Nuclear Medicine, Charité-Universitätsmedizin Berlin, Charitépl. 1, 10117, Berlin, Germany.,Siemens Healthcare GmbH, Berlin, Germany
| | - Michael Tapner
- Sirtex Medical Ltd, Level 33, 101 Miller St, North Sydney, NSW, 2060, Australia.,ABX-CRO Advanced Pharmaceutical Services, 1 Begonia Road, Normanhurst, NSW, 2076, Australia
| | - Parag J Parikh
- Department of Radiation Oncology, Washington University School of Medicine, 4921 Parkview Place, Campus Box 8224, St. Louis, MO, 63110, USA.
| | - Richard Laforest
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway, Campus Box 8225, St. Louis, MO, 63110, USA
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Olberg S, Green O, Cai B, Yang D, Rodriguez V, Zhang H, Kim JS, Parikh PJ, Mutic S, Park JC. Optimization of treatment planning workflow and tumor coverage during daily adaptive magnetic resonance image guided radiation therapy (MR-IGRT) of pancreatic cancer. Radiat Oncol 2018; 13:51. [PMID: 29573744 PMCID: PMC5866525 DOI: 10.1186/s13014-018-1000-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [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: 11/09/2017] [Accepted: 03/15/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND To simplify the adaptive treatment planning workflow while achieving the optimal tumor-dose coverage in pancreatic cancer patients undergoing daily adaptive magnetic resonance image guided radiation therapy (MR-IGRT). METHODS In daily adaptive MR-IGRT, the plan objective function constructed during simulation is used for plan re-optimization throughout the course of treatment. In this study, we have constructed the initial objective functions using two methods for 16 pancreatic cancer patients treated with the ViewRay™ MR-IGRT system: 1) the conventional method that handles the stomach, duodenum, small bowel, and large bowel as separate organs at risk (OARs) and 2) the OAR grouping method. Using OAR grouping, a combined OAR structure that encompasses the portions of these four primary OARs within 3 cm of the planning target volume (PTV) is created. OAR grouping simulation plans were optimized such that the target coverage was comparable to the clinical simulation plan constructed in the conventional manner. In both cases, the initial objective function was then applied to each successive treatment fraction and the plan was re-optimized based on the patient's daily anatomy. OAR grouping plans were compared to conventional plans at each fraction in terms of coverage of the PTV and the optimized PTV (PTV OPT), which is the result of the subtraction of overlapping OAR volumes with an additional margin from the PTV. RESULTS Plan performance was enhanced across a majority of fractions using OAR grouping. The percentage of the volume of the PTV covered by 95% of the prescribed dose (D95) was improved by an average of 3.87 ± 4.29% while D95 coverage of the PTV OPT increased by 3.98 ± 4.97%. Finally, D100 coverage of the PTV demonstrated an average increase of 6.47 ± 7.16% and a maximum improvement of 20.19%. CONCLUSIONS In this study, our proposed OAR grouping plans generally outperformed conventional plans, especially when the conventional simulation plan favored or disregarded an OAR through the assignment of distinct weighting parameters relative to the other critical structures. OAR grouping simplifies the MR-IGRT adaptive treatment planning workflow at simulation while demonstrating improved coverage compared to delivered pancreatic cancer treatment plans in daily adaptive radiation therapy.
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Affiliation(s)
- Sven Olberg
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Olga Green
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Bin Cai
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Deshan Yang
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Vivian Rodriguez
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Hao Zhang
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Jin Sung Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea.
| | - Parag J Parikh
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Sasa Mutic
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Justin C Park
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, 63110, USA
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Bertholet J, Toftegaard J, Hansen R, Worm ES, Wan H, Parikh PJ, Weber B, Høyer M, Poulsen PR. Automatic online and real-time tumour motion monitoring during stereotactic liver treatments on a conventional linac by combined optical and sparse monoscopic imaging with kilovoltage x-rays (COSMIK). Phys Med Biol 2018. [PMID: 29516868 DOI: 10.1088/1361-6560/aaae8b] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The purpose of this study was to develop, validate and clinically demonstrate fully automatic tumour motion monitoring on a conventional linear accelerator by combined optical and sparse monoscopic imaging with kilovoltage x-rays (COSMIK). COSMIK combines auto-segmentation of implanted fiducial markers in cone-beam computed tomography (CBCT) projections and intra-treatment kV images with simultaneous streaming of an external motion signal. A pre-treatment CBCT is acquired with simultaneous recording of the motion of an external marker block on the abdomen. The 3-dimensional (3D) marker motion during the CBCT is estimated from the auto-segmented positions in the projections and used to optimize an external correlation model (ECM) of internal motion as a function of external motion. During treatment, the ECM estimates the internal motion from the external motion at 20 Hz. KV images are acquired every 3 s, auto-segmented, and used to update the ECM for baseline shifts between internal and external motion. The COSMIK method was validated using Calypso-recorded internal tumour motion with simultaneous camera-recorded external motion for 15 liver stereotactic body radiotherapy (SBRT) patients. The validation included phantom experiments and simulations hereof for 12 fractions and further simulations for 42 fractions. The simulations compared the accuracy of COSMIK with ECM-based monitoring without model updates and with model updates based on stereoscopic imaging as well as continuous kilovoltage intrafraction monitoring (KIM) at 10 Hz without an external signal. Clinical real-time tumour motion monitoring with COSMIK was performed offline for 14 liver SBRT patients (41 fractions) and online for one patient (two fractions). The mean 3D root-mean-square error for the four monitoring methods was 1.61 mm (COSMIK), 2.31 mm (ECM without updates), 1.49 mm (ECM with stereoscopic updates) and 0.75 mm (KIM). COSMIK is the first combined kV/optical real-time motion monitoring method used clinically online on a conventional accelerator. COSMIK gives less imaging dose than KIM and is in addition applicable when the kV imager cannot be deployed such as during non-coplanar fields.
