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Lehrer EJ, Gurewitz J, Kondziolka D, Niranjan A, Lunsford LD, Mathieu D, Deibert C, Ruiz-Garcia H, Patel SI, Bonney P, Hwang L, Zada G, Picozzi P, Prasad RN, Palmer JD, Lee CC, Rusthoven CG, Sheehan JP, Trifiletti DM, Ahluwalia M. Immune Checkpoint Inhibition and Single Fraction Stereotactic Radiosurgery in Non-Small Cell Lung Cancer Brain Metastases: An International Multicenter Study of 395 Patients. Int J Radiat Oncol Biol Phys 2023; 117:e127-e128. [PMID: 37784682 DOI: 10.1016/j.ijrobp.2023.06.923] [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) Brain metastases most commonly arise from non-small cell lung cancer (NSCLC). In recent years, immune checkpoint inhibitors (ICI) have demonstrated improvements in overall survival (OS) in NSCLC. However, concerns remain about the risk of radiation necrosis (RN) when ICI are administered with stereotactic radiosurgery (SRS). MATERIALS/METHODS Logistic regression was used to evaluate prognostic factors associated with the development of any grade RN and symptomatic RN. Cumulative incidence of RN was evaluated using competing risks analysis and the Fine and Gray model, where the null hypothesis was rejected for p < 0.05. RESULTS There were 395 patients with 2,513 brain metastases treated across 11 international institutions included in the analysis. The median follow-up was 14.2 months. Median patient age was 67 years (Interquartile Range [IQR]: 61-73), 53.4% were male, the median Karnofsky Performance Status was 80 (IQR: 80-90), and 88.6% has active extracranial disease at the time of SRS. The median margin dose was 19 Gy (IQR: 18-20), 97.5% of patients were treated on the Gamma Knife ®, 3.8% underwent prior whole brain radiation therapy (WBRT). The median V12 Gy was 5.2 cm3 and 36.5% of patients had a V12 Gy ≥ 10 cm3, anti-PD-1 agents were administered in 91.6% of patients. A V12 Gy ³ 10 cm3 was associated with an increased risk of developing any grade RN; odds ratio (OR): 2.12, p = 0.04 and OR: 2.18; p = 0.03 on univariable and multivariable analysis, respectively. Similarly, a V12 Gy ≥ 10 cm3 was associated with an increased risk of developing symptomatic RN; OR: 3.80, p = 0.003 and OR: 3.95; p = 0.003 on univariable and multivariable analysis, respectively. Receipt of concurrent ICI and prior WBRT were not statistically significant. At 1-year, the cumulative incidence of any grade and symptomatic RN was 4.8% and 3.8%, respectively. The cumulative incidence of any grade RN was 3.8% vs. 5.3% for the concurrent and non-concurrent groups at 1-year, respectively (p = 0.35). The cumulative incidence of symptomatic RN was 3.8% vs. 3.6% for the concurrent and non-concurrent groups at 1-year, respectively (p = 0.95). CONCLUSION The risk of any grade and symptomatic RN following SRS and ICI administration for NSCLC brain metastases increases as the V12 Gy exceeds 10 cm3. Concurrent ICI and SRS does not appear to increase this risk. Radiosurgical planning techniques should aim to minimize the V12 Gy.
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Affiliation(s)
- E J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - J Gurewitz
- NYU Langone Medical Center, New York, NY
| | - D Kondziolka
- Department of Neurosurgery, NYU Langone Health, New York, NY
| | - A Niranjan
- Center for Image-guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - L D Lunsford
- Center for Image-guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - D Mathieu
- Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | | | - H Ruiz-Garcia
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL
| | - S I Patel
- Division of Radiation Oncology, University of Alberta, Edmonton, AB, Canada
| | - P Bonney
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - L Hwang
- Department of Radiation Oncology, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - G Zada
- Department of Neurosurgery, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - P Picozzi
- Humanitas Research Hospital, Rozzano, Italy
| | - R N Prasad
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - J D Palmer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - C C Lee
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - C G Rusthoven
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO
| | - J P Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
| | - D M Trifiletti
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL
| | - M Ahluwalia
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL
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Lehrer EJ, Khosla AA, Ozair A, Gurewitz J, Bernstein K, Kondziolka D, Niranjan A, Wei Z, Lunsford LD, Mathieu D, Trudel C, Deibert CP, Malouff TD, Ruiz-Garcia H, Peterson JL, Patel S, Bonney P, Hwang L, Yu C, Zada G, Picozzi P, Franzini A, Attuati L, Prasad RN, Raval RR, Palmer JD, Lee CC, Yang HC, Fakhoury KR, Rusthoven CG, Dickstein DR, Sheehan JP, Trifiletti DM, Ahluwalia MS. Immune checkpoint inhibition and single fraction stereotactic radiosurgery in brain metastases from non-small cell lung cancer: an international multicenter study of 395 patients. J Neurooncol 2023; 165:63-77. [PMID: 37889444 DOI: 10.1007/s11060-023-04413-4] [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: 04/23/2023] [Accepted: 08/02/2023] [Indexed: 10/28/2023]
Abstract
PURPOSE Approximately 80% of brain metastases originate from non-small cell lung cancer (NSCLC). Immune checkpoint inhibitors (ICI) and stereotactic radiosurgery (SRS) are frequently utilized in this setting. However, concerns remain regarding the risk of radiation necrosis (RN) when SRS and ICI are administered concurrently. METHODS A retrospective study was conducted through the International Radiosurgery Research Foundation. Logistic regression models and competing risks analyses were utilized to identify predictors of any grade RN and symptomatic RN (SRN). RESULTS The study included 395 patients with 2,540 brain metastases treated with single fraction SRS and ICI across 11 institutions in four countries with a median follow-up of 14.2 months. The median age was 67 years. The median margin SRS dose was 19 Gy; 36.5% of patients had a V12 Gy ≥ 10 cm3. On multivariable analysis, V12 Gy ≥ 10 cm3 was a significant predictor of developing any grade RN (OR: 2.18) and SRN (OR: 3.95). At 1-year, the cumulative incidence of any grade and SRN for all patients was 4.8% and 3.8%, respectively. For concurrent and non-concurrent groups, the cumulative incidence of any grade RN was 3.8% versus 5.3%, respectively (p = 0.35); and for SRN was 3.8% vs. 3.6%, respectively (p = 0.95). CONCLUSION The risk of any grade RN and symptomatic RN following single fraction SRS and ICI for NSCLC brain metastases increases as V12 Gy exceeds 10 cm3. Concurrent ICI and SRS do not appear to increase this risk. Radiosurgical planning techniques should aim to minimize V12 Gy.
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Affiliation(s)
- Eric J Lehrer
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA.
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Atulya A Khosla
- Department of Medical Oncology, Miami Cancer Institute, Miami, FL, USA
| | - Ahmad Ozair
- Department of Medical Oncology, Miami Cancer Institute, Miami, FL, USA
| | - Jason Gurewitz
- Department of Radiation Oncology, NYU Langone Medical Center, New York, NY, USA
| | - Kenneth Bernstein
- Department of Radiation Oncology, NYU Langone Medical Center, New York, NY, USA
| | - Douglas Kondziolka
- Department of Neurosurgery, NYU Langone Medical Center, New York, NY, USA
| | - Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Zhishuo Wei
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - David Mathieu
- Department of Neurosurgery, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, QC, Canada
| | - Claire Trudel
- Department of Medicine, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, QC, Canada
| | | | - Timothy D Malouff
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Henry Ruiz-Garcia
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | | | - Samir Patel
- Division of Radiation Oncology, Department of Oncology, University of Alberta, Edmonton, AB, Canada
| | - Phillip Bonney
- Department of Neurosurgery, University of Southern California, Los Angeles, CA, USA
| | - Lindsay Hwang
- Department of Radiation Oncology, University of Southern California, Los Angeles, CA, USA
| | - Cheng Yu
- Department of Neurosurgery, University of Southern California, Los Angeles, CA, USA
| | - Gabriel Zada
- Department of Neurosurgery, University of Southern California, Los Angeles, CA, USA
| | - Piero Picozzi
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano (Mi), Italy
| | - Andrea Franzini
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano (Mi), Italy
| | - Luca Attuati
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano (Mi), Italy
| | - Rahul N Prasad
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Raju R Raval
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Joshua D Palmer
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Kareem R Fakhoury
- Department of Radiation Oncology, University of Colorado, Denver, CO, USA
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado, Denver, CO, USA
| | - Daniel R Dickstein
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
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Palmer JD, Prasad RN, Cioffi G, Kruchtko C, Zaorsky NG, Trifiletti DM, Gondi V, Brown PD, Perlow HK, Mishra MV, Chakravarti A, Barnholtz-Sloan JS, Ostrom QT. Exposure to radon and heavy particulate pollution and incidence of brain tumors. Neuro Oncol 2023; 25:407-417. [PMID: 35762336 PMCID: PMC9925706 DOI: 10.1093/neuonc/noac163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Global incidence for brain tumors varies substantially without explanation. Studies correlating radon exposure and incidence are inconclusive. Particulate pollution has been linked to increased tumor incidence. Particulates may disrupt the blood-brain barrier allowing intracranial exposure to oncogenic radon. We investigated the relationship between exposure to residential radon, particulate pollution, and brain tumor incidence in the United States (US). METHODS County-level median radon testing results and annual air quality index values were obtained and divided into tertiles. Counties without both values were excluded. Four groups of counties were generated: high particulate/high radon (high/high), high/low, low/high, and low/low. Using incidence data from the Central Brain Tumor Registry of the US (provided by CDC's National Program of Cancer Registries and NCI's SEER), annual age-adjusted incidence rates (AAAIRs) by group were generated by behavior. Incidence rate ratios were calculated to examine for significant differences (α = .05). Poisson regression accounting for possible confounders was conducted. RESULTS Counties with available data included 83% of the US population. High/high exposure was significantly associated with increased AAAIR of all non-malignant tumors (up to 26% higher, including most meningiomas) even after accounting for potential confounders. An increased AAAIR was noted for all malignant tumors (up to 10% higher), including glioblastoma, but was negated after accounting for demographic/socioeconomic differences. CONCLUSIONS We present the first report suggesting increased non-malignant brain tumor incidence in regions with high particulate and radon exposure. These findings provide insight into unexplained variation in tumor incidence. Future studies are needed to validate these findings in other populations.
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Affiliation(s)
- Joshua D Palmer
- Department of Radiation Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Rahul N Prasad
- Department of Radiation Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Gino Cioffi
- Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA.,Trans Divisional Research Program, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
| | - Carol Kruchtko
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Vinai Gondi
- Brain and Spine Tumor Center, Northwestern Medicine Cancer Center and Proton Center, Warrensville, Illinois, USA
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Haley K Perlow
- Department of Radiation Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Mark V Mishra
- Department of Radiation Oncology, University of Maryland, Baltimore, Maryland, USA
| | - Arnab Chakravarti
- Department of Radiation Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Jill S Barnholtz-Sloan
- Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA.,Trans Divisional Research Program, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA.,Center for Biomedical Informatics and Information Technology (CBIIT), National Cancer Institute, Bethesda, Maryland, USA
| | - Quinn T Ostrom
- Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA.,Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA.,The Preston Robert Tisch Brain Tumor Center, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA
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4
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Lehrer EJ, Kowalchuk RO, Gurewitz J, Bernstein K, Kondziolka D, Niranjan A, Wei Z, Lunsford LD, Fakhoury KR, Rusthoven CG, Mathieu D, Trudel C, Malouff TD, Ruiz-Garcia H, Bonney P, Hwang L, Yu C, Zada G, Patel S, Deibert CP, Picozzi P, Franzini A, Attuati L, Prasad RN, Raval RR, Palmer JD, Lee CC, Yang HC, Harmsen WS, Jones BM, Sharma S, Ahluwalia MS, Sheehan JP, Trifiletti DM. Concurrent Administration of Immune Checkpoint Inhibitors and Single Fraction Stereotactic Radiosurgery in Patients With Non-Small Cell Lung Cancer, Melanoma, and Renal Cell Carcinoma Brain Metastases is Not Associated With an Increased Risk of Radiation Necrosis Over Nonconcurrent Treatment: An International Multicenter Study of 657 Patients. Int J Radiat Oncol Biol Phys 2023:S0360-3016(23)00057-3. [PMID: 36690161 DOI: 10.1016/j.ijrobp.2023.01.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 01/04/2023] [Accepted: 01/09/2023] [Indexed: 01/22/2023]
Abstract
PURPOSE Stereotactic radiosurgery (SRS) and immune checkpoint inhibitors (ICI) are highly effective treatments for brain metastases, particularly when these therapies are administered concurrently. However, there are limited data reporting the risk of radiation necrosis (RN) in this setting. METHODS AND MATERIALS Patients with brain metastases from primary non-small cell lung cancer, renal cell carcinoma, or melanoma treated with SRS and ICI were considered. Time-to-event analyses were conducted for any grade RN and symptomatic RN (SRN) with death incorporated as a competing risk. As a secondary analysis, recursive partitioning analysis (RPA) was used for model development, and a loop of potential models was analyzed, with the highest-fidelity model selected. Brain V12 Gy thresholds identified on RPA were then incorporated into the competing risks analysis. Concurrent SRS and ICI administration. RESULTS Six hundred fifty-seven patients with 4182 brain metastases across 11 international institutions were analyzed. The median follow-up for all patients was 13.4 months. The median follow-up was 12.8 months and 14.1 months for the concurrent and nonconcurrent groups, respectively (P = .03). The median patient age was 66 years, and the median Karnofsky Performance Status was 90. In patients with any grade RN, 1- and 2-year rates were 6.4% and 9.9%, respectively. In patients with SRN, 1- and 2-year rates were 4.8% and 7.2%, respectively. On RPA, the highest-fidelity models consistently identified V12 Gy as the dominant variable predictive of RN. Three risk groups were identified by V12 Gy: (1) < 12 cm3; (2) 20 cm3 ≥ V12 Gy ≥ 12 cm3; (3) V12 Gy > 20 cm3. In patients with any grade RN, 1-year rates were 3.7% (V12 Gy < 12 cm3), 10.3% (20 cm3 ≥ V12 Gy ≥ 12 cm3), and 12.6% (V12 Gy > 20 cm3); the 2-year rates were 7.5% (V12 Gy < 12 cm3), 13.8% (20 cm3 ≥ V12 Gy ≥ 12 cm3), and 15.4% (V12 Gy > 20 cm3) (P < 0.001). In patients with any SRN, 1-year rates were 2.4% (V12 Gy < 12 cm3), 8.9% (20 cm3 ≥ V12 Gy ≥ 12 cm3), and 10.3% (V12 Gy > 20 cm3); the 2-year rates were 4.4% (V12 Gy < 12 cm3), 12.4% (20 cm3 ≥ V12 Gy ≥ 12 cm3), and 13.1% (V12 Gy > 20 cm3; P < 0.001). There were no statistically significant differences in rates of any grade RN or SRN when accounting for therapy timing for all patients and by V12 risk group identified on RPA. CONCLUSIONS The use of SRS and ICI results in a low risk of any grade RN and SRN. This risk is not increased with concurrent administration. Therefore, ICI can safely be administered within 4-weeks of SRS. Three risk groups based on V12 Gy were identified, which clinicians may consider to further reduce rates of RN.
