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Adair Smith G, Dunlop A, Alexander SE, Barnes H, Casey F, Chick J, Gunapala R, Herbert T, Lawes R, Mason SA, Mitchell A, Mohajer J, Murray J, Nill S, Patel P, Pathmanathan A, Sritharan K, Sundahl N, Tree AC, Westley R, Williams B, McNair HA. Evaluation of therapeutic radiographer contouring for magnetic resonance image guided online adaptive prostate radiotherapy. Radiother Oncol 2023; 180:109457. [PMID: 36608770 PMCID: PMC10074473 DOI: 10.1016/j.radonc.2022.109457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 12/13/2022] [Accepted: 12/23/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND PURPOSE The implementation of MRI-guided online adaptive radiotherapy has facilitated the extension of therapeutic radiographers' roles to include contouring, thus releasing the clinician from attending daily treatment. Following undergoing a specifically designed training programme, an online interobserver variability study was performed. MATERIALS AND METHODS 117 images from six patients treated on a MR Linac were contoured online by either radiographer or clinician and the same images contoured offline by the alternate profession. Dice similarity coefficient (DSC), mean distance to agreement (MDA), Hausdorff distance (HD) and volume metrics were used to analyse contours. Additionally, the online radiographer contours and optimised plans (n = 59) were analysed using the offline clinician defined contours. After clinical implementation of radiographer contouring, target volume comparison and dose analysis was performed on 20 contours from five patients. RESULTS Comparison of the radiographers' and clinicians' contours resulted in a median (range) DSC of 0.92 (0.86 - 0.99), median (range) MDA of 0.98 mm (0.2-1.7) and median (range) HD of 6.3 mm (2.5-11.5) for all 117 fractions. There was no significant difference in volume size between the two groups. Of the 59 plans created with radiographer online contours and overlaid with clinicians' offline contours, 39 met mandatory dose constraints and 12 were acceptable because 95 % of the high dose PTV was covered by 95 % dose, or the high dose PTV was within 3 % of online plan. A clinician blindly reviewed the eight remaining fractions and, using trial quality assurance metrics, deemed all to be acceptable. Following clinical implementation of radiographer contouring, the median (range) DSC of CTV was 0.93 (0.88-1.0), median (range) MDA was 0.8 mm (0.04-1.18) and HD was 5.15 mm (2.09-8.54) respectively. Of the 20 plans created using radiographer online contours overlaid with clinicians' offline contours, 18 met the dosimetric success criteria, the remaining 2 were deemed acceptable by a clinician. CONCLUSION Radiographer and clinician prostate and seminal vesicle contours on MRI for an online adaptive workflow are comparable and produce clinically acceptable plans. Radiographer contouring for prostate treatment on a MR-linac can be effectively introduced with appropriate training and evaluation. A DSC threshold for target structures could be implemented to streamline future training.
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Affiliation(s)
| | - Alex Dunlop
- Joint Department of Physics at the Royal Marsden and The Institute of Cancer Research, United Kingdom
| | - Sophie E Alexander
- The Institute of Cancer Research/The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Helen Barnes
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Francis Casey
- Joint Department of Physics at the Royal Marsden and The Institute of Cancer Research, United Kingdom
| | - Joan Chick
- Joint Department of Physics at the Royal Marsden and The Institute of Cancer Research, United Kingdom
| | - Ranga Gunapala
- Clinical Trials and Statistic Unit, The Institute for Cancer Research, London, United Kingdom
| | - Trina Herbert
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Rebekah Lawes
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Sarah A Mason
- Joint Department of Physics at the Royal Marsden and The Institute of Cancer Research, United Kingdom
| | - Adam Mitchell
- Joint Department of Physics at the Royal Marsden and The Institute of Cancer Research, United Kingdom
| | - Jonathan Mohajer
- Joint Department of Physics at the Royal Marsden and The Institute of Cancer Research, United Kingdom
| | - Julia Murray
- The Institute of Cancer Research/The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Simeon Nill
- Joint Department of Physics at the Royal Marsden and The Institute of Cancer Research, United Kingdom
| | - Priyanka Patel
- The Institute of Cancer Research/The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Angela Pathmanathan
- The Institute of Cancer Research/The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Kobika Sritharan
- The Institute of Cancer Research/The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Nora Sundahl
- The Institute of Cancer Research/The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Alison C Tree
- The Institute of Cancer Research/The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Rosalyne Westley
- The Institute of Cancer Research/The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | | | - Helen A McNair
- The Institute of Cancer Research/The Royal Marsden NHS Foundation Trust, London, United Kingdom
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Adair Smith G, Dunlop A, Alexander SE, Barnes H, Casey F, Chick J, Gunapala R, Herbert T, Lawes R, Mason SA, Mitchell A, Mohajer J, Murray J, Nill S, Patel P, Pathmanathan A, Sritharan K, Sundahl N, Westley R, Tree AC, McNair HA. Interobserver variation of clinical oncologists compared to therapeutic radiographers (RTT) prostate contours on T2 weighted MRI. Tech Innov Patient Support Radiat Oncol 2023; 25:100200. [PMID: 36654720 PMCID: PMC9841345 DOI: 10.1016/j.tipsro.2022.12.007] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/22/2022] [Accepted: 12/21/2022] [Indexed: 01/01/2023] Open
Abstract
The implementation of MRI-guided online adaptive radiotherapy has enabled extension of therapeutic radiographers' roles to include contouring. An offline interobserver variability study compared five radiographers' and five clinicians' contours on 10 MRIs acquired on a MR-Linac from 10 patients. All contours were compared to a "gold standard" created from an average of clinicians' contours. The median (range) DSC of radiographers' and clinicians' contours compared to the "gold standard" was 0.91 (0.86-0.96), and 0.93 (0.88-0.97) respectively illustrating non-inferiority of the radiographers' contours to the clinicians. There was no significant difference in HD, MDA or volume size between the groups.