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Affiliation(s)
- Jenny Bertholet
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark. Current address: Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom
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Hall WA, Heerkens HD, Paulson ES, Meijer GJ, Kotte AN, Knechtges P, Parikh PJ, Bassetti MF, Lee P, Aitken KL, Palta M, Myrehaug S, Koay EJ, Portelance L, Ben-Josef E, Erickson BA. Pancreatic gross tumor volume contouring on computed tomography (CT) compared with magnetic resonance imaging (MRI): Results of an international contouring conference. Pract Radiat Oncol 2018; 8:107-115. [PMID: 29426692 DOI: 10.1016/j.prro.2017.11.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 10/25/2017] [Accepted: 11/21/2017] [Indexed: 12/19/2022]
Abstract
PURPOSE Accurate identification of the gross tumor volume (GTV) in pancreatic adenocarcinoma is challenging. We sought to understand differences in GTV delineation using pancreatic computed tomography (CT) compared with magnetic resonance imaging (MRI). METHODS AND MATERIALS Twelve attending radiation oncologists were convened for an international contouring symposium. All participants had a clinical and research interest in pancreatic adenocarcinoma. CT and MRI scans from 3 pancreatic cases were used for contouring. CT and MRI GTVs were analyzed and compared. Interobserver variability was compared using Dice's similarity coefficient (DSC), Hausdorff distances, and Jaccard indices. Mann-Whitney tests were used to check for significant differences. Consensus contours on CT and MRI scans and constructed count maps were used to visualize the agreement. Agreement regarding the optimal method to determine GTV definition using MRI was reached. RESULTS Six contour sets (3 from CT and 3 from MRI) were obtained and compared for each observer, totaling 72 contour sets. The mean volume of contours on CT was significantly larger at 57.48 mL compared with a mean of 45.76 mL on MRI, P = .011. The standard deviation obtained from the CT contours was significantly larger than the standard deviation from the MRI contours (P = .027). The mean DSC was 0.73 for the CT and 0.72 for the MRI (P = .889). The conformity index measurement was similar for CT and MRI (P = .58). Count maps were created to highlight differences in the contours from CT and MRI. CONCLUSIONS Using MRI as a primary image set to define a pancreatic adenocarcinoma GTV resulted in smaller contours compared with CT. No differences in DSC or the conformity index were seen between MRI and CT. A stepwise method is recommended as an approach to contour a pancreatic GTV using MRI.
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Affiliation(s)
- William A Hall
- Department of Radiation Oncology, Medical College of Wisconsin and Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin.
| | - Hanne D Heerkens
- UMC Utrecht, Department of Radiation Oncology, Utrecht, the Netherlands
| | - Eric S Paulson
- Department of Radiation Oncology, Medical College of Wisconsin and Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin
| | - Gert J Meijer
- UMC Utrecht, Department of Radiation Oncology, Utrecht, the Netherlands
| | - Alexis N Kotte
- UMC Utrecht, Department of Radiation Oncology, Utrecht, the Netherlands
| | - Paul Knechtges
- Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Parag J Parikh
- Department of Radiation Oncology, Washington University, St. Louis, Missouri
| | - Michael F Bassetti
- Department of Radiation Oncology, University of Wisconsin Madison, Madison, Wisconsin
| | - Percy Lee
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | | | - Manisha Palta
- Department of Radiation Oncology, Duke University, Durham, North Carolina
| | - Sten Myrehaug
- Department of Radiation Oncology, Sunnybrook Hospital, Toronto, Canada
| | - Eugene J Koay
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | | | - Edgar Ben-Josef
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Beth A Erickson
- Department of Radiation Oncology, Medical College of Wisconsin and Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin
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Zuckerman DA, Kennard RF, Roy A, Parikh PJ, Weiner AA. Outcomes and toxicity following Yttrium-90 radioembolization for hepatic metastases from neuroendocrine tumors-a single-institution experience. J Gastrointest Oncol 2018; 10:118-127. [PMID: 30788167 DOI: 10.21037/jgo.2018.10.05] [Citation(s) in RCA: 12] [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: 12/23/2022] Open
Abstract
Background The prognosis of patients with hepatic metastases from neuroendocrine tumors (NET) is generally good, and radioembolization with Yttrium-90 microspheres is a locoregional therapy that is used in efforts to improve hepatic disease control and survival. This study aims to describe the survival outcomes and toxicities associated with radioembolization for hepatic-predominant metastatic NET in a large single-institution cohort. Methods A total of 59 patients underwent radioembolization for metastatic NET with hepatic predominant disease at a single academic center. Patient outcomes were analyzed by Kaplan-Meier survival analysis and toxicities were detailed and described. Ten patients within the cohort underwent post-treatment dosimetric analysis using PET-MRI and normal liver dosimetry was correlated with hepatic fibrosis and toxicity. Results Median overall survival from time of radioembolization in the patient cohort was 31 months, and the 1- and 2-year overall survival was 80.4% and 65.6% respectively. Median hepatic progression-free survival and overall progression-free survival were 18 and 13 months, respectively. Three patients died of hepatic failure that was possibly therapy-related. Ten patients underwent evaluation of post-treatment dosimetry following radioembolization. In patients who did not develop hepatotoxicity or hepatic fibrosis, mean dose to normal liver was 25.4 Gy, while the mean liver dose in patients who experienced toxicity (hepatic fibrosis in n=2 and death from hepatic failure in n=1) was 59.1 Gy. Conclusions Overall survival following radioembolization for hepatic metastases from NET is excellent; however, deaths that are potentially treatment-related have been observed. Preliminary data regarding dose to normal liver is suggestive of a relation between dosimetry and toxicity, however further work is required to further elucidate the mechanism, correlation with dosimetry, as well as additional patient and tumor factors that may predispose these patients to toxicity.
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Affiliation(s)
- Darryl A Zuckerman
- Department of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Richard F Kennard
- Department of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Amit Roy
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Parag J Parikh
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Ashley A Weiner
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
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Vlacich G, Samson PP, Perkins SM, Roach MC, Parikh PJ, Bradley JD, Lockhart AC, Puri V, Meyers BF, Kozower B, Robinson CG. Treatment utilization and outcomes in elderly patients with locally advanced esophageal carcinoma: a review of the National Cancer Database. Cancer Med 2017; 6:2886-2896. [PMID: 29139215 PMCID: PMC5727236 DOI: 10.1002/cam4.1250] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 10/06/2017] [Accepted: 10/09/2017] [Indexed: 11/30/2022] Open
Abstract
For elderly patients with locally advanced esophageal cancer, therapeutic approaches and outcomes in a modern cohort are not well characterized. Patients ≥70 years old with clinical stage II and III esophageal cancer diagnosed between 1998 and 2012 were identified from the National Cancer Database and stratified based on treatment type. Variables associated with treatment utilization were evaluated using logistic regression and survival evaluated using Cox proportional hazards analysis. Propensity matching (1:1) was performed to help account for selection bias. A total of 21,593 patients were identified. Median and maximum ages were 77 and 90, respectively. Treatment included palliative therapy (24.3%), chemoradiation (37.1%), trimodality therapy (10.0%), esophagectomy alone (5.6%), or no therapy (12.9%). Age ≥80 (OR 0.73), female gender (OR 0.81), Charlson–Deyo comorbidity score ≥2 (OR 0.82), and high‐volume centers (OR 0.83) were associated with a decreased likelihood of palliative therapy versus no treatment. Age ≥80 (OR 0.79) and Clinical Stage III (OR 0.33) were associated with a decreased likelihood, while adenocarcinoma histology (OR 1.33) and nonacademic cancer centers (OR 3.9), an increased likelihood of esophagectomy alone compared to definitive chemoradiation. Age ≥80 (OR 0.15), female gender (OR 0.80), and non‐Caucasian race (OR 0.63) were associated with a decreased likelihood, while adenocarcinoma histology (OR 2.10) and high‐volume centers (OR 2.34), an increased likelihood of trimodality therapy compared to definitive chemoradiation. Each treatment type demonstrated improved survival compared to no therapy: palliative treatment (HR 0.49) to trimodality therapy (HR 0.25) with significance between all groups. Any therapy, including palliative care, was associated with improved survival; however, subsets of elderly patients with locally advanced esophageal cancer are less likely to receive aggressive therapy. Care should be taken to not unnecessarily deprive these individuals of treatment that may improve survival.