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Affiliation(s)
- Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Roman O Kowalchuk
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minneapolis
| | - Jason Gurewitz
- Department of Radiation Oncology, NYU Langone Medical Center, New York, New York
| | - Kenneth Bernstein
- Department of Radiation Oncology, NYU Langone Medical Center, New York, New York
| | - Douglas Kondziolka
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York
| | - Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Zhishuo Wei
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kareem R Fakhoury
- Department of Radiation Oncology, University of Colorado, Aurora, Colorado
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado, Aurora, Colorado
| | - David Mathieu
- Department of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Quebec, Canada
| | - Claire Trudel
- Department of Medicine, Université de Sherbrooke, Centre de recherche du CHUS, Quebec, Canada
| | - Timothy D Malouff
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - Henry Ruiz-Garcia
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - Phillip Bonney
- Department of Neurosurgery, University of Southern California, Los Angeles, California
| | - Lindsay Hwang
- Department of Radiation Oncology, University of Southern California, Los Angeles, California
| | - Cheng Yu
- Department of Neurosurgery, University of Southern California, Los Angeles, California
| | - Gabriel Zada
- Department of Neurosurgery, University of Southern California, Los Angeles, California
| | - Samir Patel
- Division of Radiation Oncology, Department of Oncology, University of Alberta, Edmonton, AB, Canada
| | | | - Piero Picozzi
- Department of Neurosurgery, Humanitas Research Hospital-IRCCS, Rozzano (Mi), Italy
| | - Andrea Franzini
- Department of Neurosurgery, Humanitas Research Hospital-IRCCS, Rozzano (Mi), Italy
| | - Luca Attuati
- Department of Neurosurgery, Humanitas Research Hospital-IRCCS, Rozzano (Mi), Italy
| | - Rahul N Prasad
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Raju R Raval
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Joshua D Palmer
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taiwan
| | | | - Brianna M Jones
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sonam Sharma
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
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Prasad RN, Gokun Y, Ritter AR, Jhawar SR, Vudatala S, Wang SJ, Martin D, Diaz DA. Prostate brachytherapy utilization in the COVID-19 era: A cross-sectional study of radiation oncologists in the United States. Brachytherapy 2023; 22:53-57. [PMID: 36347762 PMCID: PMC9489987 DOI: 10.1016/j.brachy.2022.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 08/04/2022] [Accepted: 08/28/2022] [Indexed: 02/08/2023]
Abstract
PURPOSE Despite advantages such as abbreviated treatment course, brachytherapy (BT) utilization rates for prostate cancer (PC) in the United States (US) are declining. We surveyed practicing US radiation oncologists (ROs) to determine the proportion who offer BT for PC and whether the COVID-19 pandemic influenced practice patterns. MATERIALS AND METHODS From July-October 2021, we surveyed practicing US ROs. Provider demographic and practice characteristics were collected. Questions assessing utilization of BT and external beam (EBRT) for patients of varying risk groups and the effect of the pandemic on practice patterns were administered. Descriptive statistics were reported. The bivariate relationships between provider characteristics and likelihood of offering BT were assessed using the Chi-square test (α < 0.05). RESULTS Six percent of surveyed ROs responded, with 203 meeting inclusion criteria (72% male, 72% white, 53% non-academic, 69% >10 years in practice) and 156 (77%) treating PC. For low-risk, fewer providers offered BT (41% total; 25% low dose rate [LDR], 10% high dose rate [HDR], 6% both) than stereotactic body (SBRT) (54%) and moderately hypofractionated radiation therapy (MHFRT) (83%). For favorable intermediate risk, fewer offered BT (37% total; 21% LDR, 10% HDR, 6% both) than SBRT (48%), MHFRT (87%), and conventionally fractionated EBRT (38%). For high (44%) and very-high (37%) risk, fewer offered EBRT+BT than EBRT alone. For every risk group, academic ROs were significantly more likely to offer BT (all p-values<0.05). <1% of respondents reported increased pandemic-related BT usage. CONCLUSIONS US ROs, particularly in non-academic settings, do not routinely offer BT monotherapy or boost (<50%). Practice patterns were unaffected by COVID-19. Retraining may be critical to increasing utilization.
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Affiliation(s)
- Rahul N Prasad
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH, 43210
| | - Yevgeniya Gokun
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University Wexner Medical Center, Columbus, OH, 43210
| | - Alex R Ritter
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH, 43210
| | - Sachin R Jhawar
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH, 43210
| | - Sundari Vudatala
- Recruitment, Intervention, and Survey Shared Resource, The Ohio State University Comprehensive Cancer Center, Columbus, OH, 43210
| | - Shang-Jui Wang
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH, 43210
| | - Douglas Martin
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH, 43210
| | - Dayssy A Diaz
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH, 43210.
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6
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Lehrer EJ, Gurewitz J, Bernstein K, Kondziolka D, Fakhoury KR, Rusthoven CG, Niranjan A, Wei Z, Lunsford LD, Malouff TD, Ruiz-Garcia H, Peterson JL, Bonney P, Hwang L, Yu C, Zada G, Deibert CP, Prasad RN, Raval RR, Palmer JD, Patel S, Picozzi P, Franzini A, Attuati L, Mathieu D, Trudel C, Lee CC, Yang HC, Jones BM, Green S, Ahluwalia MS, Sheehan JP, Trifiletti DM. Concurrent Administration of Immune Checkpoint Inhibitors and Stereotactic Radiosurgery Is Well-Tolerated in Patients With Melanoma Brain Metastases: An International Multicenter Study of 203 Patients. Neurosurgery 2022; 91:872-882. [PMID: 36255215 DOI: 10.1227/neu.0000000000002127] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 06/20/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Melanoma brain metastases are commonly treated with stereotactic radiosurgery (SRS) and immune checkpoint inhibitors (ICIs). However, the toxicity of these 2 treatments is largely unknown when administered concurrently. OBJECTIVE To evaluate the risk of radiation necrosis (RN) with concurrent and nonconcurrent SRS and ICIs. METHODS The guidelines from the Strengthening the Reporting of Observational Studies in Epidemiology checklist were used. Inverse probability of treatment weighting, univariable and multivariable logistic regression, and the Kaplan-Meier method was utilized. RESULTS There were 203 patients with 1388 brain metastases across 11 international institutions in 4 countries with a median follow-up of 15.6 months. The rates of symptomatic RN were 9.4% and 8.2% in the concurrent and nonconcurrent groups, respectively ( P =.766). On multivariable logistic regression, V12 ≥ 10 cm 3 (odds ratio [OR]: 2.76; P =.006) and presence of BRAF mutation (OR: 2.20; P =.040) were associated with an increased risk of developing symptomatic RN; the use of concurrent over nonconcurrent therapy was not associated with an increased risk (OR: 1.06; P =.877). There were 20 grade 3 toxic events reported, and no grade 4 events reported. One patient experienced a grade 5 intracranial hemorrhage. The median overall survival was 36.1 and 19.8 months for the concurrent and nonconcurrent groups (log-rank P =.051), respectively. CONCLUSION Concurrent administration of ICIs and SRS are not associated with an increased risk of RN. Tumors harboring BRAF mutation, or perhaps prior exposure to targeted agents, may increase this risk. Radiosurgical optimization to maintain V12 < 10 cm 3 is a potential strategy to reduce the risk of RN.
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Affiliation(s)
- Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jason Gurewitz
- Department of Radiation Oncology, NYU Langone Medical Center, New York, New York, USA
| | - Kenneth Bernstein
- Department of Radiation Oncology, NYU Langone Medical Center, New York, New York, USA
| | - Douglas Kondziolka
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York, USA
| | - Kareem R Fakhoury
- Department of Radiation Oncology, University of Colorado, Denver, Colorado, USA
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado, Denver, Colorado, USA
| | - Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Zhishuo Wei
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Timothy D Malouff
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - Henry Ruiz-Garcia
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Phillip Bonney
- Department of Neurosurgery, University of Southern California, Los Angeles, California, USA
| | - Lindsay Hwang
- Department of Radiation Oncology, University of Southern California, Los Angeles, California, USA
| | - Cheng Yu
- Department of Neurosurgery, University of Southern California, Los Angeles, California, USA
| | - Gabriel Zada
- Department of Neurosurgery, University of Southern California, Los Angeles, California, USA
| | | | - Rahul N Prasad
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Raju R Raval
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Joshua D Palmer
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Samir Patel
- Division of Radiation Oncology, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Piero Picozzi
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Andrea Franzini
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Luca Attuati
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | - David Mathieu
- Department of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Quebec, Canada
| | - Claire Trudel
- Department of Medicine, Université de Sherbrooke, Centre de recherche du CHUS, Quebec, Canada
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taiwan
| | - Brianna M Jones
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sheryl Green
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
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Dibs K, Palmer JD, Prasad RN, Olausson A, Bourekas EC, Boulter D, Ayan AS, Cochran E, Marras WS, Mageswaran P, Thomas E, Grecula J, Guiou M, Soghrati S, Tili E, Raval RR, Mendel E, Scharschmidt T, Elder JB, Lonser R, Chakravarti A, Blakaj DM. Feasibility, safety, and efficacy of circumferential spine stereotactic body radiotherapy. Front Oncol 2022; 12:912799. [PMID: 36505845 PMCID: PMC9727181 DOI: 10.3389/fonc.2022.912799] [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: 04/04/2022] [Accepted: 10/31/2022] [Indexed: 11/24/2022] Open
Abstract
Background With advances in systemic therapy translating to improved survival in metastatic malignancies, spine metastases have become an increasingly common source of morbidity. Achieving durable local control (LC) for patients with circumferential epidural disease can be particularly challenging. Circumferential stereotactic body radiotherapy (SBRT) may offer improved LC for circumferential vertebral and/or epidural metastatic spinal disease, but prospective (and retrospective) data are extremely limited. We sought to evaluate the feasibility, toxicity, and cancer control outcomes with this novel approach to circumferential spinal disease. Methods We retrospectively identified all circumferential SBRT courses delivered between 2013 and 2019 at a tertiary care institution for post-operative or intact spine metastases. Radiotherapy was delivered to 14-27.5 Gy in one to five fractions. Feasibility was assessed by determining the proportion of plans for which ≥95% planning target volume (PTV) was coverable by ≥95% prescription dose. The primary endpoint was 1-year LC. Factors associated with increased likelihood of local failure (LF) were explored. Acute and chronic toxicity were assessed. Detailed dosimetric data were collected. Results Fifty-eight patients receiving 64 circumferential SBRT courses were identified (median age 61, KPS ≥70, 57% men). With a median follow-up of 15 months, the 12-month local control was 85% (eight events). Five and three recurrences were in the epidural space and bone, respectively. On multivariate analysis, increased PTV and uncontrolled systemic disease were significantly associated with an increased likelihood of LF; ≥95% PTV was covered by ≥95% prescription dose in 94% of the cases. The rate of new or progressive vertebral compression fracture was 8%. There were no myelitis events or any grade 3+ acute or late toxicities. Conclusions For patients with circumferential disease, circumferential spine SBRT is feasible and may offer excellent LC without significant toxicity. A prospective evaluation of this approach is warranted.