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Affiliation(s)
| | - Alex Dunlop
- Joint Department of Physics at the Royal Marsden and The Institute of Cancer Research, United Kingdom
| | - Sophie E. Alexander
- The Institute of Cancer Research/The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Helen Barnes
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Francis Casey
- Joint Department of Physics at the Royal Marsden and The Institute of Cancer Research, United Kingdom
| | - Joan Chick
- Joint Department of Physics at the Royal Marsden and The Institute of Cancer Research, United Kingdom
| | - Ranga Gunapala
- Clinical Trials and Statistic Unit, The Institute for Cancer Research, London, United Kingdom
| | - Trina Herbert
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Rebekah Lawes
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Sarah A. Mason
- Joint Department of Physics at the Royal Marsden and The Institute of Cancer Research, United Kingdom
| | - Adam Mitchell
- Joint Department of Physics at the Royal Marsden and The Institute of Cancer Research, United Kingdom
| | - Jonathan Mohajer
- Joint Department of Physics at the Royal Marsden and The Institute of Cancer Research, United Kingdom
| | - Julia Murray
- The Institute of Cancer Research/The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Simeon Nill
- Joint Department of Physics at the Royal Marsden and The Institute of Cancer Research, United Kingdom
| | - Priyanka Patel
- The Institute of Cancer Research/The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Angela Pathmanathan
- The Institute of Cancer Research/The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Kobika Sritharan
- The Institute of Cancer Research/The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Nora Sundahl
- The Institute of Cancer Research/The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Rosalyne Westley
- The Institute of Cancer Research/The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Alison C. Tree
- The Institute of Cancer Research/The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Helen A. McNair
- The Institute of Cancer Research/The Royal Marsden NHS Foundation Trust, London, United Kingdom
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Murray J, Tree A, Potts L, Gunapala R, Greenlay E, Alexander E, Gao A, McNair H, Blasiak-Wal I, Sohaib A, Parker C, deSouza N, Dearnaley D. OC-0106 Late Toxicity and Efficacy of Hypofractionated Prostate RT with Focal Boost in the DELINEATE trial. Radiother Oncol 2022. [DOI: 10.1016/s0167-8140(22)02482-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Bainbridge H, Dunlop A, McQuaid D, Gulliford S, Gunapala R, Ahmed M, Locke I, Nill S, Oelfke U, McDonald F. A Comparison of Isotoxic Dose-escalated Radiotherapy in Lung Cancer with Moderate Deep Inspiration Breath Hold, Mid-ventilation and Internal Target Volume Techniques. Clin Oncol (R Coll Radiol) 2022; 34:151-159. [PMID: 34503896 DOI: 10.1016/j.clon.2021.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 07/31/2021] [Accepted: 08/23/2021] [Indexed: 12/25/2022]
Abstract
AIMS With interest in normal tissue sparing and dose-escalated radiotherapy in the treatment of inoperable locally advanced non-small cell lung cancer, this study investigated the impact of motion-managed moderate deep inspiration breath hold (mDIBH) on normal tissue sparing and dose-escalation potential and compared this to planning with a four-dimensional motion-encompassing internal target volume or motion-compensating mid-ventilation approach. MATERIALS AND METHODS Twenty-one patients underwent four-dimensional and mDIBH planning computed tomography scans. Internal and mid-ventilation target volumes were generated on the four-dimensional scan, with mDIBH target volumes generated on the mDIBH scan. Isotoxic target dose-escalation guidelines were used to generate six plans per patient: three with a target dose cap and three without. Target dose-escalation potential, normal tissue complication probability and differences in pre-specified dose-volume metrics were evaluated for the three motion-management techniques. RESULTS The mean total lung volume was significantly greater with mDIBH compared with four-dimensional scans. Lung dose (mean and V21 Gy) and mean heart dose were significantly reduced with mDIBH in comparison with four-dimensional-based approaches, and this translated to a significant reduction in heart and lung normal tissue complication probability with mDIBH. In 20/21 patients, the trial target prescription dose cap of 79.2 Gy was achievable with all motion-management techniques. CONCLUSION mDIBH aids lung and heart dose sparing in isotoxic dose-escalated radiotherapy compared with four-dimensional planning techniques. Given concerns about lung and cardiac toxicity, particularly in an era of consolidation immunotherapy, reduced normal tissue doses may be advantageous for treatment tolerance and outcome.
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Affiliation(s)
- H Bainbridge
- Department of Radiotherapy at The Royal Marsden NHS Foundation Trust, Sutton, UK; The Institute of Cancer Research, London, UK
| | - A Dunlop
- Joint Department of Physics at The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London, UK
| | - D McQuaid
- Joint Department of Physics at The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London, UK
| | - S Gulliford
- Joint Department of Physics at The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London, UK
| | - R Gunapala
- Department of Statistics at The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - M Ahmed
- Department of Radiotherapy at The Royal Marsden NHS Foundation Trust, Sutton, UK; The Institute of Cancer Research, London, UK
| | - I Locke
- Department of Radiotherapy at The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - S Nill
- Joint Department of Physics at The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London, UK
| | - U Oelfke
- Joint Department of Physics at The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research, London, UK
| | - F McDonald
- Department of Radiotherapy at The Royal Marsden NHS Foundation Trust, Sutton, UK; The Institute of Cancer Research, London, UK.
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Cui W, Milner-Watts C, McVeigh TP, Minchom A, Bholse J, Davidson M, Yousaf N, MacMahon S, Mugalaasi H, Gunapala R, Lee R, George A, Popat S, O'Brien M. A pilot of Blood-First diagnostic cell free DNA (cfDNA) next generation sequencing (NGS) in patients with suspected advanced lung cancer. Lung Cancer 2022; 165:34-42. [PMID: 35085982 DOI: 10.1016/j.lungcan.2022.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/11/2022] [Accepted: 01/15/2022] [Indexed: 12/22/2022]
Abstract
INTRODUCTION The diagnostic pathway for lung cancer can be long. Availability of front-line targeted therapies for NSCLC demands access to good quality tissue for genomic sequencing and rapid reporting of results. Diagnosis of lung cancer and availability of tissue was delayed during the COVID-19 pandemic. METHODS A pilot study assessing Guardant360™ cfDNA-NGS in patients with radiological-suspected advanced-stage lung cancer was performed at an academic cancer centre during COVID-19. Variants were tiered using AMP/ASCO/CAP guidelines and discussed at a tumour molecular board. The primary endpoint was the proportion of patients who commenced targeted treatment based on cfDNA-NGS results without tissue molecular results, predicted to be ≥ 10%. RESULTS Between April 2020-May 2021, 51 patients were enrolled; 49 were evaluable. The median age was 71 years, 43% were never-smokers, 86% had stage IV disease. 80% of evaluable cfDNA-NGS were informative (tumour-derived cfDNA detected). cfDNA-NGS detected 30 (61%) AMP/ASCO/CAP tier 1 variants, including 20 additional tier 1 variants compared to tissue testing. Three patients with non-informative cfDNA-NGS had tier 1 variants identified on tissue testing. Eleven (22%; 95%CI 12%-27%) patients commenced targeted therapy based on cfDNA-NGS results without tissue molecular results, meeting the primary endpoint. Median time to results was shorter for cfDNA-NGS compared to standard-of-care tissue tests (9 versus 25 days, P < 0.0001). CONCLUSION Blood-first cfDNA-NGS in NSCLC patients increased the breadth and rapidity of detection of actionable variants with high tissue concordance and led to timely treatment decisions. A blood-first approach should be considered to improve the speed and accuracy of therapeutic decision-making.