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Affiliation(s)
- Gregory Vlacich
- Department of Radiation Oncology, Washington University, St. Louis, Missouri
| | - Pamela P Samson
- Department of Radiation Oncology, Washington University, St. Louis, Missouri
| | - Stephanie M Perkins
- Department of Radiation Oncology, Washington University, St. Louis, Missouri
| | - Michael C Roach
- Department of Radiation Oncology, Washington University, St. Louis, Missouri
| | - Parag J Parikh
- Department of Radiation Oncology, Washington University, St. Louis, Missouri
| | - Jeffrey D Bradley
- Department of Radiation Oncology, Washington University, St. Louis, Missouri
| | - A Craig Lockhart
- Department of Medicine, Division of Oncology, Washington University, St. Louis, Missouri
| | - Varun Puri
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
| | - Bryan F Meyers
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
| | - Benjamin Kozower
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
| | - Cliff G Robinson
- Department of Radiation Oncology, Washington University, St. Louis, Missouri
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Markovina S, Youssef F, Roy A, Aggarwal S, Khwaja S, DeWees T, Tan B, Hunt S, Myerson RJ, Chang DT, Parikh PJ, Olsen JR. Improved Metastasis- and Disease-Free Survival With Preoperative Sequential Short-Course Radiation Therapy and FOLFOX Chemotherapy for Rectal Cancer Compared With Neoadjuvant Long-Course Chemoradiotherapy: Results of a Matched Pair Analysis. Int J Radiat Oncol Biol Phys 2017; 99:417-426. [PMID: 28871992 DOI: 10.1016/j.ijrobp.2017.05.048] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 04/26/2017] [Accepted: 05/30/2017] [Indexed: 12/19/2022]
Abstract
PURPOSE To compare treatment and toxicity outcomes between a phase 2 institutional trial of near total neoadjuvant therapy (nTNT) for locally advanced rectal cancer and a similar historical control cohort treated at Washington University in St. Louis with the current US standard of care, defined as neoadjuvant chemoradiotherapy (NCRT), total mesorectal excision (TME), and adjuvant FOLFOX chemotherapy; to expand the comparison to an additional institution, patients treated with similar NCRT at Stanford University were included. METHODS AND MATERIALS Sixty-nine patients with cT3-4N0-2M0 rectal adenocarcinoma enrolled on the Washington University in St. Louis phase 2 study of nTNT were included for analysis. Patients treated at the same institution with conventional NCRT and adjuvant FOLFOX were matched for exact cTNM stage. Forty-one patients treated with NCRT at Stanford University were included in a second analysis. Kaplan-Meier analysis with log-rank test was used to compare local control, distant metastasis-free survival, disease-free survival, and overall survival. RESULTS Median follow-up was 49 and 54 months for nTNT and NCRT, respectively. Pathologic complete response and T-downstaging rates were 28% versus 16% (P=.21) and 75% versus 41% (P<.001) in the nTNT and NCRT cohorts, respectively. Three-year disease-free survival (85% vs 68%, P=.032) was significantly better in the nTNT group. Actuarial 3-year local control (92% vs 96%, P=.36) and overall survival (96% vs 88%, P=.67) were similar. The Stanford cohort had significantly lower clinical stage. After controlling for clinical stage, age, tumor location, institution, and number of chemotherapy cycles, nTNT treatment remained significantly associated with lower risk of recurrence (P=.006). CONCLUSIONS Patients treated with nTNT had higher T-downstaging and superior distant metastasis-free survival and disease-free survival compared with conventional NCRT when matched for tumor location and exact cTNM stage. Near total neoadjuvant therapy remained a significant multivariate predictor for improved outcome when including patients treated with NCRT at another institution.
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Affiliation(s)
- Stephanie Markovina
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri; Siteman Cancer Center, 4921 Parkview Place, St. Louis, Missouri
| | - Fady Youssef
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Amit Roy
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Sonya Aggarwal
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Shariq Khwaja
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Todd DeWees
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Benjamin Tan
- Siteman Cancer Center, 4921 Parkview Place, St. Louis, Missouri; Division of Medical Oncology, Washington University, St. Louis, Missouri
| | - Steven Hunt
- Siteman Cancer Center, 4921 Parkview Place, St. Louis, Missouri; Section of Colon and Rectal Surgery, Division of General Surgery, Washington University, St. Louis, Missouri
| | - Robert J Myerson
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Daniel T Chang
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Parag J Parikh
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri; Siteman Cancer Center, 4921 Parkview Place, St. Louis, Missouri
| | - Jeffrey R Olsen
- Department of Radiation Oncology, University of Colorado Denver, Denver, Colorado.