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Affiliation(s)
- Khaled Dibs
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Joshua D. Palmer
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Rahul N. Prasad
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Alexander Olausson
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Eric C. Bourekas
- Department of Radiology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Daniel Boulter
- Department of Radiology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Ahmet S. Ayan
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Eric Cochran
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - William S. Marras
- Department of Biomedical Engineering, Spine Research Institute, The Ohio State University, Columbus, OH, United States
| | - Prasath Mageswaran
- Department of Biomedical Engineering, Spine Research Institute, The Ohio State University, Columbus, OH, United States
| | - Evan Thomas
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - John Grecula
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Michael Guiou
- Department of Radiation Oncology, Green Bay Oncology, Green Bay, WI, United States
| | - Soheil Soghrati
- Department of Mechanical and Aerospace Engineering at the Ohio State University, Columbus, OH, United States
| | - Esmerina Tili
- Department of Anesthesiology, Ohio State College of Medicine, Columbus, OH, United States
| | - Raju R. Raval
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Ehud Mendel
- Department of Neurosurgery, School of Medicine, Yale University, New Haven, CT, United States
| | - Thomas Scharschmidt
- Department of Orthopedic Surgery, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - James B. Elder
- Department of Neurosurgery, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Russell Lonser
- Department of Neurosurgery, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Arnab Chakravarti
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Dukagjin M. Blakaj
- Department of Radiation Oncology, The James Cancer Center at the Ohio State University Wexner Medical Center, Columbus, OH, United States,*Correspondence: Dukagjin M. Blakaj,
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Prasad RN, Royce TJ, Chino F, Jagsi R, Palmer JD. Financial Toxicity as an End Point in Prospective Clinical Trials Involving Radiation Therapy. Adv Radiat Oncol 2022; 7:100970. [PMID: 35620674 PMCID: PMC9126781 DOI: 10.1016/j.adro.2022.100970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 04/12/2022] [Indexed: 12/02/2022] Open
Abstract
Prior research, predominately retrospective, has increased awareness that patients with cancer are at elevated risk for financial toxicity (FT). Radiation therapy (RT) can be particularly disruptive due to weeks of daily treatments. Yet, FT in patients receiving RT is less studied, and the extent to which FT has been incorporated as an end point in prospective clinical trials involving RT is unknown. Clinicaltrials.gov was queried to identify all observational or interventional studies from 2001 to 2020 wherein RT was administered for cancer. Studies with primary, secondary, or exploratory FT end points were identified through keyword search. For trials incorporating FT outcomes, pertinent study characteristics were collected. Detailed information regarding FT measures was recorded. Descriptive statistics, including frequency counts and proportions, were performed. The overall rate of inclusion of FT end points was calculated, and rates over 5-year intervals were compared using the χ2 test (α = 0.05). Overall, 10,550 studies involving RT were identified, of which 88 reported FT end points (0.8%). Included FT end points were typically secondary (78%), with just 15 studies (17%), including primary end points. Notably, only 19 studies (22%) reported a standalone FT end point. The majority measured FT as part of a larger quality of life (QoL) questionnaire. The rate of inclusion of FT end points significantly increased over time from 0.1% from 2001 to 2005 to 1.5% from 2016 to 2020, (P < .0001). FT is a major stressor for patients with cancer, yet even after a relative increase over time, the absolute rate of inclusion of FT end points remains low among RT-based trials. When included, FT outcomes were typically a single question within a QoL assessment not validated as a standalone measure of FT, preventing meaningful study and inference. To characterize and mitigate this burden more accurately, future prospective studies should include FT end points with greater frequency.
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Affiliation(s)
- Rahul N. Prasad
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Trevor J. Royce
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Flatiron Health, New York, New York
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Joshua D. Palmer
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio
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Perlow HK, Ho C, Matsui JK, Prasad RN, Klamer BG, Wang J, Damante M, Upadhyay R, Thomas E, Blakaj DM, Beyer S, Lonser R, Hardesty D, Raval RR, Prabhu R, Elder JB, Palmer JD. Comparing Pre-Operative Versus Post-Operative Single and Multi-Fraction Stereotactic Radiotherapy for Patients with Resectable Brain Metastases. Clin Transl Radiat Oncol 2022; 38:117-122. [PMID: 36420099 PMCID: PMC9676204 DOI: 10.1016/j.ctro.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 11/06/2022] [Accepted: 11/07/2022] [Indexed: 11/11/2022] Open
Abstract
Pre-operative radiation therapy for brain metastases may reduce meningeal disease. Pre-operative radiation therapy for brain metastases may reduce radionecrosis. Fractionated radiation therapy for brain metastases may reduce local failure. Fractionated pre-operative radiation therapy requires prospective validation.
Background The standard treatment for patients with large brain metastases and limited intracranial disease is surgical resection and post-operative stereotactic radiosurgery (SRS). However, post-operative SRS still has elevated rates of local failure (LF) and is complicated by radiation necrosis (RN), and meningeal disease (MD). Pre-operative SRS may reduce the risk of RN and MD, while fractionated therapy may improve local control through delivering a higher biological effective dose. We hypothesize that pre-operative fractionated stereotactic radiation therapy (FSRT) will have less toxicity compared to patients who receive post-operative SRS or FSRT. Methods A multi-institutional analysis was conducted and included patients who had surgical resection and stereotactic radiation therapy to treat at least one brain metastasis. Pertinent demographic, clinical, radiation, surgical, and follow up data were collected for each patient. The primary outcome was a composite endpoint defined as patients with one of the following adverse events: 1) LF, 2) MD, and/or 3) Grade 2 or higher (symptomatic) RN. Results 279 patients were eligible for analysis. The median follow-up time was 9 months. 87 % of patients received fractionated treatment. 29 % of patients received pre-operative treatment. The composite endpoint incidences for post-operative SRS (n = 10), post-operative FSRT (n = 189), pre-operative SRS (n = 27), and pre-operative FSRT (n = 53) were 0 %, 17 %, 15 %, and 7.5 %, respectively. Conclusions In our study, the composite endpoint of 7.5% for pre-operative FSRT compares favorably to our post-operative FSRT rate of 17%. Pre-operative FSRT was observed to have low rates of LF, MD, and RN. Prospective validation is needed.
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Affiliation(s)
- Haley K. Perlow
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Cindy Ho
- Ohio State University School of Medicine, Columbus, OH, USA
| | | | - Rahul N. Prasad
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Brett G. Klamer
- Center for Biostatistics, The Ohio State University, Columbus, OH, USA
| | - Joshua Wang
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mark Damante
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Rituraj Upadhyay
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Evan Thomas
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Dukagjin M. Blakaj
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sasha Beyer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Russell Lonser
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Douglas Hardesty
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Raju R. Raval
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Roshan Prabhu
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
- Southeast Radiation Oncology Group, Charlotte, NC, USA
| | - James B. Elder
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Joshua D. Palmer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Corresponding author at: 460 W. 10 Avenue, Columbus, OH 43210, USA.
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Lehrer EJ, Ahluwalia MS, Gurewitz J, Bernstein K, Kondziolka D, Niranjan A, Wei Z, Lunsford LD, Fakhoury KR, Rusthoven CG, Mathieu D, Trudel C, Malouff TD, Ruiz-Garcia H, Bonney P, Hwang L, Yu C, Zada G, Patel S, Deibert CP, Picozzi P, Franzini A, Attuati L, Prasad RN, Raval RR, Palmer JD, Lee CC, Yang HC, Jones BM, Green S, Sheehan JP, Trifiletti DM. Imaging-defined necrosis after treatment with single-fraction stereotactic radiosurgery and immune checkpoint inhibitors and its potential association with improved outcomes in patients with brain metastases: an international multicenter study of 697 patients. J Neurosurg 2022; 138:1178-1187. [PMID: 36115055 DOI: 10.3171/2022.7.jns22752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 07/15/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Immune checkpoint inhibitors (ICIs) and stereotactic radiosurgery (SRS) are commonly utilized in the management of brain metastases. Treatment-related imaging changes (TRICs) are a frequently observed clinical manifestation and are commonly classified as imaging-defined radiation necrosis. However, these findings are not well characterized and may predict a response to SRS and ICIs. The objective of this study was to investigate predictors of TRICs and their impact on patient survival. METHODS This retrospective multicenter cohort study was conducted through the International Radiosurgery Research Foundation. Member institutions submitted de-identified clinical and dosimetric data for patients with non-small cell lung cancer (NSCLC), melanoma, and renal cell carcinoma (RCC) brain metastases that had been treated with SRS and ICIs. Data were collected from March 2020 to February 2021. Univariable and multivariable Cox and logistic regression analyses were performed. The Kaplan-Meier method was used to evaluate overall survival (OS). The diagnosis-specific graded prognostic assessment was used to guide variable selection. TRICs were determined on the basis of MRI, PET/CT, or MR spectroscopy, and consensus by local clinical providers was required. RESULTS The analysis included 697 patients with 4536 brain metastases across 11 international institutions in 4 countries. The median follow-up after SRS was 13.6 months. The median age was 66 years (IQR 58-73 years), 54.1% of patients were male, and 57.3%, 36.3%, and 6.4% of tumors were NSCLC, melanoma, and RCC, respectively. All patients had undergone single-fraction radiosurgery to a median margin dose of 20 Gy (IQR 18-20 Gy). TRICs were observed in 9.8% of patients. The median OS for all patients was 24.5 months. On univariable analysis, Karnofsky Performance Status (KPS; HR 0.98, p < 0.001), TRICs (HR 0.67, p = 0.03), female sex (HR 0.67, p < 0.001), and prior resection (HR 0.60, p = 0.03) were associated with improved OS. On multivariable analysis, KPS (HR 0.98, p < 0.001) and TRICs (HR 0.66, p = 0.03) were associated with improved OS. A brain volume receiving ≥ 12 Gy of radiation (V12Gy) ≥ 10 cm3 (OR 2.78, p < 0.001), prior whole-brain radiation therapy (OR 3.46, p = 0.006), and RCC histology (OR 3.10, p = 0.01) were associated with an increased probability of developing TRICs. The median OS rates in patients with and without TRICs were 29.0 and 23.1 months, respectively (p = 0.03, log-rank test). CONCLUSIONS TRICs following ICI and SRS were associated with a median OS benefit of approximately 6 months in this retrospective multicenter study. Further prospective study and additional stratification are needed to validate these findings and further elucidate the role and etiology of this common clinical scenario.
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Affiliation(s)
- Eric J Lehrer
- 1Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | | | | | - Ajay Niranjan
- 5Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Zhishuo Wei
- 5Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - L Dade Lunsford
- 5Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kareem R Fakhoury
- 6Department of Radiation Oncology, University of Colorado, Aurora, Colorado
| | - Chad G Rusthoven
- 6Department of Radiation Oncology, University of Colorado, Aurora, Colorado
| | | | - Claire Trudel
- 8Medicine, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Québec, Canada
| | - Timothy D Malouff
- 9Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - Henry Ruiz-Garcia
- 9Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | | | - Lindsay Hwang
- 11Radiation Oncology, University of Southern California, Los Angeles, California
| | - Cheng Yu
- Departments of10Neurosurgery and
| | | | - Samir Patel
- 12Division of Radiation Oncology, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | | | - Piero Picozzi
- 14Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Andrea Franzini
- 14Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Luca Attuati
- 14Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Rahul N Prasad
- 15Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Raju R Raval
- 15Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Joshua D Palmer
- 15Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Cheng-Chia Lee
- 16Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; and
| | - Huai-Che Yang
- 16Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; and
| | - Brianna M Jones
- 1Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sheryl Green
- 1Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jason P Sheehan
- 17Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
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Prasad RN, Royce TJ, Palmer JD, Wang SJ. Lack of Price Transparency for Prostate-Directed Radiation Therapy Relative to Radical Prostatectomy. Int J Radiat Oncol Biol Phys 2022; 113:518-520. [PMID: 35777397 DOI: 10.1016/j.ijrobp.2022.03.009] [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: 02/07/2022] [Accepted: 03/05/2022] [Indexed: 12/01/2022]
Affiliation(s)
- Rahul N Prasad
- Department of Radiation Oncology, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Trevor J Royce
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina; Flatiron Health, New York, New York
| | - Joshua D Palmer
- Department of Radiation Oncology, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Shang-Jui Wang
- Department of Radiation Oncology, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio.