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Affiliation(s)
- Wanyuan Cui
- Lung Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | | | - Terri P McVeigh
- Cancer Genetics Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Anna Minchom
- Lung Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Jaishree Bholse
- Lung Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Michael Davidson
- Lung Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Nadia Yousaf
- Lung Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom; Thoracic Oncology, Institute of Cancer Research, London, United Kingdom
| | - Suzanne MacMahon
- Centre for Molecular Pathology, Royal Marsden NHS Foundation Trust, London, United Kingdom; Cancer Genomics, North Thames Genomic Laboratory Hub, London, United Kingdom
| | - Hood Mugalaasi
- Centre for Molecular Pathology, Royal Marsden NHS Foundation Trust, London, United Kingdom; Division of Molecular Pathology, Institute of Cancer Research, London, United Kingdom
| | - Ranga Gunapala
- Lung Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Richard Lee
- Lung Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom; Early Diagnosis and Detection, NIHR Royal Marsden and ICR Biomedical Research Centre, United Kingdom
| | - Angela George
- Cancer Genetics Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom; Gynaecology Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Sanjay Popat
- Lung Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom; Thoracic Oncology, Institute of Cancer Research, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Mary O'Brien
- Lung Unit, Royal Marsden NHS Foundation Trust, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom.
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Karunaratne P, Gunapala R, Weerasekara K, Jayatissa R. Practice of routine oral zinc supplementation during diarrheal illnesses in children. Clin Nutr ESPEN 2021. [DOI: 10.1016/j.clnesp.2021.09.273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Murray JR, Tree AC, Alexander EJ, Sohaib A, Hazell S, Thomas K, Gunapala R, Parker CC, Huddart RA, Gao A, Truelove L, McNair HA, Blasiak-Wal I, deSouza NM, Dearnaley D. Standard and Hypofractionated Dose Escalation to Intraprostatic Tumor Nodules in Localized Prostate Cancer: Efficacy and Toxicity in the DELINEATE Trial. Int J Radiat Oncol Biol Phys 2020; 106:715-724. [PMID: 31812718 DOI: 10.1016/j.ijrobp.2019.11.402] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 11/11/2019] [Accepted: 11/25/2019] [Indexed: 12/16/2022]
Abstract
PURPOSE To report a planned analysis of the efficacy and toxicity of dose escalation to the intraprostatic dominant nodule identified on multiparametric magnetic resonance imaging using standard and hypofractionated external beam radiation therapy. METHODS AND MATERIALS DELINEATE is a single centre prospective phase 2 multicohort study including standard (cohort A: 74 Gy in 37 fractions) and moderately hypofractionated (cohort B: 60 Gy in 20 fractions) prostate image guided intensity modulated radiation therapy in patients with National Comprehensive Cancer Network intermediate- and high-risk disease. Patients received an integrated boost of 82 Gy (cohort A) and 67 Gy (cohort B) to lesions visible on multiparametric magnetic resonance imaging. Fifty-five patients were treated in cohort A, and 158 patients were treated in cohort B; the first 50 sequentially treated patients in cohort B were included in this planned analysis. The primary endpoint was late Radiation Therapy Oncology Group rectal toxicity at 1 year. Secondary endpoints included acute and late toxicity measured with clinician- and patient-reported outcomes at other time points and biochemical relapse-free survival for cohort A. Median follow-up was 74.5 months for cohort A and 52.0 months for cohort B. RESULTS In cohorts A and B, 27% and 40% of patients, respectively, were classified as having National Comprehensive Cancer Network high-risk disease. The cumulative 1-year incidence of Radiation Therapy Oncology Group grade 2 or worse rectal and urinary toxicity was 3.6% and 0% in cohort A and 8% and 10% in cohort B, respectively. There was no reported late grade 3 rectal toxicity in either cohort. Within cohort A, 4 of 55 (7%) patients had biochemical relapse. CONCLUSIONS Delivery of a simultaneous integrated boost to intraprostatic dominant nodules is feasible in prostate radiation therapy using standard and moderately hypofractionated regimens, with rectal and genitourinary toxicity comparable to contemporary series without an intraprostatic boost.
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Affiliation(s)
- Julia R Murray
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom.
| | - Alison C Tree
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | | | - Aslam Sohaib
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Steve Hazell
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Karen Thomas
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Ranga Gunapala
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Chris C Parker
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | - Robert A Huddart
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | - Annie Gao
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | - Lesley Truelove
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | - Helen A McNair
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | - Irena Blasiak-Wal
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | - Nandita M deSouza
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | - David Dearnaley
- The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
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Weller A, Dunlop A, Oxer A, Gunapala R, Murray I, Gray MJ, Flux GD, deSouza NM, Ahmed M. Spect perfusion imaging versus CT for predicting radiation injury to normal lung in lung cancer patients. Br J Radiol 2019; 92:20190184. [PMID: 31287737 PMCID: PMC6732923 DOI: 10.1259/bjr.20190184] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/07/2019] [Accepted: 06/03/2019] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES In non-small cell lung cancer (NSCLC) patients, to establish whether the fractional volumes of irradiated anatomic or perfused lung differed between those with and without deteriorating lung function or radiation associated lung injury (RALI). METHODS 48 patients undergoing radical radiotherapy for NSCLC had a radiotherapy-planning CT scan and single photon emission CT lung perfusion imaging (99mTc-labelled macroaggregate albumin). CT defined the anatomic and the single photon emission CT scan (co-registered with CT) identified the perfused (threshold 20 % of maximum) lung volumes. Fractional volumes of anatomic and perfused lung receiving more than 5, 10, 13, 20, 30, 40, 50 Gy were compared between patients with deteriorating (>median decline) vs stable ( RESULTS Fractional volumes of anatomic and perfused lung receiving more than 10, 13 and 20 Gy were significantly higher in patients with deteriorating vs stable FEV1 ( p = 0.005, 0.005 and 0.025 respectively) but did not differ for higher doses of radiation (>30, 40, 50 Gy). Fractional volumes of anatomic and perfused lung receiving > 10 Gy best predicted decline in FEV1 (Area under receiver operating characteristic curve (Az = 0.77 and 0.76 respectively); sensitivity/specificity 75%/81 and 80%/71%) for a 32.7% anatomic and 33.5% perfused volume cut-off. Irradiating an anatomic fractional volume of 4.7% to > 50 Gy had a sensitivity/specificity of 83%/89 % for indicating RALI (Az = 0.83). CONCLUSION A 10-20 Gy radiation dose to anatomic or perfused lung results in decline in FEV1. A fractional anatomic volume of >5% receiving >50 Gy influences development of RALI. ADVANCES IN KNOWLEDGE Extent of low-dose radiation to normal lung influences functional respiratory decline.