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Maughan NM, Garcia-Ramirez J, Arpidone M, Swallen A, Laforest R, Goddu SM, Parikh PJ, Zoberi JE. Commissioning of Post-Treatment PET-Based Dosimetry Software for Hepatic Radioembolization with Yttrium-90 Microspheres. Brachytherapy 2017. [DOI: 10.1016/j.brachy.2017.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Cardenas ML, Spencer CR, Markovina S, DeWees TA, Mazur TR, Weiner AA, Parikh PJ, Olsen JR. Quantitative FDG-PET/CT predicts local recurrence and survival for squamous cell carcinoma of the anus. Adv Radiat Oncol 2017; 2:281-287. [PMID: 29114593 PMCID: PMC5605304 DOI: 10.1016/j.adro.2017.04.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [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: 10/25/2016] [Revised: 03/10/2017] [Accepted: 04/20/2017] [Indexed: 12/22/2022] Open
Abstract
Purpose 18F-fluorodeoxyglucose (FDG) positron emission tomography–(PET)/computed tomography (CT) imaging is used for staging and treatment planning of patients with anal cancer. Quantitative pre- and posttreatment metrics that are predictive of recurrence are unknown. We evaluated the association between pre- and posttreatment FDG-PET/CT parameters and outcomes for patients with squamous cell carcinoma of the anus (SCCA). Methods and materials The records of 110 patients treated between 2003 and 2013 with definitive radiation therapy for SCCA were reviewed under an institutional review board–approved protocol. The median radiation therapy dose was 50.4 Gy (range, 35-60 Gy). Concurrent chemotherapy was administered for 109 of 110 patients and generally consisted of 5-fluorouracil and mitomycin C (n = 94). All patients underwent pretreatment FDG-PET/CT and 101 of 110 underwent posttreatment FDG-PET/CT 3 months after completion of radiation therapy. The maximum standard uptake value (SUVmax) was analyzed, in addition to multiple patient and treatment factors, by univariate and multivariate Cox regression for correlation with local recurrence (LR) and overall survival (OS). Results The median follow-up was 28.6 months. LR occurred in 1 of 15 (6.7%), 5 of 47 (10.6%), and 6 of 48 (12.5%) patients with stage I, II, and III disease, respectively. On univariate analysis, a significant association was observed between reduced LR and posttreatment SUVmax <6.1 (P = .0095) and between increased OS and posttreatment SUVmax <6.1 (P = .0086). On multivariate analysis, a significant association was observed between reduced LR and posttreatment SUVmax <6.1 (P = .0013) and the use of intensity modulated radiation therapy (P < .001). A significant multivariate association was observed between increased OS and posttreatment SUVmax <6.1 (P = .0373) and the use of 5-fluorouracil/mitomycin C chemotherapy (P = .001). Conclusion Posttreatment SUVmax <6.1 is associated with reduced LR and increased OS after chemoradiation therapy for SCCA independent of T and N stage on multivariate analysis. Greater follow-up is required to confirm this association with late patterns of failure.
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Affiliation(s)
- Michael L Cardenas
- Department of Radiation Oncology, University of California, Davis, California
| | - Christopher R Spencer
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Stephanie Markovina
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Todd A DeWees
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Thomas R Mazur
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Ashley A Weiner
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Parag J Parikh
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Jeffrey R Olsen
- Department of Radiation Oncology, University of Colorado School of Medicine, Denver, Colorado
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Brauer DG, Strand MS, Sanford DE, Kushnir VM, Lim KH, Mullady DK, Tan BR, Wang-Gillam A, Morton AE, Ruzinova MB, Parikh PJ, Narra VR, Fowler KJ, Doyle MB, Chapman WC, Strasberg SS, Hawkins WG, Fields RC. Utility of a multidisciplinary tumor board in the management of pancreatic and upper gastrointestinal diseases: an observational study. HPB (Oxford) 2017; 19:133-139. [PMID: 27916436 PMCID: PMC5477647 DOI: 10.1016/j.hpb.2016.11.002] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 08/08/2016] [Accepted: 11/11/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND & OBJECTIVES Multidisciplinary tumor boards (MDTBs) are frequently employed in cancer centers but their value has been debated. We reviewed the decision-making process and resource utilization of our MDTB to assess its utility in the management of pancreatic and upper gastrointestinal tract conditions. METHODS A prospectively-collected database was reviewed over a 12-month period. The primary outcome was change in management plan as a result of case discussion. Secondary outcomes included resources required to hold MDTB, survival, and adherence to treatment guidelines. RESULTS Four hundred seventy cases were reviewed. MDTB resulted in a change in the proposed plan of management in 101 of 402 evaluable cases (25.1%). New plans favored obtaining additional diagnostic workup. No recorded variables were associated with a change in plan. For newly-diagnosed cases of pancreatic ductal adenocarcinoma (n = 33), survival time was not impacted by MDTB (p = .154) and adherence to National Comprehensive Cancer Network guidelines was 100%. The estimated cost of physician time per case reviewed was $190. CONCLUSIONS Our MDTB influences treatment decisions in a sizeable number of cases with excellent adherence to national guidelines. However, this requires significant time expenditure and may not impact outcomes. Regular assessments of the effectiveness of MDTBs should be undertaken.
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Affiliation(s)
- David G Brauer
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA
| | - Matthew S Strand
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA
| | - Dominic E Sanford
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA
| | - Vladimir M Kushnir
- Department of Medicine, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA
| | - Kian-Huat Lim
- Department of Medicine, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA
| | - Daniel K Mullady
- Department of Medicine, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA
| | - Benjamin R Tan
- Department of Medicine, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA
| | - Andrea Wang-Gillam
- Department of Medicine, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA
| | - Ashley E Morton
- Department of Medicine, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA
| | - Marianna B Ruzinova
- Department of Pathology and Immunology, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA
| | - Parag J Parikh
- Department of Radiation Oncology, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA
| | - Vamsi R Narra
- Mallinckrodt Institute of Radiology, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA
| | - Kathryn J Fowler
- Mallinckrodt Institute of Radiology, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA
| | - Majella B Doyle
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA
| | - William C Chapman
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA
| | - Steven S Strasberg
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA
| | - William G Hawkins
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA
| | - Ryan C Fields
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center at Washington University School of Medicine, Saint Louis, MO, USA.
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Vlacich GR, Samson PP, Perkins SM, Roach MC, Parikh PJ, Bradley JD, Lockhart AC, Puri V, Meyers BF, Kozower BD, Robinson CG. A National Cancer Database analysis of treatment utilization and associated outcomes in elderly patients with locally advanced esophageal cancer. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.4_suppl.138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
138 Background: Elderly patients with locally advanced esophageal cancer pose a therapeutic challenge since definitive treatment involves aggressive combined-modality therapy. Whether these individuals are offered or benefit from these approaches in the modern, trimodality era has not been widely explored. Methods: Patients ≥ 70 years old with clinical stage II and III esophageal cancer diagnosed between 1998 and 2012 were identified from the National Cancer Database and stratified based on treatment. Variables independently associated with treatment utilization were evaluated using logistic regression and mortality hazard evaluated using Cox-proportional hazards analysis. The primary aim was to compare overall survival by treatment group. The secondary aim was to identify variables associated with receiving each modality. Results: A total of 21,593 patients were identified. Median and maximum ages were 77 and 90 respectively. In 12.9%, no therapy was delivered, 24.3% received palliative therapy, 37.1% received definitive chemoradiation, 5.6% received esophagectomy alone, and 10.0% received trimodality therapy. On multivariate analysis, age ≥ 80 (OR 0.73, p < 0.001), female gender (OR 0.81, p < 0.001), and treatment at high-volume centers (OR 0.83, p = 0.008) were associated with a decreased likelihood of palliative therapy over no treatment. Age ≥ 80 (OR 0.15, p < 0.001), female gender (OR 0.80, p = 0.03), and non-Caucasian race (OR 0.63, p < 0.001) were associated with decreased trimodality use compared to definitive chemoradiation. Each treatment independently demonstrated improved survival compared to no therapy: palliative treatment (HR 0.49), concurrent chemoradiation (HR 0.36), esophagectomy (HR 0.31), trimodality therapy (HR 0.25), all p < 0.001. Conclusions: Any therapy, including palliative care, was associated with improved survival compared to no treatment in elderly patients with esophageal cancer. Subsets of patients are less likely to receive aggressive therapy based on social and institutional factors. Care should be taken to not unnecessarily deprive elderly patients of treatment that may improve survival.