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Dibs K, Blakaj DM, Prasad RN, Olausson A, Bourekas EC, Boulter D, Ayan AS, Cochran E, Marras WS, Mageswaran P, Thomas E, Lee H, Grecula J, Raval RR, Mendel E, Scharschmidt T, Lonser R, Chakravarti A, Elder JB, Palmer JD. Spine Stereotactic Body Radiotherapy to Three or More Contiguous Vertebral Levels. Front Oncol 2022; 12:912804. [PMID: 35756685 PMCID: PMC9213679 DOI: 10.3389/fonc.2022.912804] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 05/16/2022] [Indexed: 11/13/2022] Open
Abstract
Background With survival improving in many metastatic malignancies, spine metastases have increasingly become a source of significant morbidity; achieving durable local control (LC) is critical. Stereotactic body radiotherapy (SBRT) may offer improved LC and/or symptom palliation. However, due to setup concerns, SBRT is infrequently offered to patients with ≥3 contiguous involved levels. Because data are limited, we sought to evaluate the feasibility, toxicity, and cancer control outcomes of spine SBRT delivered to ≥3 contiguous levels. Methods We retrospectively identified all SBRT courses delivered between 2013 and 2019 at a tertiary care institution for postoperative or intact spine metastases. Radiotherapy was delivered to 14-35 Gy in 1-5 fractions. Patients were stratified by whether they received SBRT to 1-2 or ≥3 contiguous levels. The primary endpoint was 1-year LC and was compared between groups. Factors associated with increased likelihood of local failure (LF) were explored. Acute and chronic toxicity was assessed. In-depth dosimetric data were collected. Results Overall, 165 patients with 194 SBRT courses were identified [54% were men, median age was 61 years, 93% had Karnofsky Performance Status (KPS) ≥70, and median follow-up was 15 months]. One hundred thirteen patients (68%) received treatment to 1-2 and 52 to 3-7 (32%) levels. The 1-year LC was 88% (89% for 1-2 levels vs. 84% for ≥3 levels, p = 0.747). On multivariate analysis, uncontrolled systemic disease was associated with inferior LC for patients with ≥3 treated levels. No other demographic, disease, treatment, or dosimetric variables achieved significance. Rates of new/progressive fracture were equivalent (8% vs. 9.5%, p = 0.839). There were no radiation-induced myelopathy or grade 3+ acute or late toxicities in either group. Coverage of ≥95% of the planning target volume with ≥95% prescription dose was similar between groups (96% 1-2 levels vs. 89% ≥3 levels, p = 0.078). Conclusions For patients with ≥3 contiguous involved levels, spine SBRT is feasible and may offer excellent LC without significant toxicity. Prospective evaluation is warranted.
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Affiliation(s)
- Khaled Dibs
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Dukagjin M Blakaj
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Rahul N Prasad
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Alexander Olausson
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Eric C Bourekas
- Department of Radiology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Daniel Boulter
- Department of Radiology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Ahmet S Ayan
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Eric Cochran
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - William S Marras
- Spine Research Institute, Department of Biomedical Engineering, College of Engineering, The Ohio State University, Columbus, OH, United States
| | - Prasath Mageswaran
- Spine Research Institute, Department of Biomedical Engineering, College of Engineering, The Ohio State University, Columbus, OH, United States
| | - Evan Thomas
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Hyeri Lee
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - John Grecula
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Raju R Raval
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Ehud Mendel
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - Thomas Scharschmidt
- Department of Orthopedic Surgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, GA, United States
| | - Russell Lonser
- Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, GA, United States
| | - Arnab Chakravarti
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - James B Elder
- Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, GA, United States
| | - Joshua D Palmer
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, OH, United States
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Prasad RN, Kobalka PJ, Perlow HK, Prevedello DM, Blakaj DM, Raval RR, Palmer JD. Craniospinal irradiation for respiratory failure secondary to central nervous system Erdheim-Chester disease. Radiat Oncol J 2022; 40:162-168. [PMID: 35796119 PMCID: PMC9262703 DOI: 10.3857/roj.2021.01074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 03/17/2022] [Indexed: 12/01/2022] Open
Abstract
Erdheim-Chester disease (ECD) is a rare non-Langerhans cell histiocytosis typically featuring lower extremity osteosclerosis (96%) from Langerin-negative histiocytes with fibrosis. Central nervous system (CNS)-only disease is extremely rare, and particularly difficult to diagnose and manage. Neurologic complaints may be refractory to systemic therapy (ST), and the role of radiation therapy (RT) is undefined. We present a patient with ECD of the medulla complicated by respiratory failure and strength deficits with disseminated leptomeningeal disease (LMD) but not systemic disease, representing the first report of CNS-limited ECD with LMD. He received upfront craniospinal irradiation (CSI), representing a rare account of CSI for ESD, with marked clinical improvement resulting in extubation and improved strength. CSI facilitated excellent preservation of quality of life, and no treatment-related toxicity was observed prior to eventual, unrelated cardiopulmonary arrest. Thus, palliative CSI may augment ST by safely offering improved local control and symptomatic relief for CNS ECD.
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Affiliation(s)
- Rahul N. Prasad
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Peter J. Kobalka
- Department of Neuropathology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Haley K. Perlow
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Daniel M. Prevedello
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Dukagjin M. Blakaj
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Raju R. Raval
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Joshua D. Palmer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Correspondence: Joshua D. Palmer Department of Radiation Oncology, The Ohio State University Wexner Medical Center, 460 W 10th Ave, Columbus, OH 43210, USA. Tel: +1-614-685-9707 E-mail:
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Perlow HK, Prasad RN, Yang M, Klamer B, Matsui J, Marrazzo L, Detti B, Scorsetti M, Clerici E, Arnett A, Beyer S, Ammirati M, Chakravarti A, Raval RR, Brown PD, Navarria P, Scoccianti S, Grecula JC, Palmer JD. Accelerated hypofractionated radiation for elderly or frail patients with a newly diagnosed glioblastoma: A pooled analysis of patient-level data from 4 prospective trials. Cancer 2022; 128:2367-2374. [PMID: 35315512 DOI: 10.1002/cncr.34192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/14/2022] [Accepted: 02/28/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND The standard of care for elderly or frail patients with glioblastoma (GBM) is 40 Gy in 15 fractions of radiotherapy. However, this regimen has a lower biological effective dose (BED) compared with the Stupp regimen of 60 Gy in 30 fractions. It is hypothesized that accelerated hypofractionated radiation of 52.5 Gy in 15 fractions (BED equivalent to Stupp) is safe and efficacious. METHODS Elderly or frail patients with GBM treated with 52.5 Gy in 15 fractions were pooled from 3 phase 1/2 studies and a prospective observational study. Overall survival (OS) and progression-free survival (PFS) were defined time elapsing between surgery/biopsy and death from any cause or progression of disease. RESULTS Sixty-two newly diagnosed patients were eligible for this pooled analysis of individual patient data. The majority (66%) had a Karnofsky performance status (KPS) score <70. The median age was 73 years. The median OS and PFS were 10.3 and 6.9 months, respectively. Patients with KPS scores ≥70 and <70 had a median OS of 15.3 and 9.5 months, respectively. Concurrent chemotherapy was an independent prognostic factor for improved PFS and OS. Grade 3 neurologic toxicity was seen in 2 patients (3.2%). There was no grade 4/5 toxicity. CONCLUSIONS This is the only analysis of elderly/frail patients with GBM prospectively treated with a hypofractionated radiation regimen that is isoeffective to the Stupp regimen. Treatment was well tolerated and demonstrated excellent OS and PFS compared with historical studies. This regimen gives the elderly/frail population an alternative to regimens with a lower BED. Randomized trials are needed to validate these results.
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Affiliation(s)
- Haley K Perlow
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Rahul N Prasad
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Mike Yang
- Ohio State University School of Medicine, Columbus, Ohio
| | - Brett Klamer
- Center for Biostatistics, The Ohio State University, Columbus, Ohio
| | | | - Livia Marrazzo
- Department of Medical Physics, Azienda Ospedaliera Universitaria, Florence, Italy
| | - Beatrice Detti
- Department of Radiation Oncology, Azienda Ospedaliera Universitaria, Florence, Italy
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Elena Clerici
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Andrea Arnett
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Sasha Beyer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Mario Ammirati
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Arnab Chakravarti
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Raju R Raval
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Pierina Navarria
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Silvia Scoccianti
- Department of Radiation Oncology, Azienda Ospedaliera Universitaria, Florence, Italy
| | - John C Grecula
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Joshua D Palmer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
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15
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Prasad RN, Patel M, Palmer JD. COVID-19 Booster Vaccine Equity for Patients with Cancer. Adv Radiat Oncol 2022; 7:100939. [PMID: 35280348 PMCID: PMC8904322 DOI: 10.1016/j.adro.2022.100939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 02/28/2022] [Indexed: 11/02/2022] Open
Abstract
Current CDC recommendations mimic guidelines during initial vaccine phases by prioritizing extremely large patient populations for expedited booster vaccinations. We identified every states' COVID vaccination webpage in February of 2021. Nearly twothirds of states elected not to give adequate vaccination prioritization to patients with cancer during the initial phases under similar guidance, this approach raises the question of whether state-level decisions on how to sub prioritize patients may again inadvertently result in delayed immunizations for particularly vulnerable subgroups - such as patients with cancer. With the delta variant continuing its unchecked global spread and vaccine-related immunity potentially waning, equitable distribution of booster immunizations is essential to minimizing inherent medical, age-related, and socioeconomic inequities in COVID-related morbidity and mortality between populations.
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Affiliation(s)
- Rahul N Prasad
- Department of Radiation Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Manali Patel
- Stanford University School of Medicine and VA Palo Alto Health Care System, 291 Campus Drive, Stanford, California, 94305
| | - Joshua D Palmer
- Department of Radiation Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
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Palmer JD, Prasad RN, Fabian D, Wei L, Yildiz VO, Tan Y, Grecula J, Welliver M, Williams T, Elder JB, Raval R, Blakaj D, Haglund K, Bazan J, Kendra K, Arnett A, Beyer S, Liebner D, Giglio P, Puduvalli V, Chakravarti A, Wuthrick E. Phase I study of trametinib in combination with whole brain radiation therapy for brain metastases. Radiother Oncol 2022; 170:21-26. [DOI: 10.1016/j.radonc.2022.03.016] [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: 12/27/2021] [Revised: 03/15/2022] [Accepted: 03/25/2022] [Indexed: 11/25/2022]
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17
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Prasad RN, Patel T, Perlow HK, Yildiz VO, Baliga S, Brownstein J, Gamez ME, Konieczkowski DJ, Royce TJ, Palmer JD. List Prices for Proton Radiation Therapy. Pract Radiat Oncol 2022; 12:e163-e168. [DOI: 10.1016/j.prro.2021.11.013] [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: 09/09/2021] [Revised: 11/03/2021] [Accepted: 11/04/2021] [Indexed: 10/18/2022]
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Prasad RN, McIntyre M, Guha A, Carter RR, Yildiz VO, Paskett E, Lustberg M, Ruz P, Williams TM, Kola-Kehinde O, Miller ED, Addison D. Cardiovascular Event Reporting in Modern Cancer Radiation Therapy Trials. Adv Radiat Oncol 2022; 7:100888. [PMID: 35198835 PMCID: PMC8844682 DOI: 10.1016/j.adro.2021.100888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 12/21/2021] [Indexed: 01/14/2023] Open
Abstract
Purpose Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in cancer survivors, particularly after chest radiation therapy (RT). However, the extent to which CVD events are consistently reported in contemporary prospective trials is unknown. Methods and Materials From 10 high-impact RT, oncology, and medicine journals, we identified all latter phase trials from 2000 to 2019 enrolling patients with breast, lung, lymphoma, mesothelioma, or esophageal cancer wherein chest-RT was delivered. The primary outcome was the report of major adverse cardiac events (MACEs), defined as incident myocardial infarction, heart failure, coronary revascularization, arrhythmia, stroke, or CVD death across treatment arms. The secondary outcome was the report of any CVD event. Multivariable regression was used to identify factors associated with CVD reporting. Pooled annualized incidence rates of MACEs across RT trials were compared with contemporary population rates using relative risks (RRs). Results The 108 trials that met criteria enrolled 59,070 patients (mean age, 58.0 ± 10.2 years; 46.0% female), with 273,587 person-years of available follow-up. During a median follow-up of 48 months, 468 MACEs were reported (including 96 heart failures, 75 acute coronary syndrome, 1 revascularization, 94 arrhythmias, 28 strokes, and 20 CVD deaths; 307 occurred in the intervention arms vs 144 in the control arms; RR, 1.96; P < .001). Altogether, 50.0% of trials did not report MACEs, and 37.0% did not report any CVD. The overall weighted-trial incidence was 376 events per 100,000 person-years compared with 1408 events per 100,000 person-years in similar nontrial patients (RR, 0.27; P < .001). There were no RT factors associated with CVD reporting. Conclusion In contemporary chest RT–based clinical trials, reported CVD rates were lower than expected population rates.