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Affiliation(s)
| | - Alex Dunlop
- The Joint Department of Physics, The Royal Marsden Hospital NHS Foundation Trust and The Institute of Cancer Research, Sutton, Surrey
| | - Adam Oxer
- The Royal Marsden Hospital NHS Foundation Trust, Sutton, Surrey
| | - Ranga Gunapala
- The Royal Marsden Hospital NHS Foundation Trust, Sutton, Surrey
| | - Iain Murray
- The Joint Department of Physics, The Royal Marsden Hospital NHS Foundation Trust and The Institute of Cancer Research, Sutton, Surrey
| | - Matthew J Gray
- The Joint Department of Physics, The Royal Marsden Hospital NHS Foundation Trust and The Institute of Cancer Research, Sutton, Surrey
| | - Glenn D Flux
- The Joint Department of Physics, The Royal Marsden Hospital NHS Foundation Trust and The Institute of Cancer Research, Sutton, Surrey
| | - Nandita M deSouza
- The CRUK Cancer Imaging Centre, The Institute of Cancer Research and The Royal Marsden Hospital NHS Foundation Trust, Sutton, Surrey
| | - Merina Ahmed
- The Royal Marsden Hospital NHS Foundation Trust, Sutton, Surrey
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Kumar R, Walder D, Pejanaute A, Gunapala R, Bhosle J, Yousef N, Popat S, McDonald F, Locke I, Harrington K, Tree A, Lalondrelle S, Huddart R, O’Brien M, Ahmed M. Phase I dose escalation of pembrolizumab given concurrently with palliative thoracic radiotherapy (RT) for NSCLC. Ann Oncol 2018. [DOI: 10.1093/annonc/mdy292.087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Milner-Watts C, Kumar R, Gunapala R, Walder D, Minchom A, Yousef N, Popat S, Bhosle J, O’Brien M. Less frequent monitoring of response in patients with advanced thoracic malignancies receiving palliative chemotherapy, does not adversely impact patient care. Lung Cancer 2018. [DOI: 10.1016/s0169-5002(18)30127-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Dolly S, Brandão M, Taylor C, Gunapala R, Myerson J, Waddell T, Popat S, Bhosle J, O’Brien M. The impact of the UK Government ‘two week rule’ (TWR) on lung cancer stage and 5-year survival – a decade of experience from the Royal Marsden Hospital (RMH). Lung Cancer 2018. [DOI: 10.1016/s0169-5002(18)30070-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Saya S, Killick E, Thomas S, Taylor N, Bancroft EK, Rothwell J, Benafif S, Dias A, Mikropoulos C, Pope J, Chamberlain A, Gunapala R, Izatt L, Side L, Walker L, Tomkins S, Cook J, Barwell J, Wiles V, Limb L, Eccles D, Leach MO, Shanley S, Gilbert FJ, Hanson H, Gallagher D, Rajashanker B, Whitehouse RW, Koh DM, Sohaib SA, Evans DG, Eeles RA. Baseline results from the UK SIGNIFY study: a whole-body MRI screening study in TP53 mutation carriers and matched controls. Fam Cancer 2017; 16:433-440. [PMID: 28091804 PMCID: PMC5487773 DOI: 10.1007/s10689-017-9965-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
In the United Kingdom, current screening guidelines for TP53 germline mutation carriers solely recommends annual breast MRI, despite the wide spectrum of malignancies typically seen in this group. This study sought to investigate the role of one-off non-contrast whole-body MRI (WB MRI) in the screening of asymptomatic TP53 mutation carriers. 44 TP53 mutation carriers and 44 population controls were recruited. Scans were read by radiologists blinded to participant carrier status. The incidence of malignancies diagnosed in TP53 mutation carriers against general population controls was calculated. The incidences of non-malignant relevant disease and irrelevant disease were measured, as well as the number of investigations required to determine relevance of findings. In TP53 mutation carriers, 6 of 44 (13.6, 95% CI 5.2-27.4%) participants were diagnosed with cancer during the study, all of which would be considered life threatening if untreated. Two were found to have two primary cancers. Two participants with cancer had abnormalities on the MRI which were initially thought to be benign (a pericardial cyst and a uterine fibroid) but transpired to be sarcomas. No controls were diagnosed with cancer. Fifteen carriers (34.1, 95% CI 20.5-49.9%) and seven controls (15.9, 95% CI 6.7-30.1%) underwent further investigations following the WB MRI for abnormalities that transpired to be benign (p = 0.049). The cancer detection rate in this group justifies a minimum baseline non-contrast WB MRI in germline TP53 mutation carriers. This should be adopted into national guidelines for management of adult TP53 mutation carriers in addition to the current practice of contrast enhanced breast MRI imaging.
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Affiliation(s)
- Sibel Saya
- The Institute of Cancer Research, 15 Cotswold Road, Sutton SM2 5NG, London, UK
| | - Emma Killick
- The Institute of Cancer Research, 15 Cotswold Road, Sutton SM2 5NG, London, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | | | | | - Jeanette Rothwell
- Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Sarah Benafif
- The Institute of Cancer Research, 15 Cotswold Road, Sutton SM2 5NG, London, UK
| | - Alexander Dias
- The Institute of Cancer Research, 15 Cotswold Road, Sutton SM2 5NG, London, UK
| | - Christos Mikropoulos
- The Institute of Cancer Research, 15 Cotswold Road, Sutton SM2 5NG, London, UK
- Cancer Unit, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Jenny Pope
- The Institute of Cancer Research, 15 Cotswold Road, Sutton SM2 5NG, London, UK
| | - Anthony Chamberlain
- The Institute of Cancer Research, 15 Cotswold Road, Sutton SM2 5NG, London, UK
| | | | - Louise Izatt
- Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Lucy Side
- Great Ormond Street Hospital & UCL Institute for Women's Health, London, UK
| | | | - Susan Tomkins
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Jackie Cook
- Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | | | | | | | - Diana Eccles
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Martin O Leach
- The Institute of Cancer Research, 15 Cotswold Road, Sutton SM2 5NG, London, UK
- Royal Marsden NHS Foundation Trust, London, UK
| | - Susan Shanley
- Royal Marsden NHS Foundation Trust, London, UK
- Peter MacCallum Cancer Centre, Melbourne, Australia
| | | | | | | | - Bala Rajashanker
- Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | | | - Dow-Mu Koh
- The Institute of Cancer Research, 15 Cotswold Road, Sutton SM2 5NG, London, UK
- Royal Marsden NHS Foundation Trust, London, UK
| | | | - D Gareth Evans
- Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Rosalind A Eeles
- The Institute of Cancer Research, 15 Cotswold Road, Sutton SM2 5NG, London, UK.