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Affiliation(s)
| | | | | | | | - Parag J. Parikh
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | | | | | - Varun Puri
- Washington University in St. Louis, St. Louis, MO
| | - Bryan F Meyers
- Washington University School of Medicine in St. Louis, St. Louis, MO
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Bertholet J, Wan H, Toftegaard J, Schmidt ML, Chotard F, Parikh PJ, Poulsen PR. Fully automatic segmentation of arbitrarily shaped fiducial markers in cone-beam CT projections. Phys Med Biol 2017; 62:1327-1341. [DOI: 10.1088/1361-6560/aa52f7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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40
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Cai B, Altman MB, Garcia-Ramirez J, LaBrash J, Goddu SM, Mutic S, Parikh PJ, Olsen JR, Saad N, Zoberi JE. Process improvement for the safe delivery of multidisciplinary-executed treatments-A case in Y-90 microspheres therapy. Brachytherapy 2016; 16:236-244. [PMID: 27618420 DOI: 10.1016/j.brachy.2016.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 07/15/2016] [Accepted: 08/02/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE To develop a safe and robust workflow for yttrium-90 (Y-90) radioembolization procedures in a multidisciplinary team environment. METHODS AND MATERIALS A generalized Define-Measure-Analyze-Improve-Control (DMAIC)-based approach to process improvement was applied to a Y-90 radioembolization workflow. In the first DMAIC cycle, events with the Y-90 workflow were defined and analyzed. To improve the workflow, a web-based interactive electronic white board (EWB) system was adopted as the central communication platform and information processing hub. The EWB-based Y-90 workflow then underwent a second DMAIC cycle. Out of 245 treatments, three misses that went undetected until treatment initiation were recorded over a period of 21 months, and root-cause-analysis was performed to determine causes of each incident and opportunities for improvement. The EWB-based Y-90 process was further improved via new rules to define reliable sources of information as inputs into the planning process, as well as new check points to ensure this information was communicated correctly throughout the process flow. RESULTS After implementation of the revised EWB-based Y-90 workflow, after two DMAIC-like cycles, there were zero misses out of 153 patient treatments in 1 year. CONCLUSIONS The DMAIC-based approach adopted here allowed the iterative development of a robust workflow to achieve an adaptable, event-minimizing planning process despite a complex setting which requires the participation of multiple teams for Y-90 microspheres therapy. Implementation of such a workflow using the EWB or similar platform with a DMAIC-based process improvement approach could be expanded to other treatment procedures, especially those requiring multidisciplinary management.
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Affiliation(s)
- Bin Cai
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO
| | - Michael B Altman
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO
| | - Jose Garcia-Ramirez
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO
| | - Jason LaBrash
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO
| | - S Murty Goddu
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO
| | - Sasa Mutic
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO
| | - Parag J Parikh
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO
| | - Jeffrey R Olsen
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO
| | - Nael Saad
- Department of Radiology, Vascular and Interventional Radiology Section, Washington University School of Medicine, Saint Louis, MO
| | - Jacqueline E Zoberi
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO.
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Roy A, Mahasittiwat P, Weiner AA, Hunt SR, Mutch MG, Birnbaum EH, Kodner IJ, Read TE, Fleshman JW, Olsen JR, Myerson RJ, Parikh PJ. Preoperative short-course radiation therapy for rectal cancer provides excellent disease control and toxicity: Results from a single US institution. Pract Radiat Oncol 2016; 7:e51-e58. [PMID: 27720702 DOI: 10.1016/j.prro.2016.08.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 08/19/2016] [Accepted: 08/23/2016] [Indexed: 12/14/2022]
Abstract
PURPOSE Preoperative short-course radiation therapy (SCRT) has rarely been used for rectal cancer in the United States, although 2 randomized phase 3 trials demonstrate equivalence to conventional chemoradiation (CRT), and recent updates to national guidelines include this regimen as a treatment option. We sought to evaluate the efficacy and safety of preoperative SCRT followed by immediate surgery within 1 week to treat rectal cancer in the US setting. METHODS AND MATERIALS All patients treated with preoperative SCRT (4 Gy × 5 fractions for total 20 Gy) followed by planned surgery within 1 week at our institution were retrospectively evaluated. Censored cases with ≥2 years of follow-up were included along with any disease failure or death. Patients with cM1 disease were excluded. Patients with yp stage II/III disease typically received adjuvant chemotherapy from the 1990s onwards. The primary outcomes were actuarial (Kaplan-Meier) 5-year locoregional control (LC), disease-free survival (DFS), and overall survival (OS) as well as late severe (greater than or equal to grade 3) toxicity. RESULTS Our analysis included 202 consecutive patients with clinical stage I-III disease treated from 1977 through 2011. Median follow-up was 6.5 years (range, 2-29.2). Five-year disease outcomes were 95.9% ± 1.5% for LC, 76.4% ± 3.1% for DFS, and 84.6% ± 2.6% for OS. For patients with locally advanced rectal cancer (cT3-4 and/or cN+), 5-year LC, DFS, and OS were 95.1% ± 2.1%, 73.3% ± 4.3%, and 80.6% ± 3.7%, respectively. The late severe toxicity rate was 11.4%. CONCLUSIONS SCRT followed by immediate surgery is a safe and effective treatment for patients with rectal cancer in the United States. Though SCRT has not been widely adopted, recent updates to the national guidelines for rectal cancer as well as financial pressures to reduce healthcare costs may lead to increased utilization of this treatment regimen in the future.