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Affiliation(s)
- Rahul N. Prasad
- Department of Radiation Oncology, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Mark McIntyre
- Cardio-Oncology Program, Division of Cardiology, Ohio State University Medical Center, Columbus, Ohio
| | - Avirup Guha
- Cardio-Oncology Program, Division of Cardiology, Ohio State University Medical Center, Columbus, Ohio
- Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, Ohio
| | - Rebecca R. Carter
- Cardio-Oncology Program, Division of Cardiology, Ohio State University Medical Center, Columbus, Ohio
- Center for the Advancement of Team Science, Analytics, and Systems Thinking (CATALYST), Ohio State University College of Medicine, Columbus, Ohio
| | - Vedat O. Yildiz
- Cardio-Oncology Program, Division of Cardiology, Ohio State University Medical Center, Columbus, Ohio
- Center for Biostatistics, Department of Biomedical Informatics, Ohio State University, Columbus, Ohio
| | - Electra Paskett
- Division of Cancer Control and Prevention, Department of Internal Medicine, College of Medicine and Comprehensive Cancer Center, Ohio State University, Columbus, Ohio
| | - Maryam Lustberg
- Department of Breast Medical Oncology, Yale Cancer Center, New Haven, Connecticut
| | - Patrick Ruz
- Cardio-Oncology Program, Division of Cardiology, Ohio State University Medical Center, Columbus, Ohio
| | - Terence M. Williams
- Department of Radiation Oncology, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Onaopepo Kola-Kehinde
- Cardio-Oncology Program, Division of Cardiology, Ohio State University Medical Center, Columbus, Ohio
| | - Eric D. Miller
- Department of Radiation Oncology, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Daniel Addison
- Cardio-Oncology Program, Division of Cardiology, Ohio State University Medical Center, Columbus, Ohio
- Division of Cancer Control and Prevention, Department of Internal Medicine, College of Medicine and Comprehensive Cancer Center, Ohio State University, Columbus, Ohio
- Corresponding author: Daniel Addison, MD
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19
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Prasad RN, Miller ED, Addison D, Bazan JG. Lack of Cardiotoxicity Endpoints in Prospective Trials Involving Chest Radiation Therapy: A Review of Registered, Latter-Phase Studies. Front Oncol 2022; 12:808531. [PMID: 35223489 PMCID: PMC8863863 DOI: 10.3389/fonc.2022.808531] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/20/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Chest radiation therapy (RT) has been associated with increased cardiac morbidity and mortality in numerous studies including the landmark Darby study published in 2013 demonstrating a linear increase in cardiac mortality with increasing mean heart radiation dose. However, the extent to which cardiotoxicity has been incorporated as an endpoint in prospective RT studies remains unknown. METHODS We queried clincaltrials.gov to identify phase II/III trials in lung, esophageal, lymphoma, mesothelioma, thymoma, or breast cancer from 1/1/2006-2/1/2021 enrolling greater than 100 patients wherein chest RT was delivered in at least one treatment arm. The primary endpoint was the rate of inclusion of cardiotoxicity as a specific primary or secondary endpoint in the pre- (enrollment started prior to 1/1/2014) versus post-Darby era using the Chi-square test (p<0.05 considered significant). We also analyzed clinical trial factors associated with the inclusion of cardiotoxicity as an endpoint using logistic regression analysis. RESULTS In total, 1,822 trials were identified, of which 256 merited inclusion. 32% were for esophageal, 31% lung, 28% breast, and 7% lymphoma/thymoma/mesothelioma cancers, respectively. 5% (N=13) included cardiotoxicity as an endpoint: 6 breast cancer, 3 lung cancer, 3 esophageal cancer, and 1 lymphoma study. There was no difference in the inclusion of cardiotoxicity endpoints in the pre-Darby versus post-Darby era (3.9% vs. 5.9%, P=0.46). The greatest absolute increase in inclusion of cardiotoxicity as an endpoint was seen for lung cancer (0% vs. 6%, p=0.17) and breast cancer (5.7% vs. 10.8%, p=0.43) studies, though these increases remained statistically non-significant. We found no clinical trial factors associated with the inclusion of cardiotoxicity as an endpoint. CONCLUSIONS Among prospective trials involving chest RT, cardiotoxicity remains an uncommon endpoint despite its prevalence as a primary source of toxicity following treatment. In order to better characterize cardiac toxicities, future prospective studies involving chest RT should include cardiotoxicity endpoints.
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Affiliation(s)
- Rahul N. Prasad
- Department of Radiation Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, OH, United States
| | - Eric D. Miller
- Department of Radiation Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, OH, United States
| | - Daniel Addison
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, OH, United States
- Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, OH, United States
| | - Jose G. Bazan
- Department of Radiation Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, OH, United States
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Lehrer EJ, Gurewitz J, Bernstein K, Patel D, Kondziolka D, Niranjan A, Wei Z, Lunsford LD, Malouff TD, Ruiz‐Garcia H, Patel S, Bonney PA, Hwang L, Yu C, Zada G, Mathieu D, Trudel C, Prasad RN, Palmer JD, Jones BM, Sharma S, Fakhoury KR, Rusthoven CG, Deibert CP, Picozzi P, Franzini A, Attuati L, Lee C, Yang H, Ahluwalia MS, Sheehan JP, Trifiletti DM. Radiation necrosis in renal cell carcinoma brain metastases treated with checkpoint inhibitors and radiosurgery: An international multicenter study. Cancer 2022; 128:1429-1438. [DOI: 10.1002/cncr.34087] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 11/08/2021] [Accepted: 11/22/2021] [Indexed: 12/18/2022]
Affiliation(s)
- Eric J. Lehrer
- Department of Radiation Oncology Icahn School of Medicine at Mount Sinai New York New York
| | - Jason Gurewitz
- Department of Radiation Oncology NYU Langone Medical Center New York New York
| | - Kenneth Bernstein
- Department of Radiation Oncology NYU Langone Medical Center New York New York
| | - Dev Patel
- Department of Neurosurgery NYU Langone Medical Center New York New York
| | | | - Ajay Niranjan
- Department of Neurological Surgery University of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | - Zhishuo Wei
- Department of Neurological Surgery University of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | - L. Dade Lunsford
- Department of Neurological Surgery University of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | | | | | - Samir Patel
- Division of Radiation Oncology Department of Oncology University of Alberta Edmonton Alberta Canada
| | - Phillip A. Bonney
- Department of Neurosurgery University of Southern California Los Angeles California
| | - Lindsay Hwang
- Department of Radiation Oncology University of Southern California Los Angeles California
| | - Cheng Yu
- Department of Neurosurgery University of Southern California Los Angeles California
| | - Gabriel Zada
- Department of Neurosurgery University of Southern California Los Angeles California
| | - David Mathieu
- Department of Neurosurgery Université de Sherbrooke, Centre de Recherche du CHUS Quebec Quebec Canada
| | - Claire Trudel
- Department of Medicine Université de Sherbrooke, Centre de Recherche du CHUS Quebec Quebec Canada
| | - Rahul N. Prasad
- Department of Radiation Oncology Ohio State University Wexner Medical Center Columbus Ohio
| | - Joshua D. Palmer
- Department of Radiation Oncology Ohio State University Wexner Medical Center Columbus Ohio
| | - Brianna M. Jones
- Department of Radiation Oncology Icahn School of Medicine at Mount Sinai New York New York
| | - Sonam Sharma
- Department of Radiation Oncology Icahn School of Medicine at Mount Sinai New York New York
| | | | - Chad G. Rusthoven
- Department of Radiation Oncology University of Colorado Denver Colorado
| | | | - Piero Picozzi
- Department of Neurosurgery Humanitas Research Hospital–IRCCS Rozzano Italy
| | - Andrea Franzini
- Department of Neurosurgery Humanitas Research Hospital–IRCCS Rozzano Italy
| | - Luca Attuati
- Department of Neurosurgery Humanitas Research Hospital–IRCCS Rozzano Italy
| | - Cheng‐Chia Lee
- Department of Neurosurgery Neurological InstituteTaipei Veteran General Hospital Taipei Taiwan
| | - Huai‐Che Yang
- Department of Neurosurgery Neurological InstituteTaipei Veteran General Hospital Taipei Taiwan
| | | | - Jason P. Sheehan
- Department of Neurological Surgery University of Virginia Charlottesville Virginia
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21
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Prasad RN, Royce TJ, Palmer JD. Do Federal Price Transparency Regulations Neglect Oncology Patients? JCO Oncol Pract 2022; 18:413-416. [DOI: 10.1200/op.21.00751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Rahul N. Prasad
- Department of Radiation Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Trevor J. Royce
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, NC
| | - Joshua D. Palmer
- Department of Radiation Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, OH
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22
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Prasad RN, Baliga S, Banner J, Cadieux C, Centnar A, Degnan M, Depinet M, Ewing A, Hobbs N, Jiang AL, Manring I, Perlow HK, Rock A, Skinner LB, Tenney L, Walls V, Hiniker SM, Palmer JD. Radiation Therapy without Anesthesia for a 2-Year Old Child using Audio-Visual Assisted Therapeutic Ambience in Radiotherapy (AVATAR). Pract Radiat Oncol 2021; 12:e216-e220. [PMID: 34971793 DOI: 10.1016/j.prro.2021.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 12/09/2021] [Accepted: 12/16/2021] [Indexed: 10/19/2022]
Abstract
Radiation therapy (RT) is essential to managing many pediatric malignancies, but can be anxiety, fear, and discomfort provoking for children due to prolonged treatment time, extended course, and restrictive immobilization. Patients under 10 years frequently require daily general anesthesia (GA), which is resource intensive, expensive, potentially toxic, and anxiety/fear provoking. The Audio-Visual Assisted Therapeutic Ambience in Radiotherapy (AVATAR), a video streaming device, has been proposed as an alternative to anesthesia in patients aged 3-10. A pilot study evaluating the efficacy of this novel innovation is accruing, but patients under 3 are ineligible. We simulated a 2-year-old with Stage IV Wilms tumor for bilateral whole lung and left flank irradiation without GA. Using the AVATAR, we attempted to deliver RT to this patient without sedation. Patient anxiety at the time of simulation and at the beginning, middle, and end of the treatment course was characterized using the validated Modified Yale Preoperative Anxiety Score (mYPAS) measurement tool. Although the patient tolerated CT simulation without GA or AVATAR use, his mYPAS of 14/18 indicated significant anxiety. Using the AVATAR, all treatments were delivered without GA; mYPAS scores were 5, 4 (lowest possible), and 4 at the first, mid-course and final treatments, indicating no significant anxiety and a decrease from pre-AVATAR baseline. Without GA, the package time to deliver RT decreased by 66% from 90 to 30 minutes. In summary, we describe an expanded, previously unreported indication for the AVATAR by demonstrating the feasibility of this anesthesia-reducing/omitting approach in appropriate younger patients currently excluded from ongoing trials. The financial and quality of life benefits (including decreased stress, anxiety, toxicity, cost, and appointment time) of AVATAR utilization may be extendable to a younger patient population than previously thought. In older children, prospective validation is ongoing, but additional study in patients under 3 is needed.
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Affiliation(s)
- Rahul N Prasad
- Department of Radiation Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Sujith Baliga
- Department of Radiation Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Julie Banner
- Department of Radiation Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Catherine Cadieux
- Department of Radiation Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Ashley Centnar
- Department of Radiation Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Michael Degnan
- Department of Radiation Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Megan Depinet
- Department of Radiation Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Ashlee Ewing
- Department of Radiation Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Nikki Hobbs
- Department of Radiation Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Alice L Jiang
- Department of Radiation Therapy, Stanford Cancer Institute
| | - Isabel Manring
- Department of Radiation Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Haley K Perlow
- Department of Radiation Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Ashley Rock
- Department of Radiation Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | | | - Lyndsie Tenney
- Department of Radiation Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Vanessa Walls
- Department of Radiation Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | | | - Joshua D Palmer
- Department of Radiation Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA.
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23
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Siedow M, Brownstein J, Prasad RN, Loccoh E, Harfi TT, Okabe T, Tong MS, Afzal MR, Williams T. Cardiac radioablation in the treatment of ventricular tachycardia. Clin Transl Radiat Oncol 2021; 31:71-79. [PMID: 34646951 PMCID: PMC8498093 DOI: 10.1016/j.ctro.2021.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/02/2021] [Accepted: 02/08/2021] [Indexed: 11/25/2022] Open
Abstract
Cardiac radioablation with SBRT is a very promising non-invasive modality for the treatment of refractory VT and potentially other cardiac arrhythmias. Initial reports indicate that it is relatively safe and associated with excellent responses, particularly in reduction of ICD-related events, need for anti-arrhythmic medications, and resulting in significantly improved quality of life for patients. Establishment of objective criteria for candidates for cardiac radioablation will accelerate the adoption of this important radiation therapy modality in the treatment of refractory VT and other cardiac arrhythmias in the coming years. In addition, in order to develop more prospective safety and efficacy data, treatment of patients should ideally be performed in the context of clinical trials or prospective registries at, or in collaboration with, experienced centers. Taken together, the future of cardiac radioablation is rich and worthy of further investigation to become a standard treatment in the armamentarium against refractory VT.