- Royal Marsden NHS Foundation Trust, London, UK.
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13
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Minchom A, Punwani R, Filshie J, Bhosle J, Nimako K, Myerson J, Gunapala R, Popat S, O'Brien M. P3.05-006 Anxiolytic Effect of Acupuncture in a Phase II Study of Acupuncture and Morphine for Dyspnea in Lung Cancer and Mesothelioma. J Thorac Oncol 2017. [DOI: 10.1016/j.jtho.2016.11.2168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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14
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Kumar R, Bhosle J, Yap T, Minchom A, Walder D, Ali Z, Ratnayake G, Yousaf N, Popat S, Gunapala R, O'Brien M. PUB129 Optimal Frequency of Tumor Response Evaluation during Palliative Chemotherapy in the Management of Patients with Advanced Thoracic Cancers. J Thorac Oncol 2017. [DOI: 10.1016/j.jtho.2016.11.2100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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15
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Tokaca N, Crawford M, Greystoke A, Appel W, Lal R, Steele N, Ali C, Bezecny P, Fernando S, Karapanagiotou E, Skailes G, Dorey N, Harrow S, Bhosle J, Khan O, Newsom-Davis T, Spicer J, Toy L, O'Brien M, Gunapala R, Lu S, Popat S. 69: Outcomes with nintedanib and docetaxel in patients with relapsed NSCLC adenocarcinoma treated within the UK Nintedanib Individual Patient Supply programme. Lung Cancer 2017. [DOI: 10.1016/s0169-5002(17)30119-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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16
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Kumar R, Lu SK, Minchom A, Sharp A, Davidson M, Gunapala R, Yap TA, Bhosle J, Popat S, O'Brien MER. A phase 1b trial of the combination of an all-oral regimen of capecitabine and erlotinib in advanced non-small cell lung cancer in Caucasian patients. Cancer Chemother Pharmacol 2015; 77:375-83. [PMID: 26706729 DOI: 10.1007/s00280-015-2950-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 12/14/2015] [Indexed: 12/01/2022]
Abstract
PURPOSE Erlotinib is active in advanced non-small cell lung cancer (aNSCLC) particularly in patients with EGFR-sensitizing mutations. The thymidylate synthase inhibitors are active in NSCLC, but capecitabine is not well studied. This study explored the safety and activity of this oral combination. METHODS This phase Ib trial used a 3 + 3 escalation design with a combination of erlotinib (100 mg daily) with increasing doses of capecitabine (500, 750 and 1000 mg/m(2) BD, 14/21 days), in first- and second-line aNSCLC of adenocarcinoma histology. The DLT was any drug-induced toxicity ≥grade (G)2 causing dose interruption or dose delay during the first 2 cycles. RESULTS Forty patients were recruited, and 1 patient had an EGFR mutation. Dose escalation stopped at capecitabine 1000 mg/m(2) with expansion to 6 patients due to unpredicted DLTs in 2/6 patients: G2 creatinine rise, G2 anaemia, G3 atrial fibrillation and G3 pneumonia. MTD was capecitabine 750 mg/m(2). First-line dose escalation at the MTD led to unpredicted DLTs in 3/4 patients (G3 troponin rise, G2 rash and G2 hyperbilirubinaemia). MTD expansion in the second-line setting was well tolerated. The most common drug toxicities were gastrointestinal (35 %), followed by skin disorders (28 %). The response rate was 3 % with a disease control rate of 34 %. Median progressive-free survival was 1.6 months (95 % CI 1.4-3.5), and median overall survival was 6.1 months (95 % CI 5.1-10.1). CONCLUSION The MTD for the combination of capecitabine and erlotinib is 750 mg/m(2) BD, 14/21 days, and 100 mg daily, respectively, which is lower than predicted. Capecitabine did not improve the efficacy of erlotinib in aNSCLC unselected for EGFR mutation.
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Affiliation(s)
- Rajiv Kumar
- Department of Medicine, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey, UK
| | - Shir Kiong Lu
- Department of Medicine, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey, UK
| | - Anna Minchom
- The Institute of Cancer Research & The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey, UK
| | - Adam Sharp
- The Institute of Cancer Research & The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey, UK
| | - Michael Davidson
- Department of Medicine, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey, UK
| | - Ranga Gunapala
- Department of Medicine, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey, UK
| | - Timothy A Yap
- The Institute of Cancer Research & The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey, UK
| | - Jaishree Bhosle
- Department of Medicine, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey, UK
| | - Sanjay Popat
- Department of Medicine, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey, UK
| | - Mary E R O'Brien
- Department of Medicine, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey, UK. Mary.O'
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Nimako K, Ayite B, Priest K, Severn J, Fries HM, Gunapala R, Bhosle J, Popat S, O'Brien M. A randomised assessment of the use of a quality of life questionnaire with or without intervention in patients attending a thoracic cancer clinic. Eur J Cancer Care (Engl) 2015; 26. [PMID: 26556778 DOI: 10.1111/ecc.12402] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2015] [Indexed: 12/01/2022]
Abstract
The study examined the impact of using a quality of life (QoL) questionnaire during a clinic to identify QoL issues and to improve QoL. 138 patients were randomised (1:1:1) to either (1) an Intervention group that completed the European Organisation for Research and Treatment of Cancer-Core Quality of Life Questionnaire and Lung Cancer Module (EORTC QLQ-C30 and LC13) at baseline and received feedback during a clinic, (2) an Attention group that completed the questionnaire at baseline without feedback and (3) a Control group that did not complete the questionnaire. All patients completed the same questionnaire 6 weeks later and a contact diary during the study period. There was a significant difference between the Intervention and Control groups for the mean number of QoL issues identified at baseline (4.69 vs. 2.81, P = 0.006) and the mean number of actions taken (4.41 vs. 2.46, P = 0.004). At 6 weeks, there was no difference between the groups in global QoL (Intervention vs. Control group, P = 0.596; Attention vs. Control, P = 0.973). The results suggest that the completion of the EORTC QLQ-C30 LC13 with feedback improves communication and increases the number of QoL issues identified and actions taken. However, the intervention does not impact on QoL per se. Clinicaltrials.gov: NCT01213745.