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Affiliation(s)
- Amit Roy
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Pawinee Mahasittiwat
- Cancer Center, Siriraj Piyamaharajkarun Hospital, Mahidol University, Bangkok, Thailand
| | - Ashley A Weiner
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Steven R Hunt
- Department of Surgery, Section of Colorectal Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Matthew G Mutch
- Department of Surgery, Section of Colorectal Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Elisa H Birnbaum
- Department of Surgery, Section of Colorectal Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Ira J Kodner
- Department of Surgery, Section of Colorectal Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Thomas E Read
- Department of Colon and Rectal Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts; Department of Surgery, Tufts University School of Medicine, Boston, Massachusetts
| | - James W Fleshman
- Department of Surgery, Baylor University Medical Center at Dallas, Dallas, Texas
| | - Jeffrey R Olsen
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Robert J Myerson
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Parag J Parikh
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri.
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Khwaja SS, Roy A, Markovina S, Dewees TA, Hunt S, Tan B, Myerson RJ, Olsen JR, Parikh PJ. Quality of Life Outcomes From a Phase 2 Trial of Short-Course Radiation Therapy Followed by FOLFOX Chemotherapy as Preoperative Treatment for Rectal Cancer. Int J Radiat Oncol Biol Phys 2016; 95:1429-1438. [DOI: 10.1016/j.ijrobp.2016.03.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 03/14/2016] [Accepted: 03/17/2016] [Indexed: 01/03/2023]
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Feng Y, Kawrakow I, Olsen J, Parikh PJ, Noel C, Wooten O, Du D, Mutic S, Hu Y. A comparative study of automatic image segmentation algorithms for target tracking in MR-IGRT. J Appl Clin Med Phys 2016; 17:441-460. [PMID: 27074465 PMCID: PMC5875567 DOI: 10.1120/jacmp.v17i2.5820] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 11/18/2015] [Accepted: 11/11/2015] [Indexed: 12/02/2022] Open
Abstract
On-board magnetic resonance (MR) image guidance during radiation therapy offers the potential for more accurate treatment delivery. To utilize the real-time image information, a crucial prerequisite is the ability to successfully segment and track regions of interest (ROI). The purpose of this work is to evaluate the performance of different segmentation algorithms using motion images (4 frames per second) acquired using a MR image-guided radiotherapy (MR-IGRT) system. Manual con-tours of the kidney, bladder, duodenum, and a liver tumor by an experienced radiation oncologist were used as the ground truth for performance evaluation. Besides the manual segmentation, images were automatically segmented using thresholding, fuzzy k-means (FKM), k-harmonic means (KHM), and reaction-diffusion level set evolution (RD-LSE) algorithms, as well as the tissue tracking algorithm provided by the ViewRay treatment planning and delivery system (VR-TPDS). The performance of the five algorithms was evaluated quantitatively by comparing with the manual segmentation using the Dice coefficient and target registration error (TRE) measured as the distance between the centroid of the manual ROI and the centroid of the automatically segmented ROI. All methods were able to successfully segment the bladder and the kidney, but only FKM, KHM, and VR-TPDS were able to segment the liver tumor and the duodenum. The performance of the thresholding, FKM, KHM, and RD-LSE algorithms degraded as the local image contrast decreased, whereas the performance of the VP-TPDS method was nearly independent of local image contrast due to the reference registration algorithm. For segmenting high-contrast images (i.e., kidney), the thresholding method provided the best speed (< 1 ms) with a satisfying accuracy (Dice = 0.95). When the image contrast was low, the VR-TPDS method had the best automatic contour. Results suggest an image quality determination procedure before segmentation and a combination of different methods for optimal segmentation with the on-board MR-IGRT system.
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Affiliation(s)
- Yuan Feng
- Soochow University; Washington University School of Medicine; University of Texas at Austin.
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Maughan NM, Eldib M, Conti M, Knešaurek K, Faul D, Parikh PJ, Fayad ZA, Laforest R. Phantom study to determine optimal PET reconstruction parameters for PET/MR imaging of
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Y microspheres following radioembolization. Biomed Phys Eng Express 2016. [DOI: 10.1088/2057-1976/2/1/015009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Olsen JR, Parikh PJ, DeWees TA, Olsen L, Hawkins WG, Strasberg SM, Lim KH, Singh PP, Suresh R, Tan BR, Ratner L, Fields RC, Amin MA, Wang-Gillam A. Prospective phase I study of nab-paclitaxel plus gemcitabine with concurrent MR-guided IMRT in patients with locally advanced or borderline resectable pancreatic cancer. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.4_suppl.tps480] [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
TPS480 Background: Radiotherapy (RT) for locally advanced and borderline resectable pancreatic cancer (LABPC) is controversial as potential local control benefits are often obscured by high rates of distant progression. However, local failure remains a significant cause of morbidity among patients without distant progression after initial chemotherapy, although toxicity concerns may limit delivery of optimal systemic therapy concurrent with RT. Given known systemic efficacy and radiosensitization effects of nab-paclitaxel (A) with gemcitabine (G), we initiated a phase I study of nab-paclitaxel with gemcitabine (AG) and concurrent intensity modulated radiation therapy with magnetic resonance guidance (MR-IMRT) for LABPC. Methods: A planned 24 patients with LABPC will be enrolled to a phase I dose escalation trial using the Time-to-Event Continual Reassessment Method (TITE-CRM) design. Following one lead-in cycle of GA, MR-IMRT is administered daily with concurrent weekly GA for a total of 25 fractions in 5 weeks. The initial dose levels for RT and AG, respectively, are: 40 Gy MR-IMRT, 75 mg/m2 A and 600mg/m2 G. The maximum possible dose level is 60 Gy MR-IMRT, 100mg/m2 A and 1000mg/m2 G. To reduce toxicity risk, MR-IMRT volumes include the primary tumor only, with cine-MR used for intra-fraction tumor tracking in place of fiducial markers. The primary endpoint is determination of the maximum tolerated dose level, with secondary endpoints including rate of conversion to resectable disease, progression- free survival, overall survival, and patient reported quality of life. Clinical trial information: NCT02283372.