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Affiliation(s)
- Michael Siedow
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jeremy Brownstein
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Rahul N. Prasad
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Emefah Loccoh
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Thura T. Harfi
- Division of Cardiovascular Medicine, The Ohio State University Medical Center, Columbus, OH, USA
| | - Toshimasa Okabe
- Division of Cardiovascular Medicine, The Ohio State University Medical Center, Columbus, OH, USA
| | - Matthew S. Tong
- Division of Cardiovascular Medicine, The Ohio State University Medical Center, Columbus, OH, USA
| | - Muhammad R. Afzal
- Division of Cardiovascular Medicine, The Ohio State University Medical Center, Columbus, OH, USA
| | - Terence Williams
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, USA
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Prasad RN, Patel TT, Keith SW, Eldredge-Hindy H, Fisher SA, Palmer JD. Development of a Financial Toxicity Screening Tool for Radiation Oncology: A Secondary Analysis of a Pilot Prospective Patient-Reported Outcomes Study. Adv Radiat Oncol 2021; 6:100782. [PMID: 34660939 PMCID: PMC8503853 DOI: 10.1016/j.adro.2021.100782] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 02/02/2021] [Revised: 06/08/2021] [Accepted: 08/20/2021] [Indexed: 11/20/2022] Open
Abstract
Purpose Financial toxicity is highly prevalent in oncology. Early identification of at-risk patients is essential because financial toxicity is associated with inferior outcomes. Validated general oncology screening tools are cumbersome and not specific to challenges related to radiation therapy, such as daily treatments. In the population of radiation oncology patients, no standardized, validated, rapid screening tool exists. We sought to develop a rapid, no-cost, and reliable financial-toxicity screening tool for clinical radiation oncology. Methods and Materials We retrospectively analyzed data from a prospective survey study conducted at a large referral center with a heterogeneous population. Before treatment, a 25-item modified comprehensive survey for financial toxicity incorporating subjective and objective patient-reported measures was administered to identify factors linked to the risk of developing financial toxicity, which was defined as radiation therapy resulting in any of the following: loss of income, job, or spouse or difficulty paying for meals, housing, or transportation. We applied a logistic regression model with a stepwise, backward model selection procedure. Estimated probabilities of experiencing financial toxicity were computed using the inverse-logit transformation of the sum of patient-specific predictor values multiplied by the coefficients of the selected logistic regression model. The Youden index was used to determine a reasonable risk threshold. Results A total of 157 patients completed the questionnaire, and 34 (22%) were assessed as experiencing financial toxicity. The model retained 3 factors: age, money owed, and copayment-related worries. It resulted in a concordance statistic of 0.85, developed with a risk threshold of 18% (Youden index, 0.59). This model conferred a sensitivity of 89%, specificity of 70%, positive predictive value of 44%, and negative predictive value of 96%. Conclusions Our proposed financial-toxicity screen is rapid, free, sensitive, and specific, and in this study, it identified early-onset, patient-reported financial toxicity after radiation therapy with just 3 simple variables: age, money owed, and copayment-related concerns. Future research steps should include a validation cohort and identification of interventions to mitigate financial toxicity.
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Affiliation(s)
- Rahul N Prasad
- The James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Tejash T Patel
- Doctor of Osteopathic Medicine/Master of Business Administration Program, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania.,Department of Radiation Oncology, Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Scott W Keith
- Department of Pharmacology & Experimental Therapeutics, Division of Biostatistics, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Harriet Eldredge-Hindy
- Department of Radiation Oncology, University of Louisville School of Medicine, Louisville, Kentucky
| | - Scot A Fisher
- Department of Radiation Oncology, Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Joshua D Palmer
- The James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Prasad RN, Gardner UG, Yaney A, Prevedello DM, Koboldt DC, Thomas DL, Mardis ER, Palmer JD. Germline BAP1 Mutation in a Family With Multi-Generational Meningioma With Rhabdoid Features: A Case Series and Literature Review. Front Oncol 2021; 11:721712. [PMID: 34504799 PMCID: PMC8421801 DOI: 10.3389/fonc.2021.721712] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 06/07/2021] [Accepted: 08/05/2021] [Indexed: 12/15/2022] Open
Abstract
Meningioma is the most common primary brain tumor, and recurrence risk increases with increasing WHO Grade from I to III. Rhabdoid meningiomas are a subset of WHO Grade III tumors with rhabdoid cells, a high proliferation index, and other malignant features that follow an aggressive clinical course. Some meningiomas with rhabdoid features either only focally or without other malignant features are classified as lower grade yet still recur early. Recently, inactivating mutations in the tumor suppressor gene BAP1 have been associated with poorer prognosis in rhabdoid meningioma and meningioma with rhabdoid features, and germline mutations have been linked to a hereditary tumor predisposition syndrome (TPDS) predisposing patients primarily to melanoma and mesothelioma. We present the first report of a familial BAP1 inactivating mutation identified after multiple generations of a family presented with meningiomas with rhabdoid features instead of with previously described BAP1 loss-associated malignancies. A 24-year-old female presented with a Grade II meningioma with rhabdoid and papillary features treated with subtotal resection, adjuvant external beam radiation therapy, and salvage gamma knife radiosurgery six years later. Around that time, her mother presented with a meningioma with rhabdoid and papillary features managed with resection and adjuvant radiation therapy. Germline testing was positive for a pathogenic BAP1 mutation in both patients. Sequencing of both tumors demonstrated biallelic BAP1 inactivation via the combination of germline BAP1 mutation and either loss of heterozygosity or somatic mutation. No additional mutations implicated in oncogenesis were noted from either patient's germline or tumor sequencing, suggesting that the inactivation of BAP1 was responsible for pathogenesis. These cases demonstrate the importance of routine BAP1 tumor testing in meningioma with rhabdoid features regardless of grade, germline testing for patients with BAP1 inactivated tumors, and tailored cancer screening in this population.
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Affiliation(s)
- Rahul N Prasad
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, OH, United States
| | - Ulysses G Gardner
- Boonshoft School of Medicine, Wright State University, Dayton, OH, United States
| | - Alexander Yaney
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, OH, United States
| | - Daniel M Prevedello
- Department of Neurosurgery, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, OH, United States
| | - Daniel C Koboldt
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, United States
| | - Diana L Thomas
- Department of Pathology, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, OH, United States
| | - Elaine R Mardis
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, United States
| | - Joshua D Palmer
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, OH, United States
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Prasad RN, Williams TM. A narrative review of toxicity of chemoradiation and immunotherapy for unresectable, locally advanced non-small cell lung cancer. Transl Lung Cancer Res 2020; 9:2040-2050. [PMID: 33209624 PMCID: PMC7653152 DOI: 10.21037/tlcr-20-638] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Despite declining smoking rates, lung cancer remains the second most common malignancy in the United States and the leading cause of cancer-related mortality. Non-small cell lung cancer (NSCLC) comprises roughly 85% of cases, and patients tend to present with advanced disease. Historically, concurrent chemoradiotherapy (CRT) has been the standard of care for stage III unresectable NSCLC but outcomes even with multimodal therapy have remained relatively poor. Efforts to improve outcomes through radiation dose escalation with conventional dose fractionation were unsuccessful with RTOG 0617, demonstrating significantly decreased overall survival (OS) with high dose radiation with respect to standard therapy. The recent PACIFIC trial established a new role for consolidative immune checkpoint blockade therapy after CRT using the programmed death ligand 1 (PD-L1) inhibitor durvalumab, by demonstrating significantly improved progression free survival and OS. Although promising, the addition of immunotherapy to multimodal therapy has generated debate regarding the most effective immune pathways to target, appropriate sequencing of therapy, most effective radiation techniques, and toxicity-related concerns. This review will highlight recent and ongoing trials in unresectable, locally advanced NSCLC that incorporate chemotherapy, radiation, and immunotherapy with an emphasis on analysis of treatment-related toxicities and implications for future study design.
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Affiliation(s)
- Rahul N Prasad
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio, USA
| | - Terence M Williams
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio, USA
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Prasad RN, Breneman JC, Struve T, Warnick RE, Pater LE. Linac-based fractionated stereotactic radiosurgery for high-risk meningioma. J Radiosurg SBRT 2018; 5:269-276. [PMID: 30538887 PMCID: PMC6255720] [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] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Accepted: 07/30/2018] [Indexed: 06/09/2023]
Abstract
PURPOSE Single-fraction stereotactic radiosurgery(SRS) for meningioma has high rates of symptomatic perilesional edema in some settings. Fractionated stereotactic radiosurgery(fSRS) could decrease edema rates while maintaining tumor control. METHODS AND MATERIALS Patients at an institution were retrospectively reviewed(2013-2017). Adults receiving definitive, linear accelerator(linac)-based fSRS (25-30Gy/5 fractions) were included. fSRS was recommended for tumors at high risk for perilesional edema with SRS due to large size, prior irradiation, or proximity to organs at risk. Endpoints included rates of symptomatic, radiographically-defined perilesional edema and local control(LC). RESULTS 12 Patients with 13 meningiomas met criteria. 24-month actuarial LC and overall survival were 87% and 100%. Symptomatic, post-treatment edema was identified on follow-up MRI in 31% of cases. No variables predicted edema, but affected lesions were larger(6.82 v. 2.46cc). CONCLUSION Linac-based fSRS for meningioma has high local control and modest toxicity rates similar to SRS in the literature. Prospective studies comparing fSRS/SRS are warranted.
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Affiliation(s)
- Rahul N Prasad
- Department of Radiation Oncology at the University of Cincinnati Barrett Cancer Center, 234 Goodman Street, Cincinnati, OH 45219, USA
| | - John C Breneman
- Department of Radiation Oncology at the University of Cincinnati Barrett Cancer Center, 234 Goodman Street, Cincinnati, OH 45219, USA
| | - Timothy Struve
- Department of Radiation Oncology at the University of Cincinnati Barrett Cancer Center, 234 Goodman Street, Cincinnati, OH 45219, USA
| | - Ronald E Warnick
- Mayfield Clinic, 3825 Edwards Road, Suite 300, Cincinnati, OH 45209, USA
| | - Luke E. Pater
- Department of Radiation Oncology at the University of Cincinnati Barrett Cancer Center, 234 Goodman Street, Cincinnati, OH 45219, USA
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Prasad RN, Virk KJ. Entamoeba histolytica: is it necessary to characterize pathogenic strains? ACTA ACUST UNITED AC 2005; 3:352; discussion 353, author reply 353. [PMID: 15462888 DOI: 10.1016/0169-4758(87)90124-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Koh SC, Tham KF, Razvi K, Oei PL, Lim FK, Roy AC, Prasad RN. Hemostatic and fibrinolytic status in patients with ovarian cancer and benign ovarian cysts: could D-dimer and antithrombin III levels be included as prognostic markers for survival outcome? Clin Appl Thromb Hemost 2001; 7:141-8. [PMID: 11292192 DOI: 10.1177/107602960100700211] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We determined the hemostatic and fibrinolytic status in 60 patients with ovarian cancer and benign ovarian cysts. Hypercoagulation, increased platelets, and enhanced fibrinolysis were seen in patients with preoperative ovarian cancer compared to patients with benign ovarian cysts. Enhanced thrombin generation, evidenced by increased F1+2 and decreased antithrombin III (ATIII) levels with further enhanced fibrinolysis by elevated D-dimer, was seen in advanced cancer. Ten ovarian cancer patients died within 13 months after diagnosis and another died at 24 months, all from advanced stage of cancer, except one from stage IC cancer who died at 11 months. The survival rates from the disease at 13 months and 24 months were 66.7% and 45%, respectively. Most of the patients had gone through the complete course of chemotherapy, and those patients still alive have been disease free between 13 and 42 months. No statistical relationships for the hemostatic parameters studied in ovarian cancer patients could be found between those who died and those still living 13 and 24 months after diagnosis, except for ATIII and D-dimer levels. Elevated D-dimer levels were associated with those who died within 13 and 24 months from the disease, and the decreased ATIII levels only reached statistical significance by 24 months. It could be suggested that these two parameters might be useful as systemic prognostic markers in survival outcome from the disease for the first 24 months in advanced ovarian cancer, in addition to the known correlation with the International Federation of Gynecology and Obstetrics stage.
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Affiliation(s)
- S C Koh
- National University of Singapore, Department of Obstetrics and Gynaecology, National University Hospital, Singapore.
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Adaikan PG, Gauthaman K, Prasad RN, Ng SC. Proerectile pharmacological effects of Tribulus terrestris extract on the rabbit corpus cavernosum. Ann Acad Med Singap 2000; 29:22-6. [PMID: 10748960] [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] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
INTRODUCTION The objective of the present study was to investigate the effect of oral treatment of Tribulus terrestris (TT) extract on the isolated corpus cavernosal tissue of New Zealand white (NZW) rabbits and to determine the mechanism by which protodioscin (PTN), a constituent of the TT, exerts its pharmacological effects. MATERIALS AND METHODS Twenty-four NZW rabbits were randomly assigned to 4 experimental groups of 6 each. Group I served as control. Groups II to IV were treated with the extract at different dose levels, i.e. 2.5 mg/kg, 5 mg/kg and 10 mg/kg body weight, respectively. The TT extract was administered orally, once daily, for a period of 8 weeks. The rabbits were then sacrificed and their penile tissue isolated to evaluate the responses to both contracting and relaxing pharmacological agents and electrical field stimulation (EFS). RESULTS PTN on its own had no effect on the isolated corpus cavernosal strips. The relaxant responses to EFS, acetylcholine and nitroglycerin in noradrenaline precontracted tissues from treated groups showed an increase in relaxation of a concentration dependent nature compared to that of the tissues from control group. However, the contractile, anti-erectile response of corpus cavernosal tissue to noradrenaline and histamine showed no significant change between the treatment and the control groups. CONCLUSIONS The relaxant responses to acetylcholine, nitroglycerin and EFS by more than 10%, 24% and 10% respectively compared to their control values and the lack of such effect on the contractile response to noradrenaline and histamine indicate that PTN has a proerectile activity. The enhanced relaxant effect observed is probably due to increase in the release of nitric oxide from the endothelium and nitrergic nerve endings, which may account for its claims as an aphrodisiac. However, further study is needed to clarify the precise mechanism of its action.