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Affiliation(s)
- K Nimako
- The Royal Marsden Hospital, NHS Foundation Trust, Sutton, UK.,Surrey and Sussex Healthcare NHS Trust, Surrey, UK
| | - B Ayite
- The Royal Marsden Hospital, NHS Foundation Trust, Sutton, UK
| | - K Priest
- The Royal Marsden Hospital, NHS Foundation Trust, Sutton, UK
| | - J Severn
- The Royal Marsden Hospital, NHS Foundation Trust, Sutton, UK
| | - H M Fries
- The Royal Marsden Hospital, NHS Foundation Trust, Sutton, UK
| | - R Gunapala
- The Royal Marsden Hospital, NHS Foundation Trust, Sutton, UK
| | - J Bhosle
- The Royal Marsden Hospital, NHS Foundation Trust, Sutton, UK
| | - S Popat
- The Royal Marsden Hospital, NHS Foundation Trust, Sutton, UK.,Molecular Genetics and Genomics Group, Imperial College London, London, UK
| | - M O'Brien
- The Royal Marsden Hospital, NHS Foundation Trust, Sutton, UK
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Balachandran K, Okines A, Gunapala R, Morganstein D, Popat S. Resolution of severe hyponatraemia is associated with improved survival in patients with cancer. BMC Cancer 2015; 15:163. [PMID: 25885450 PMCID: PMC4381411 DOI: 10.1186/s12885-015-1156-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Accepted: 03/03/2015] [Indexed: 01/16/2023] Open
Abstract
Background Hyponatraemia is a common finding in patients with cancer, and has been shown to be associated with poor prognosis in different settings. We have analysed the impact of severe hyponatraemia in patients with cancer. Methods A retrospective review of all patients admitted to a specialist cancer hospital with a plasma sodium of less than 115 mmol/l and a diagnosis of malignancy was undertaken. Patient and tumour characteristics were analysed as well as impact of hyponatraemia management on overall survival and number of lines of cancer treatment received. Results 57 patients were identified. 84% had advanced Stage 3 or 4 cancer and approximately 85% with data available had symptoms attributable to hyponatraemia. Mean length of hospital stay was 12 days, and overall survival (OS) was 5.1 months. Plasma sodium level corrected in 56% of patients and here OS was 13.6 months compared to 16 days in those whose sodium did not correct (p < 0.001). Those whose sodium corrected were more likely to receive further lines of anti-cancer treatment. Conclusions Severe hyponatraemia in cancer is associated with very poor survival, but correction of the sodium level leads to additional treatment and significantly greater overall survival (although it is not possible to determine if this is due to specific therapy of the hyponatraemia or the resolving hyponatraemia reflects an improvement in the clinical condition). Aggressive treatment of hyponatraemia may allow more anti-cancer treatment and improve survival. Electronic supplementary material The online version of this article (doi:10.1186/s12885-015-1156-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kirsty Balachandran
- Department of Medicine, Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK.
| | - Alicia Okines
- Department of Medicine, Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK.
| | - Ranga Gunapala
- Department of Medicine, Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK.
| | - Daniel Morganstein
- Department of Endocrinology, Chelsea and Westminster Hospital, London, SW10 9NH, UK.
| | - Sanjay Popat
- Department of Medicine, Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK.
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19
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Gennatas S, Noble J, Stanway S, Gunapala R, Chowdhury R, Wotherspoon A, Benepal T, Popat S. Patterns of relapse in extrapulmonary small cell carcinoma: retrospective analysis of outcomes from two cancer centres. BMJ Open 2015; 5:e006440. [PMID: 25588780 PMCID: PMC4298106 DOI: 10.1136/bmjopen-2014-006440] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVES We conducted a retrospective review of patients with extrapulmonary small cell carcinomas (EPSCCs) to explore the distribution, treatments, patterns of relapse and outcomes by primary site. SETTING We have reviewed the outcomes of one of the largest data sets of consecutive patients with EPSCC identified from two major cancer centres. PARTICIPANTS Consecutive patients with a histopathological diagnosis of EPSCC from the two institutions were retrospectively identified. PRIMARY AND SECONDARY OUTCOME MEASURES Outcomes were evaluated including stage at presentation, treatments given, sites of relapse, time to distant relapse, progression-free survival and overall survival (OS). RESULTS From a total 159 patients, 114 received first-line chemotherapy, 80.5% being platinum-based. Response rate was 48%. Commonest primary sites were genitourinary and gynaecological. 44% of patients presented with metastatic disease. 55.9% relapsed with liver the commonest site, whereas only 2.5% developed brain metastases. Median OS was 13.4 months for all patients, 7.6 months and 19.5 months for those with metastatic and non-metastatic disease, respectively. Gynaecological and head and neck patients had significantly better OS compared to gastrointestinal patients. CONCLUSIONS EPSCCs demonstrate high response rates to chemotherapy and high rates of distant metastases. Primary sites may influence prognosis, and survival is optimal with a radical strategy. Brain metastases are rare and we therefore do not recommend prophylactic cranial irradiation.
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Affiliation(s)
- S Gennatas
- Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, UK
- Department of Medicine, Royal Marsden Hospital, London, UK
| | - J Noble
- Department of Medicine, Royal Marsden Hospital, London, UK
| | - S Stanway
- Department of Medicine, Royal Marsden Hospital, London, UK
| | - R Gunapala
- Department of Medicine, Royal Marsden Hospital, London, UK
| | - R Chowdhury
- Department of Medicine, Dimbleby Cancer Centre, Kings College London, London, UK
| | - A Wotherspoon
- Department of Histopathology, Royal Marsden Hospital, London, UK
| | - T Benepal
- Department of Oncology, St George's Hospital, London, UK
| | - S Popat
- Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, UK
- Department of Medicine, Royal Marsden Hospital, London, UK
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20
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Minchom AR, Saksornchai K, Bhosle J, Gunapala R, Puglisi M, Lu SK, Nimako K, Coward J, Yu KC, Bordi P, Popat S, O'Brien MER. An unblinded, randomised phase II study of platinum-based chemotherapy with vitamin B12 and folic acid supplementation in the treatment of lung cancer with plasma homocysteine blood levels as a biomarker of severe neutropenic toxicity. BMJ Open Respir Res 2015; 1:e000061. [PMID: 25553247 PMCID: PMC4265128 DOI: 10.1136/bmjresp-2014-000061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 11/20/2014] [Accepted: 11/21/2014] [Indexed: 12/29/2022] Open
Abstract
Background Vitamin B12 and folic acid (referred to as vitamin supplementation) improves the toxicity profile of pemetrexed containing regimens. Low baseline vitamin B12 and folate levels are reflected in a raised total homocysteine level (HC). Studies have suggested that pretreatment HC levels predict neutropenia toxicity. We have tested supplementation with vitamin B12 and folate in non-pemetrexed platinum-based regimens to decrease treatment-related toxicity and looked for a correlation between toxicity and change in homocysteine levels. Patient and method Eighty-three patients with advanced lung cancer and malignant mesothelioma were randomly assigned to receive platinum-based chemotherapy with (arm A) or without (arm B) vitamin B12 and folic acid supplementation. The primary end point was grade 3/4 neutropenia and death within 30 days of treatment. Secondary end points included quality of life, overall survival (OS) and the relationship between baseline and post supplementation HC levels and toxicity. Results In the intention-to-treat population, no significant difference was seen between the two groups with respect to chemotherapy-induced grade 3/4 neutropenia and death within 30 days of chemotherapy (36% vs 37%; p=0.966, emesis (2% vs 6%; p=0.9) or OS (12.3 months vs 7 months; p=0.41). There was no significant difference in survival rates by baseline HC level (p=0.9). Decrease in HC with vitamin supplementation was less frequent than expected. High baseline HC levels decreased with vitamin supplementation in only 9/36 (25%) patients (successful supplementation). Post hoc analysis showed that patients in arm A who were successfully supplemented (9/36=25%) had less neutropenic toxicity (0% vs 69%; p=0.02) compared to unsupplemented patients. Conclusions The addition of vitamin B12 and folic acid to platinum-containing regimens did not overall improve the toxicity, quality of life or OS. Rates of grade 3/4 neutropenia at 36/37% was as predicted. Further studies to increase the rate of successful supplementation and to further test the biomarker potential of post supplementation HC levels in predicting chemotherapy-induced neutropenia in platinum-based chemotherapy are warranted. Trial registration number: EudracCT 2005-002736-10 ISRCTN8734355.