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Affiliation(s)
- Jeffrey R. Olsen
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Parag J. Parikh
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Todd A. DeWees
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Lindsey Olsen
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO
| | | | - Steven M. Strasberg
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | | | - Preet Paul Singh
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Rama Suresh
- Division of Oncology, Washington University in St. Louis, St. Louis, MO
| | - Benjamin R. Tan
- Division of Oncology, Washington University in St. Louis, St. Louis, MO
| | - Lee Ratner
- Washington University in St. Louis, St. Louis, MO
| | - Ryan C. Fields
- Department of Surgery, Washington University in St. Louis, St. Louis, MO
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Brauer DG, Strand MS, Sanford DE, Doyle MM, Murad F, Mullady D, Kushnir VM, Ruzinova M, Olsen JR, Parikh PJ, Lim KH, Tan BR, Edmundowicz SA, Wang-Gillam A, Hawkins WG, Chapman WC, Strasberg SM, Fields RC. Utility of a multidisciplinary tumor board in the management of pancreatic diseases. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.4_suppl.319] [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
319 Background: Multidisciplinary Tumor Boards (MTBs) are a requirement for comprehensive cancer centers and are routinely used to coordinate multidisciplinary care in oncology. Despite their widespread use, the impact of MTBs is not well characterized. We studied the outcomes of all patients presented at our pancreas MTB, with the goal of evaluating our current practices and resource utilization. Methods: Data were prospectively collected for all patients presented at a weekly pancreas-specific MTB over the 12-month period at a single-institution NCI-designated cancer center. The conference is attended by surgical, medical, and radiation oncologists, interventional gastroenterologists, pathologists, and radiologists (diagnostic and interventional). Retrospective chart review was performed at the end of the 12-month period under an IRB-approved protocol. Results: A total of 470 patient presentations were made over a 12-month period. Average age at time of presentation was 61.5 years (range 17 – 89) with 51% males. 61.7% of cases were presented by surgical oncologists and 26% by medical oncologists. 174 cases were the result of new diagnoses or referrals. 78 patients were presented more than once (average of 2.3 times). Pancreatic adenocarcinoma was the most common diagnosis (37%), followed by uncharacterized pancreatic mass (16%), and pancreatic cyst (7%). The treatment plan proposed by the presenting clinician was known or could be evaluated prior to conference in 402 cases. Presentation of a case at MTB changed the plan of management 25% (n = 100) of the time, including MTB recommendation against a planned resection in 46 cases. When the initial plan changed as a result of MTB discussion, the most common new plan was to obtain further diagnostic testing such as biopsy and/or endoscopy (n = 24). Conclusions: MTBs are required and resource-intensive but offer the opportunity to discuss a wide array of pathologies and influence management decisions in a sizable proportion of cases. Additional investigations evaluating adherence rates to MTB decisions and to published guidelines (i.e. National Comprehensive Cancer Network) will further enhance the assessment and utility of MTBs.
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Affiliation(s)
- David G. Brauer
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Matthew S. Strand
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | | | | | - Faris Murad
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Daniel Mullady
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | | | - Marianna Ruzinova
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Jeffrey R. Olsen
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Parag J. Parikh
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | | | - Benjamin R. Tan
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | | | | | | | | | - Steven M. Strasberg
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Ryan C. Fields
- Washington University School of Medicine in St. Louis, St. Louis, MO
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Abstract
PURPOSE Intensity-modulated adaptive radiotherapy (ART) has been the focus of considerable research and developmental work due to its potential therapeutic benefits. However, in light of its unique quality assurance (QA) challenges, no one has described a robust framework for its clinical implementation. In fact, recent position papers by ASTRO and AAPM have firmly endorsed pretreatment patient-specific IMRT QA, which limits the feasibility of online ART. The authors aim to address these obstacles by applying failure mode and effects analysis (FMEA) to identify high-priority errors and appropriate risk-mitigation strategies for clinical implementation of intensity-modulated ART. METHODS An experienced team of two clinical medical physicists, one clinical engineer, and one radiation oncologist was assembled to perform a standard FMEA for intensity-modulated ART. A set of 216 potential radiotherapy failures composed by the forthcoming AAPM task group 100 (TG-100) was used as the basis. Of the 216 failures, 127 were identified as most relevant to an ART scheme. Using the associated TG-100 FMEA values as a baseline, the team considered how the likeliness of occurrence (O), outcome severity (S), and likeliness of failure being undetected (D) would change for ART. New risk priority numbers (RPN) were calculated. Failures characterized by RPN ≥ 200 were identified as potentially critical. RESULTS FMEA revealed that ART RPN increased for 38% (n = 48/127) of potential failures, with 75% (n = 36/48) attributed to failures in the segmentation and treatment planning processes. Forty-three of 127 failures were identified as potentially critical. Risk-mitigation strategies include implementing a suite of quality control and decision support software, specialty QA software/hardware tools, and an increase in specially trained personnel. CONCLUSIONS Results of the FMEA-based risk assessment demonstrate that intensity-modulated ART introduces different (but not necessarily more) risks than standard IMRT and may be safely implemented with the proper mitigations.
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Affiliation(s)
- Camille E Noel
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri 63110
| | - Lakshmi Santanam
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri 63110
| | - Parag J Parikh
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri 63110
| | - Sasa Mutic
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri 63110
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Noel CE, Parikh PJ, Spencer CR, Green OL, Hu Y, Mutic S, Olsen JR. Comparison of onboard low-field magnetic resonance imaging versus onboard computed tomography for anatomy visualization in radiotherapy. Acta Oncol 2015. [PMID: 26206517 DOI: 10.3109/0284186x.2015.1062541] [Citation(s) in RCA: 110] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Onboard magnetic resonance imaging (OB-MRI) for daily localization and adaptive radiotherapy has been under development by several groups. However, no clinical studies have evaluated whether OB-MRI improves visualization of the target and organs at risk (OARs) compared to standard onboard computed tomography (OB-CT). This study compared visualization of patient anatomy on images acquired on the MRI-(60)Co ViewRay system to those acquired with OB-CT. MATERIAL AND METHODS Fourteen patients enrolled on a protocol approved by the Institutional Review Board (IRB) and undergoing image-guided radiotherapy for cancer in the thorax (n = 2), pelvis (n = 6), abdomen (n = 3) or head and neck (n = 3) were imaged with OB-MRI and OB-CT. For each of the 14 patients, the OB-MRI and OB-CT datasets were displayed side-by-side and independently reviewed by three radiation oncologists. Each physician was asked to evaluate which dataset offered better visualization of the target and OARs. A quantitative contouring study was performed on two abdominal patients to assess if OB-MRI could offer improved inter-observer segmentation agreement for adaptive planning. RESULTS In total 221 OARs and 10 targets were compared for visualization on OB-MRI and OB-CT by each of the three physicians. The majority of physicians (two or more) evaluated visualization on MRI as better for 71% of structures, worse for 10% of structures, and equivalent for 14% of structures. 5% of structures were not visible on either. Physicians agreed unanimously for 74% and in majority for > 99% of structures. Targets were better visualized on MRI in 4/10 cases, and never on OB-CT. CONCLUSION Low-field MR provides better anatomic visualization of many radiotherapy targets and most OARs as compared to OB-CT. Further studies with OB-MRI should be pursued.