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Affiliation(s)
- P G Adaikan
- Department of Obstetrics & Gynaecology, National University Hospital, National University of Singapore, Singapore.
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Abstract
OBJECTIVE To determine the optimal interval for evacuation after preabortion cervical priming with vaginal misoprostol. METHODS One hundred eighty healthy nulliparas requesting legal termination of pregnancy between 6 and 11 weeks' gestation were assigned randomly to receive 400, 600, or 800 microg of intravaginal misoprostol. Vacuum aspiration was done after 3 hours in the 400-microg group and after 2 hours in the 600- and 800-microg groups. The degree of cervical dilatation before operation was measured with a Hegar dilator. Preoperative and intraoperative blood loss and associated side effects were also assessed. RESULTS Eleven (18.3%) and 15 (25.0%) women in the 600-and 800-microg groups, respectively, had cervical dilatation of at least 8 mm after an interval of 2 hours; 55 (91.7%) women who received 400 microg for a 3-hour interval had similar cervical dilatation. Using 400 microg as a baseline, the odds ratio (OR) was 0.02; 95% confidence interval (CI) was 0.01, 0.06 for 600 microg and OR 0.03; 95% CI 0.01, 0.09 for 800 microg for achieving successful preabortion cervical dilatation of at least 8 mm. The mean cervical dilatation of 6.7 mm and 6.8 mm for the higher doses was also significantly less than that of 8.1 for the 400-microg dose (P<.001). The mean preoperative and intraoperative blood loss was only statistically different when the 400- and 800-microg groups were compared (P = .03). There were also significantly more side effects, namely abdominal pain and fever above 38.0 C, in the 600- and 800-microg groups (P<.001), compared with the 400-microg group. When the 600- and 800-microg groups were compared, there were still significantly more women complaining of abdominal pain (P<.001). None of the women in the study required analgesics for pain or antipyretics for fever. CONCLUSION The minimal evacuation interval should be at least 3 hours for successful preabortion cervical priming.
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Affiliation(s)
- K Singh
- Department of Obstetrics and Gynaecology, National University Hospital, Singapore.
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Abstract
Absorption pharmacokinetics reveal a relationship between plasma concentrations of misoprostol and its therapeutic effect. To achieve a constant plasma profile and optimal efficacy, it is important to develop a medium that ensures complete dissolution of vaginal misoprostol tablets. Vaginal misoprostol is said to liquefy better in an acidic medium; thus, the aim of this study was to determine whether a 200 microg misoprostol tablet dissolved in acetic acid would be more efficacious than 200 microg misoprostol dissolved in water for pre-abortion cervical priming. A total of 120 healthy nulliparous women requesting legal termination of pregnancy between 6-12 weeks gestation were allocated randomly to either of the study groups. Vacuum aspiration was performed 3-4 h after insertion of the misoprostol tablet. Using Hegar's dilator, the degree of cervical dilatation before operation was measured. Of 60 women, 14 (23%) achieved a cervical dilatation of >/=8 mm when the misoprostol dose was dissolved in acetic acid; 12 (20%) achieved a similar cervical dilatation when the dose was dissolved in water. The mean cervical dilatation for the acid and water media used was 6.3 mm and 6.2 mm respectively; these differences were not statistically significant, neither were pre-operative and intra-operative blood losses statistically different between the two groups. Twenty-four (40%) and four (7%) respectively of women in whom a water medium was used experienced vaginal bleeding and abdominal pain; 20 (33%) and 0 women respectively among those in whom an acetic acid medium was used experienced vaginal bleeding and abdominal pain. These differences in side effects were not statistically significant. Our study shows that the use of acetic acid to dissolve vaginal misoprostol does not improve the efficacy in achieving successful cervical dilatation for pre-abortion cervical priming.
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Affiliation(s)
- K Singh
- Department of Obstetrics and Gynaecology, National University of Singapore, Singapore
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Abstract
OBJECTIVE To determine the optimal evacuation time interval in the use of vaginal misoprostol for cervical priming before first trimester termination of pregnancy. DESIGN Prospective double-blind randomised study. SETTING Fertility Control Centre, National University Hospital, Singapore. METHODS Sixty healthy nulliparous women requesting legal termination of pregnancy between 6 and 11 weeks of gestation were randomly allocated to either the 400 microg or 600 microg misoprostol group. Vacuum aspiration was performed after three hours in the 400 microg group and at the end of two hours in the women given 600 microg misoprostol. Using Hegar's dilator, degree of cervical dilatation before operation was measured. Other parameters assessed included the amount of additional dilatation required (if < Hegar 8), pre-operative and intra-operative blood loss, and associated side effects. RESULTS For the 600 microg group, only five women (16.7%) achieved a cervical dilatation of > or = 8 mm, compared with 28 women (93.3%) in the 400 microg group. Using the 400 microg misoprostol group as a baseline, the odds ratio was 0.014 (95% CI 0.003-0.080) for 600 microg for successful pre-operative cervical dilatation of > or = 8 mm. The mean cervical dilatation for 400 and 600 microg misoprostol was 8.1 mm and 6.6 mm, respectively (P < 0.001). Despite the shorter evacuation time interval of two hours, the 600 microg dose was associated with an increase in side effects such as vaginal bleeding, abdominal pain and a fever of > 38.0 degrees C. However, other than abdominal pain, no significant differences in the frequency of these side effects were shown. CONCLUSION Use of 400 microg misoprostol with a minimal evacuation time interval of three hours still appears the optimal dosage and evacuation time for cervical priming before first trimester termination of pregnancy.
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Affiliation(s)
- K Singh
- Department of Obstetrics and Gynaecology, National University Hospital, Singapore
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Affiliation(s)
- Y F Fong
- Department of Obstetrics and Gynaecology, National University of Singapore, Singapore
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Prasad RN, Koh SC, Viegas OA, Ratnam SS. Effects on hemostasis after two-year use of low dose combined oral contraceptives with gestodene or levonorgestrel. Clin Appl Thromb Hemost 1999; 5:60-70. [PMID: 10725985 DOI: 10.1177/107602969900500112] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We studied 67 healthy women who were randomly allocated to receive third generation gestodene (Gynera) or second generation levonorgestrel (Microgynon 30) combination of low-dose estrogen oral contraceptives (OCs) for their hemostatic effects over 2 years. Hemostatic changes were apparent within 3 months of OC use. Hematocrit (Hct) was not affected, but hemoglobin (Hb) concentration decreased by 18 months. Shortened prothrombin time (PT) and activated plasma thromboplastin time (APTT) were associated with elevated fibrinogen within the 12-month use of both OCs. Factor VII was reduced only in Micro 30 during the 18 months of use. Enhanced thrombin-antithrombin (TAT)-complex level was seen at 18 months of Gynera use. Prothrombin fragment1+2 (F1+2) rise was seen at 3 months with Micro 30. Reduced antithrombin III (ATIII) activity was seen at 18 months with Gynera and at 24 months with Micro 30. Increased protein C activity was seen at 3 months and reduced protein S occurred at 18 months of Gynera use. Tissue plasminogen activator (t-PA) activity was enhanced for 6 months in both OCs with raised D-dimer levels for 12 months with Gynera and 6 months with Micro 30. Decreased t-PA antigen was seen at 18 months and decreased urokinaselike plasminogen activator (u-PA) antigen occurred throughout the 24 months of both OCs use. Enhanced u-PA activity was only seen in Gynera users. Elevated plasminogen levels were apparent throughout both OCs use. PAI-1 levels were significantly decreased with Micro 30. With Gynera, the decreased PAI-1 activity was seen only at 18 months and PAI-1 antigen at 12 months. No change in platelets and von Willebrand factor (vWF) were seen in long-term OC use except that beta-thromboglobulin (beta-TG) showed decreased trends reaching statistical significance by 18 and 24 months of Micro 30 use and by 24 months of Gynera use. A further significant decrease in beta-TG, u-PA antigen, ATIII, and protein S levels were seen 3 months after pill stoppage compared with pretreatment levels. Activated protein C resistance (APCR) was negative in all subjects before and during OC use. The study indicated dynamic balance between coagulation and fibrinolysis with no endothelial activation. However, because some hemostatic markers showed wide fluctuations during OC use, a longer term study is warranted to investigate any adverse hemostatic changes that might enhance the risks of venous thromboembolism in Asian subjects known to be less prone to thrombosis.
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Affiliation(s)
- R N Prasad
- National University of Singapore, Department of Obstetrics & Gynaecology, National University of Hospital, Singapore
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Abstract
OBJECTIVE To determine the optimal dosage of vaginal misoprostol for cervical priming before vacuum aspiration abortion. METHODS One hundred twenty women were assigned randomly to receive 200, 400, 600, or 800 microg of misoprostol given vaginally. Vacuum aspiration was performed 3-4 hours after the insertion of misoprostol tablets. The degree of cervical dilation before operation was measured with a Hegar dilator. Preoperative and intraoperative blood loss and associated side effects also were assessed. RESULTS Twenty-nine (96.7%) women in the 400-microg group and all in the 600-microg and 800-microg groups achieved cervical dilation of at least 8 mm. The success rate for the 200-microg group was only 23.3%, significantly less efficacious than the 400-microg dose (odds ratio 95.3; 95% confidence interval 10.9, 830.9; P < .001). There was no significant difference among the 400-, 600-, and 800-microg groups (P = .364) with respect to achieving cervical dilation at least 8 mm. However, 800 microg was associated with significantly more side effects than 600 microg (preoperative and intraoperative blood loss, P < .001; abdominal pain, P = .005; products of conception at os, P < .001; fever higher than 38.0C, P = .002). When 400 microg and 600 microg were compared, we found that the higher dose also was associated with significantly more side effects. The 600-microg group was used twice in the comparison, but all P values remained significant even after the Bonferroni adjustment for multiple comparisons. CONCLUSION Vaginal application of 400 microg of misoprostol is the optimal dose for vacuum aspiration preabortion cervical dilation in first-trimester nulliparas.
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Affiliation(s)
- K Singh
- Department of Obstetrics and Gynaecology, National University of Singapore, National University of Singapore Medical Institute, Singapore
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Fong YF, Singh K, Prasad RN. A comparative study using two dose regimens (200 microg or 400 microg) of vaginal misoprostol for pre-operative cervical dilatation in first trimester nulliparae. Br J Obstet Gynaecol 1998; 105:413-7. [PMID: 9609268 DOI: 10.1111/j.1471-0528.1998.tb10126.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the optimal dosage and dosing interval for the use of misoprostol administered vaginally for pre-operative cervical dilatation. DESIGN Prospective double-blind randomised study. SETTING Fertility Control Centre, National University Hospital, Singapore. METHODS Women were randomly allocated to either the 200 microg or the 400 microg misoprostol group. Vacuum aspiration was performed at either three or four hours after the insertion of misoprostol tablets. Using Hegar's dilatator, degree of cervical dilatation before operation was measured. Other parameters assessed included the amount of additional dilatation required (if it was < Hegar 8), pre-operative and intra-operative blood loss, and associated side effects. RESULTS For the 200 microg misoprostol group, only seven (23.3%) achieved a dilatation of > or = 8 mm compared with 29 women (96.7%) in the 400 microg misoprostol group. The odds ratio was 95.3 (95% CI 10.9-830.9) for 400 microg misoprostol for successful pre-operative cervical dilatation of > or = 8 mm. The mean cervical dilatation for 400 microg and 200 microg misoprostol was 8.2 mm and 6.4 mm, respectively (P < 0.001). The use of 400 microg misoprostol with an evacuation interval of three hours appears to be the optimal dosage and evacuation time interval. Increasing the time interval beyond three hours did not confer any additional advantage on the rate of successful cervical dilatation but was instead associated with an increase in side effects such as vaginal bleeding, lower abdominal pain and the appearance of products of conception at the cervical os. However, besides vaginal bleeding, no significant differences in the frequency of these side effects were demonstrated. CONCLUSION This first report on the comparison of differing dosages and time intervals to determine the optimal dosage treatment schedule shows that the vaginal application of 400 microg misoprostol for at least three hours is optimal for pre-operative cervical dilatation before vacuum aspiration in first trimester nulliparae.
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Affiliation(s)
- Y F Fong
- Department of Obstetrics and Gynaecology, National University Hospital, Singapore
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38
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Abstract
STUDY OBJECTIVE Abortion legislation in Singapore has gone through dramatic changes in the past 25 years. In this paper, we studied the effect of abortion legislation on abortion trends in Singapore. SETTING AND PARTICIPANTS The Ministry of Health, Singapore, collects data on all abortions performed in Singapore. These data have been analyzed and are presented in this paper. RESULTS The liberalization of abortion legislation resulted in a dramatic increase in the number of abortions performed beginning in 1974. The rate peaked at 23,512 abortions in 1985, and in fact, 35% of all pregnancies were terminated in 1985. The introduction of mandatory abortion counseling in 1986 resulted in a decline in the number of abortions to 16,476 in 1993 with only 24.6% of pregnancies being terminated. The teenage abortion rate was 0.2 per 1000 female teenagers under 20 years of age in 1970. With the liberalization of abortions, the rate reached a peak of 13.7 per 1000 female teenagers in 1985. In 1993, the teenage abortion rate was 9.5%. The proportion of nulliparous women seeking abortion has increased phenomenally from 0.5% in 1976 to 40.6% in 1993. Close to 95% of the women seeking abortions in 1993 did so for social reasons, 3.7% for medical reasons, and 2.0% for failed contraception (Table 3). CONCLUSION Mandatory abortion counseling and a change in the government policy which now encourages Singaporeans to have more children if they can afford it, have resulted in a decrease in the number of abortions being performed. The problems of teenage abortions, nulliparous abortions, and repeated abortions need to be further addressed.