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Affiliation(s)
- A R Minchom
- Department of Medicine , The Royal Marsden Hospital , Sutton , UK
| | - K Saksornchai
- Department of Medicine , The Royal Marsden Hospital , Sutton , UK
| | - J Bhosle
- Department of Medicine , The Royal Marsden Hospital , Sutton , UK
| | - R Gunapala
- Department of Medicine , The Royal Marsden Hospital , Sutton , UK
| | - M Puglisi
- Department of Medicine , The Royal Marsden Hospital , Sutton , UK
| | - S K Lu
- Department of Medicine , The Royal Marsden Hospital , Sutton , UK
| | - K Nimako
- Department of Medicine , The Royal Marsden Hospital , Sutton , UK
| | - J Coward
- Department of Medicine , The Royal Marsden Hospital , Sutton , UK
| | - K C Yu
- Department of Medicine , The Royal Marsden Hospital , Sutton , UK
| | - P Bordi
- Department of Medicine , The Royal Marsden Hospital , Sutton , UK
| | - S Popat
- Department of Medicine , The Royal Marsden Hospital , Sutton , UK
| | - M E R O'Brien
- Department of Medicine , The Royal Marsden Hospital , Sutton , UK
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21
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Linch M, Gennatas S, Kazikin S, Iqbal J, Gunapala R, Priest K, Severn J, Norton A, Ayite B, Bhosle J, O'Brien M, Popat S. A serum mesothelin level is a prognostic indicator for patients with malignant mesothelioma in routine clinical practice. BMC Cancer 2014; 14:674. [PMID: 25227779 PMCID: PMC4182776 DOI: 10.1186/1471-2407-14-674] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 09/10/2014] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Malignant mesothelioma (MM) carries a poor prognosis and response rates to palliative chemotherapy remain low. Identifying patients with MM that are unlikely to respond to chemotherapy could prevent futile treatments and improve patient quality of life. Studies have suggested that soluble mesothelin is a potential biomarker for early diagnosis and prognosis of MM. We set out to explore the utility of serum mesothelin in routine clinical practice. METHODS We conducted a prospective exploratory study of serum mesothelin levels in 53 consecutive patients with MM at our institution between April 2009 and February 2011. Survival was assessed and analysed by mesothelin level as both continuous and categorical variables using Cox regression models. Differences in response rate between treatment groups were assessed by the Kruskal-Wallis Test. RESULTS All 53 patients, who had been given study information agreed to participate. The patients' median age was 69 (range 24-90). Median mesothelin level was 2.7 nM and this value was used to dichotomize categories: ≤2.7 nM (low) and >2.7 nM (high). The progression free survival (PFS) for low vs high mesothelin was 8.0 vs 5.1 months (HR 1.8, p-0.058). When mesothelin was accessed as a continuous variable for PFS the HR was 1.03 (95% CI: 1.01-1.06; p=0.013). The overall survival (OS) for low vs high mesothelin was 17.2 vs 11.3 months (HR 1.9, p=0.088). When mesothelin was assessed as a continuous variable for OS the HR was 1.02 (95% CI: 0.99 - 1.04; p=0.073). Thirty patients received chemotherapy of which 18 had a pre-chemotherapy serum mesothelin level. In these 18 patients, the pre-chemotherapy mesothelin level did not correlate with response. CONCLUSIONS A single random sample provides information about patient prognosis but does not predict treatment response. We suggest further prospective validation of mesothelin testing as a prognostic biomarker.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Sanjay Popat
- Royal Marsden Hospital, Fulham Road, SW3 6JJ London, Surrey, UK.
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22
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Nimako K, Lu SK, Ayite B, Priest K, Winkley A, Gunapala R, Popat S, O'Brien ME. A pilot study of a novel home telemonitoring system for oncology patients receiving chemotherapy. J Telemed Telecare 2013; 19:148-152. [PMID: 23615717 DOI: 10.1177/1357633x13483258] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2013] [Indexed: 11/16/2022]
Abstract
We examined the accuracy and acceptability of a home telemonitoring system for patients receiving chemotherapy. Patients undergoing two cycles of chemotherapy (over six weeks) used the telemonitoring system to analyse their own blood (capillary) and to enter symptom and temperature data. The blood results obtained from self-testing were compared with those from a venous blood sample analysed in the hospital laboratory analyser (the gold standard). We also documented the number and type of alerts generated by the telemonitoring system. Acceptability (ease of use and patient satisfaction) was assessed using questionnaires. Ten patients (mean age 61 years, 60% female) provided 48-paired samples. None of the patients succeeded in obtaining all blood results within pre-defined limits of agreement (i.e. within 15% for haemoglobin, haematocrit, white cell count; and 20% for neutrophil count) during the study. However, the level of clinical agreement between the system and the laboratory standard was good; only three out of the 48 samples and two out of the 10 patients had differences in blood results that might have had clinical implications. The telemonitoring system correctly generated 42 alerts. The patients found the telemonitoring system easy to use. With further refinement this should become an acceptable component of routine clinical practice for monitoring patients receiving chemotherapy.