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Affiliation(s)
- Camille E Noel
- a Department of Radiation Oncology , Washington University School of Medicine , St. Louis , Missouri , USA
| | - Parag J Parikh
- a Department of Radiation Oncology , Washington University School of Medicine , St. Louis , Missouri , USA
| | - Christopher R Spencer
- a Department of Radiation Oncology , Washington University School of Medicine , St. Louis , Missouri , USA
| | - Olga L Green
- a Department of Radiation Oncology , Washington University School of Medicine , St. Louis , Missouri , USA
| | - Yanle Hu
- a Department of Radiation Oncology , Washington University School of Medicine , St. Louis , Missouri , USA
| | - Sasa Mutic
- a Department of Radiation Oncology , Washington University School of Medicine , St. Louis , Missouri , USA
| | - Jeffrey R Olsen
- a Department of Radiation Oncology , Washington University School of Medicine , St. Louis , Missouri , USA
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Buchwald ZS, Olsen JR, Badiyan SN, DeWees TA, Hu Y, Fields RC, Wang-Gillam A, Parikh PJ. Pretreatment diffusion weighted imaging for clinical outcome assessment in patients undergoing definitive chemoradiation for pancreatic adenocarcinoma. J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.3_suppl.432] [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
432 Background: Factors predicting patterns of failure for pancreatic ductal adenocarcinoma (PDA) are not well-established. Diffusion-weighted MRI (DWI) is useful in predicting recurrence for other gastrointestinal malignancies. The purpose of this study was to evaluate for correlation between tumor DWI parameters and clinical outcomes following chemoradiotherapy (CRT) for pancreatic adenocarcinoma. Methods: From 2009 to 2013, 27 patients with locally advanced (n=14), borderline resectable (n=12) or resectable (n=1) PDA underwent CRT. All patients received upfront FOLFIRINOX or gemcitabine-based chemotherapy prior to CRT, and gemcitabine (median weekly dose 800 mg/m2) concurrent with radiotherapy. DWI was obtained during radiotherapy treatment planning, and apparent diffusion coefficient (ADC) maps were generated to allow determination of median tumor ADC. Tumor-directed CRT was administered with respiratory gated intensity modulated radiation therapy, 55Gy in 25 fractions without elective nodal coverage. Patients were followed by imaging every 2-3 months. Log rank test was used to estimate an optimal ADC cut-point of 1.4*10-3mm2/sec based on distant metastasis free survival (DMFS) and overall survival (OS). Analysis of local recurrence was not performed due to limited events. The log-rank test was used to evaluate differences in outcome between groups based on ADC classification. Results: The median time to last follow-up from completion of CRT was 9.7 months for all patients and 11 months among living patients. 5 patients underwent resection following CRT. The 1-year DMFS for patients with median ADC<1.4*10-3mm2/sec was 79.5 percent, compared to 47.6 percent for those with median ADC >1.4. The 1-year OS for patients with median ADC<1.4 was 100 percent, compared to 46.3 percent for those with median ADC >1.4. Both DMFS (p=.041) and OS (p=.003) were significantly improved on log-rank test for ADC<1.4 compared to ADC>1.4. Conclusions: A correlation was observed between DWI parameters and clinical outcomes for PDA. Further prospective study should be explored to validate DWI as a prognostic imaging biomarker.
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Affiliation(s)
| | - Jeffrey R. Olsen
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | | | - Todd A. DeWees
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Yanle Hu
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | | | | | - Parag J. Parikh
- Washington University School of Medicine in St. Louis, St. Louis, MO
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Youssef F, Markovina SS, Khwaja SS, DeWees TA, Hunt SR, Tan BR, Myerson RJ, Parikh PJ, Olsen JR. Matched pair analysis of sequential short course radiotherapy and FOLFOX chemotherapy as preoperative therapy for rectal cancer compared to neoadjuvant long course chemoradiotherapy. J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.3_suppl.665] [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
665 Background: A recently completed institutional phase II trial evaluated near-total neoadjuvant therapy (nTNT) for locally advanced rectal cancer using short course radiotherapy (SCRT) followed by four cycles of FOLFOX prior to total mesorectal excision (TME). A matched pair analysis is presented to compare clinical outcomes for nTNT with conventional chemoradiotherapy (CRT), TME, and postoperative chemotherapy (CT) for patients treated at our institution. Methods: 80 patients with cT3-4N0-2M0-1 rectal adenocarcinoma planned for resection of all tumor enrolled on a phase II study of preoperative SCRT (25 Gy to the involved mesorectum, 20 Gy to elective nodes, in 5 fractions) followed by four cycles of mFOLFOX6 before TME, with 6-8 cycles of adjuvant FOLFOX suggested. 69 patients with cM0 disease comprised the study cohort for this analysis. Patients treated with conventional CRT, followed by TME and adjuvant CT (63% ≥4 cycles adjuvant FOLFOX) were identified and matched 2:1 for exact cTNM stage. Kaplan-Meier with log-rank analysis was used to compare local control (LC), distant metastasis free survival (DMFS), disease free survival (DFS), and overall survival (OS), and two-tailed Mann-Whitney and Chi-squared tests used to compare cohort characteristics. Results: Median follow-up was 26 and 49 months for the study and control groups, respectively. Median age (57 vs. 55 years, p = 0.98) and distance from the anorectal ring (6 vs. 5 cm, p = 0.16) were similar for study and control groups, respectively. Pathologic complete response (pCR) and T-downstaging rates were 30% vs. 23% (p = 0.26) and 75% vs 50% (p = 0.001) in the study and match cohort, respectively. Actuarial 2-year LC (97% vs. 98%, p = 0.69) and OS (100% vs. 95% at 2 years, p = 0.57) were similar between the study and control groups, respectively. Two-year DMFS (94% vs. 80%, p = 0.016) and DFS (94% vs. 80%, p = 0.027) were significantly better in the study cohort. Conclusions: Controlling for institutional bias, exact cTNM stage, and tumor location, nTNT resulted in increased T-downstaging, superior DMFS and DFS, and similar LC and OS compared to conventional CRT.
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Affiliation(s)
- Fady Youssef
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | | | - Shariq S. Khwaja
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Todd A. DeWees
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Steven R. Hunt
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Benjamin R. Tan
- Division of Oncology, Washington University in St. Louis, St. Louis, MO
| | | | - Parag J. Parikh
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Jeffrey R. Olsen
- Washington University School of Medicine in St. Louis, St. Louis, MO
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