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Affiliation(s)
- K Singh
- Department of Obstetrics and Gynaecology, National University Hospital, National University of Singapore, Singapore
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Prasad RN, Choolani M. Termination of early human pregnancy with either 50 mg or 200 mg single oral dose of mifepristone (RU486) in combination with either 0.5 mg or 1.0 mg vaginal gemeprost. Aust N Z J Obstet Gynaecol 1996; 36:20-3. [PMID: 8775244 DOI: 10.1111/j.1479-828x.1996.tb02915.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Mifepristone (RU486) is licensed for use in France at a dose of 600 mg in combination with 1.0 mg of vaginal gemeprost (a prostaglandin E1 analogue) for medical termination of early pregnancy up to 7 weeks' amenorrhoea resulting in 96% complete abortion rates. This study examines if it is possible to use lower doses of mifepristone and gemeprost to achieve similar success for women with pregnancies up to 56 days' amenorrhoea. Four groups of 25 women were scheduled to be given single oral doses of either 50 mg or 200 mg of mifepristone followed 48 hours later by insertion of a single vaginal pessary of 0.5 mg or 1.0 mg gemeprost. The lowest dose combination (i.e. 50 mg mifepristone + 0.5 mg gemeprost) was found to have unacceptable efficacy with a complete abortion rate of only 82%; the highest dose combination (i.e. 200 mg mifepristone + 1.0 mg gemeprost) resulted in a satisfactory complete abortion rate of 96% which is comparable with the rates for the recommended high 600 mg mifepristone dose (+ 1.0 mg gemeprost) in routine clinical use in France. The current study shows that efficacy can be maintained using a third of the recommended dose of mifepristone.
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Affiliation(s)
- R N Prasad
- University Department of Obstetrics and Gynaecology, National University Hospital, Singapore
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40
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Abstract
The combination of an antiprogestogen with prostaglandin has been shown to be an effective alternative to surgical procedures for pregnancy termination in the first 49 days of amenorrhoea and has been available in France since late 1988. Mifepristone when used alone caused poor efficacy with unacceptable vaginal bleeding. The addition of a prostaglandin analogue (sulprostone, gemeprost) produced acceptable efficacy with less bleeding. The present study provides a quantitative assessment of blood loss in a sample of 20 women undergoing medical termination of early pregnancy (amenorrhoea < or = 49 days). Vaginal bleeding occurred between days 3 and 15 of commencing therapy. The median number of days of bleeding was 4 with a median blood loss of 91.5 mL. The mean blood loss was 136.8 mL (+/- SD 159.2) but this did not adversely affect the hemoglobin level in the volunteers. Most patients describe the experience as that similar to a heavy period and viewed the procedure positively especially since they are spared the anaesthetic risks and hospitalization attendant with surgical abortion. Caution is still however advised as there may be the occasional subject with excessive haemorrhage (as in this study where one woman bled a total of 761.4 mL) and close supervision by a physician is essential.
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Affiliation(s)
- R N Prasad
- Department of Obstetrics and Gynaecology, National University Hospital, Singapore
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Prasad RN, Adaikan PG, Anandakumar C, Ratnam SS. The feasibility of early second trimester pregnancy (12 to 14 weeks) termination with single intra-amniotic injection of 15-methyl PGF2 alpha. Aust N Z J Obstet Gynaecol 1995; 35:52-4. [PMID: 7772000 DOI: 10.1111/j.1479-828x.1995.tb01830.x] [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: 01/27/2023]
Abstract
Prostaglandin analogues have proven to be safe and effective for second trimester pregnancy terminations when given by various routes. Of these, the intra-amniotic (IA) route has proven to be safer, especially in women with medical disorders, as it causes the least occurrence of systemic side-effects. Previously, blind transabdominal IA instillation of the analogue 15-methyl PGF2 alpha was routinely possible only after 16 weeks' gestation. With the advent of ultrasound-guided techniques, it has now become possible to use the IA route for very early second trimester pregnancies. This study examines the use of single 1.5 mg 15-methyl PGF2 alpha IA injection for termination of 12-14 weeks pregnancies. Single injection resulted in successful abortion in 76.5% of women and, in the unsuccessful cases, additional prostaglandin injection resulted in successful abortion in all women within 48 hours without problems. It is therefore feasible to use ultrasound-guided IA prostaglandin injection for successful termination of early second trimester pregnancies.
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Affiliation(s)
- R N Prasad
- Department of Obstetrics and Gynaecology, National University Hospital, Singapore
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Virk KJ, Prasad RN, Prasad H. Prevalence of intestinal parasites in rural areas of district Shahjahanpur, Uttar Pradesh. J Commun Dis 1994; 26:103-8. [PMID: 7989672] [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] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
A stool survey was carried out in some of the villages of Dadraul and Bhawal Khera PHC's of district Shahjahanpur (Uttar Pradesh). Out of 381 individuals examined 111 (29.2 per cent) were found positive for one or the other intestinal parasite. Ascaris lumbricoides superseded all the parasites by showing a positivity of 17.85 percent. Other parasites found were Hookworm, Hymenolepis nana, Tapeworm, Trichuris trichiura, Enterobius vermicularis, Entamoeba histolytica, E. coli and Giardia lamblia. Parasitic load was slightly higher in females (33.59 per cent) than males (28.18 per cent). The highest positivity was encountered in the age groups between 6 to 14 years. This high prevalence of intestinal parasites may be due to the lack of awareness about personal cleanliness and hygiene and illiteracy among rural women. Majority of them had helminthic infections. It is concluded that in rural areas of district Shahjahanpur intestinal helminthic infections are more prevalent that protozoan infections.
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Affiliation(s)
- K J Virk
- Malaria Research Centre, Shahjahanpur, Uttar Pradesh, India
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Abstract
The origins of pyogenic granulomas are subject to much debate. It is viewed as overexuberant growth of epithelium and capillary loops (i.e. granulation tissue) in response to trauma by some authorities, and is considered a capillary haemangioma with a unique lobular organization by others. Although the pathogenesis of the lesion is unclear, marked variation in sexual distribution suggests a hormonal factor, and the profound metabolic and endocrine changes in pregnancy seem to provide especially fertile soil for its growth. Its appearance and rapid rate of growth might easily lead the practitioner to mistake its identity for something more ominous.
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Affiliation(s)
- I J Lim
- Department of Obstetrics and Gynaecology, National University Hospital, Singapore
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Prasad RN, Virk KJ. Malaria as a cause of diarrhoea--a review. P N G Med J 1993; 36:337-41. [PMID: 7941765] [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] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Malaria causes a number of clinical complications, including diarrhoea. There are relatively few reports on the frequency of diarrhoea in malaria, but diarrhoea attributable to malaria is thought to be more common among children and nonimmune adults with hyperparasitaemia. The reported incidence of diarrhoea during malaria varies from 5 to 38%. The pathological changes in patients infected with malaria are very complex and involve many organs, including the small bowel. However, the causes of gastrointestinal manifestations during malaria are still not clear, and the mechanism of diarrhoea during malaria is likely to be multifactorial. Massive gastrointestinal bleedings with multiple foci of mucosal haemorrhage have also been observed. Tumor necrosis factor has been implicated in malaria and free oxygen radicals which can cause tissue injury in the liver, pancreas and intestine are enhanced during malaria infection; this can result in various disorders of the digestive system including diarrhoea and intestinal bleeding. Prostaglandins and cyclic AMP may also be involved in the development of diarrhoea in malaria.
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Affiliation(s)
- R N Prasad
- Malaria Research Centre, Shahjahanpur, India
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Prasad H, Prasad RN, Haq S. Control of mosquito breeding through Gambusia affinis in rice fields. Indian J Malariol 1993; 30:57-65. [PMID: 8405595] [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] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Studies on mosquito breeding and its control through Gambusia affinis in nursery and paddy fields after transplantation of seedlings were carried out during June to October 1991 in about 10 ha rice field area. Six anopheline species, viz. An. culicifacies, An. annularis, An. subpictus, An. nigerrimus, An. barbirostris and An. aconitus, and four culicine species, viz. Cx. tritaeniorhynchus, Cx. bitaeniorhynchus, Cx. quinquefasciatus, and Aedes sp. could be identified. These were found breeding in rice fields with fluctuations in their percentage composition, exhibiting species succession in different months. G. affinis survived well in submerged rice fields and provided 87.8% mosquito larval control. In rice fields which exhibited intermittent drying up leading to formation of pools, puddles etc., moderate larval control was achieved. However, in nursery rice fields, this method was not applicable. Mosquito larval control through larvivorous fish in rice fields can be achieved but the method has limitations.
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Affiliation(s)
- H Prasad
- Malaria Research Centre, Field Station, Khirni Bagh, Sadar Bazar, Shahjahanpur, India
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46
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Prasad RN, Das MK, Sharma T, Dutta GD. Prevalence of filariasis in rural areas of Shahjahanpur district (Uttar Pradesh). Indian J Med Res 1993; 97:112-4. [PMID: 8406632] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Night blood survey was carried out during May, 1990 to December, 1991 in 18 villages of 5 Primary Health Centres of district Shahjahanpur (UP), to find out the prevalence of filariasis in the area. Out of 2141 individuals surveyed randomly, 217 were found positive for microfilariae of Wuchereria bancrofti. The microfilaria rate, filarial disease rate and filarial endemicity rates were 10.1, 11.4 and 18.8 per cent respectively. An entomological survey revealed Culex quinquefasciatus as the vector. The average man hour density was 25.8. It is clear from the results that filariasis is more endemic in rural areas than urban area of Shahjahanpur as observed by local filariasis control unit.
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Haq S, Prasad H, Prasad RN, Sharma T. Availability and utility of local fishes of Shahjahanpur for mosquito control. Indian J Malariol 1993; 30:1-8. [PMID: 8100538] [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] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
A survey of fishes in Shahjahanpur in different aquatic habitats revealed 35 indigenous fish species. Out of 35 fish species, 24 were found feeding on mosquito larvae of which 6 species, viz. Chela bacaila, Puntius stigma, Rasbora daniconius, Esomus danricus, Colisa fasciatus and Danio sp., had good larvivorous potential. Most of the fish species preferred to feed on III and IV instar larvae. In the presence of planktonic food, the consumption capacity of fishes for mosquito larvae was lesser on third day (D3) of observation than on first day (D1). The difference in the consumption of mosquito larvae between D1 and D3 was significant (P < 0.01). Similarly, difference in the feeding capacity of fishes in the months of September and January was highly significant (P < 0.001). But there was no seasonal variation in the preference of instar-wise consumption. Indigenous fish species such as C. fasciatus, E. danricus, P. stigma, R. daniconius and Danio sp. could therefore play a significant role in controlling mosquito breeding in this area.
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Affiliation(s)
- S Haq
- Malaria Research Centre (Field Station), Sadar Bazar, Shahjahanpur, India
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Sharma SN, Prasad RN. Water mite (Arrenurus sp.) parasitizing mosquitoes in District Shahjahanpur, U.P. Indian J Malariol 1992; 29:255-8. [PMID: 1363318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Affiliation(s)
- S N Sharma
- Malaria Research Centre (Field Station), Sadar Bazar, Shahjahanpur, India
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49
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Affiliation(s)
- R N Prasad
- Department of Obstetrics and Gynaecology, National University Hospital, National University of Singapore
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Haq S, Prasad RN, Prasad H, Shukla RP, Sharma VP. Gambusia affinis: dispersal due to floods and its failure to colonize new water bodies in Shahjahanpur District (U.P.). Indian J Malariol 1992; 29:113-8. [PMID: 1459304] [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] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
In villages of District Shahjahanpur, 122 decentralized Gambusia multiplication ponds were established to cover the need of the entire district. Profuse breeding of Gambusia was observed in these ponds. The fishes are being successfully used in mosquito control all over the district. In July 1990 there was a widespread flood due to which 70 Gambusia multiplication ponds were affected and the fish was washed away in large numbers, leaving only a scanty population in the flood-affected ponds. We utilized this opportunity to study the natural dispersal and colonization of Gambusia in different aquatic habitats. The study revealed that Gambusia was either not found in most habitats or was present in very small numbers, and on its own Gambusia was unable to eliminate the local fauna to become a dominant species. Predatory fishes and birds played a major role in eliminating Gambusia. Gambusia is therefore unlikely to pose any ecological hazard in vector-control programmes.
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Affiliation(s)
- S Haq
- Malaria Research Centre (Field Station), Sadar Bazar, Shahjahanpur, India
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