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Affiliation(s)
- Kofi Nimako
- Royal Marsden Hospital, NHS Foundation Trust, Downs Road, Sutton, UK
| | - Shir-Kiong Lu
- Royal Marsden Hospital, NHS Foundation Trust, Downs Road, Sutton, UK
| | - Bee Ayite
- Royal Marsden Hospital, NHS Foundation Trust, Downs Road, Sutton, UK
| | - Kathy Priest
- Royal Marsden Hospital, NHS Foundation Trust, Downs Road, Sutton, UK
| | - Andrew Winkley
- Royal Marsden Hospital, NHS Foundation Trust, Downs Road, Sutton, UK
| | - Ranga Gunapala
- Royal Marsden Hospital, NHS Foundation Trust, Downs Road, Sutton, UK
| | - Sanjay Popat
- Royal Marsden Hospital, NHS Foundation Trust, Downs Road, Sutton, UK.,Molecular Genetics and Genomics Group, Imperial College London, UK
| | - Mary Er O'Brien
- Royal Marsden Hospital, NHS Foundation Trust, Downs Road, Sutton, UK
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Abstract
UNLABELLED What's known on the subject? and What does the study add? Diethylstilbestrol (DES) was the first hormone treatment used for prostate cancer and has also shown effectiveness in castration-resistant disease in small studies; however, concerns over thromboembolic toxicity have restricted its use in the past. Over 200 elderly men with castration-resistant prostate cancer were treated with 1-3 mg of DES, given with 75 mg aspirin and breast bud irradiation. Almost 30% of men showed a significant PSA response and the median time to PSA progression was 4.6 months. Almost 20% of patients with pain had a significant analgesic benefit. The most important toxicity was thromboembolism in 10% of men. Overall the drug has an acceptable toxicity profile and offers a palliative benefit in frail elderly men who may not be fit for chemotherapy. OBJECTIVE • To assess the efficacy and toxicity of diethylstilbestrol (DES) in the management of castration-resistant prostate cancer (CRPC). PATIENTS AND METHODS • A total of 231 patients with CRPC received treatment with DES at the Royal Marsden Hospital between August 1992 and August 2000. • The median pre-treatment prostate-specific antigen (PSA) level was 221 ng/mL. • DES was used at a dose of 1-3 mg daily, with aspirin 75 mg. • The primary endpoint was PSA response rate. RESULTS • The PSA response rate (using PSA Working Group criteria) was 28.9%. • The median time to PSA progression was 4.6 months. • Of patients with bone pain, 18% had an improvement in their European Organisation for the Research and Treatment of Cancer pain score. • Thromboembolic complications were seen in 9.9% of all patients. CONCLUSIONS • DES has significant activity in CRPC and can be of palliative benefit. • DES has an acceptable toxicity profile in the management of patients with symptomatic CRPC when used at a dose of 1-3 mg, combined with aspirin and prophylactic breast bud radiotherapy.
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Affiliation(s)
- Anna Wilkins
- Academic Urology Unit, Royal Marsden Hospital, Sutton, UK
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24
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Nimako K, Gunapala R, Popat S, O'Brien MER. Patient factors, health care factors and survival from lung cancer according to ethnic group in the south of London, UK. Eur J Cancer Care (Engl) 2012; 22:79-87. [PMID: 22738286 DOI: 10.1111/j.1365-2354.2012.01373.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
International and UK data suggest that there are ethnic differences in survival for some malignancies. The aim of the present study was to identify any health inequalities related to lung cancer and ethnicity. Data on 423 patients with a diagnosis of lung cancer treated at a large specialist cancer hospital in London UK were analysed. Data on stage of disease at diagnosis, co-morbidities, socio-economic status, treatments received and survival were collected and examined for differences by ethnic group. There was a significant difference between black and minority ethnic (BME) patients and White-European patients in socio-economic status (Chi-square test P-value < 0.001). BME patients were over-represented in the most deprived socio-economic groups and under-represented in the most affluent. There were no significant differences in histology, stage of disease, co-morbidities and performance status or treatments received between the different ethnic groups. Ethnicity was not associated with survival. Significant prognostic factors for overall survival were performance status (P < 0.001), stage of disease (P = 0.001) and gender (P = 0.003). Our findings suggest that patients from BME groups are over-represented in more deprived socio-economic groups; however, this did not impact on significant prognostic factors or the treatments that they received. Importantly ethnicity did not influence survival.
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Affiliation(s)
- K Nimako
- Lung Unit, The Royal Marsden Hospital, NHS Foundation Trust, Sutton, Surrey, UK.
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O'Brien MER, Myerson JS, Coward JIG, Puglisi M, Trani L, Wotherspoon A, Sharma B, Cook G, Ashley S, Gunapala R, Chua S, Popat S. A phase II study of ¹⁸F-fluorodeoxyglucose PET-CT in non-small cell lung cancer patients receiving erlotinib (Tarceva); objective and symptomatic responses at 6 and 12 weeks. Eur J Cancer 2011; 48:68-74. [PMID: 22119198 DOI: 10.1016/j.ejca.2011.10.033] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Revised: 10/25/2011] [Accepted: 10/26/2011] [Indexed: 01/14/2023]
Abstract
BACKGROUND The aim of this study was to assess if (18)F-fluorodeoxyglucose (FDG) Positron Emission Tomography (PET)-CT scanning could minimise the time non-responding patients were exposed to erlotinib (Tarceva). METHODS Patients were selected for clinical factors that would predict response to erlotinib. A FDG PET-CT and diagnostic contrast-enhanced (traditional) CT scan were carried out at baseline, and then a FDG PET-CT at 6 weeks and a traditional CT at 12 weeks were repeated. The primary end-point was rate of early progression in patients after 6 weeks, of which a minimum 12 out of 35 were required to make the study worthwhile. The responses at 6 (PET-CT) and 12 weeks (traditional CT) were compared and correlated with symptomatic response at both these time points. RESULTS Forty seven patients were recruited with 38 and 33 patients assessable by FDG PET-CT at 6 weeks and traditional CT at 12weeks, respectively. There was good correlation between Partial response (PR) at both time points and all 10 patients who had a PR at 12 weeks had a PR at 6 weeks. Of the 13 patients with progressive disease (PD) at 12 weeks, seven had PD at 6 weeks and could have had their treatment stopped early. No evaluable patient with stable disease (SD) (8/38) or PD (9/38) on FDG PET-CT at 6 weeks went on to have a later response. Symptomatic response at 6 or 12 weeks did not correlate well with objective response on scanning at either time point. CONCLUSIONS The primary end-point of this study was met as >12 (15/38) patients could have stopped treatment early on the basis of the FDG PET-CT scan result. A FDG PET-CT evaluable response of SD or PD at 6 weeks does predict future lack of response. No correlation was found between response and symptomatic response at either 6 or 12 weeks.
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Affiliation(s)
- M E R O'Brien
- Royal Marsden Hospital, Downs Road, Sutton, Surrey SM2 5PT, United Kingdom
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