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Prabhu RS, Akinyelu T, Vaslow ZK, Matsui JK, Haghighi N, Dan T, Mishra MV, Murphy ES, Boyles S, Perlow HK, Palmer JD, Udovicich C, Patel TR, Wardak Z, Woodworth GF, Ksendzovsky A, Yang K, Chao ST, Asher AL, Burri SH. Single-Fraction Versus Fractionated Preoperative Radiosurgery for Resected Brain Metastases: A PROPS-BM International Multicenter Cohort Study. Int J Radiat Oncol Biol Phys 2024; 118:650-661. [PMID: 37717787 DOI: 10.1016/j.ijrobp.2023.09.012] [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] [Received: 03/17/2023] [Revised: 09/02/2023] [Accepted: 09/09/2023] [Indexed: 09/19/2023]
Abstract
PURPOSE Preoperative stereotactic radiosurgery (SRS) is a feasible alternative to postoperative SRS for resected brain metastases (BM). Most reported studies of preoperative SRS used single-fraction SRS (SF-SRS). The goal of this study was to compare outcomes and toxicity of preoperative SF-SRS with multifraction (3-5 fractions) SRS (MF-SRS) in a large international multicenter cohort (Preoperative Radiosurgery for Brain Metastases-PROPS-BM). METHODS AND MATERIALS Patients with BM from solid cancers, of which at least 1 lesion was treated with preoperative SRS followed by planned resection, were included from 8 institutions. SRS to synchronous intact BM was allowed. Exclusion criteria included prior or planned whole brain radiation therapy. Intracranial outcomes were estimated using cumulative incidence with competing risk of death. Propensity score matched (PSM) analyses were performed. RESULTS The study cohort included 404 patients with 416 resected index lesions, of which SF-SRS and MF-SRS were used for 317 (78.5%) and 87 patients (21.5%), respectively. Median dose was 15 Gy in 1 fraction for SF-SRS and 24 Gy in 3 fractions for MF-SRS. Univariable analysis demonstrated that SF-SRS was associated with higher cavity local recurrence (LR) compared with MF-SRS (2-year: 16.3% vs 2.9%; P = .004), which was also demonstrated in multivariable analysis. PSM yielded 81 matched pairs (n = 162). PSM analysis also demonstrated significantly higher rate of cavity LR with SF-SRS (2-year: 19.8% vs 3.3%; P = .003). There was no difference in adverse radiation effect, meningeal disease, or overall survival between cohorts in either analysis. CONCLUSIONS Preoperative MF-SRS was associated with significantly reduced risk of cavity LR in both the unmatched and PSM analyses. There was no difference in adverse radiation effect, meningeal disease, or overall survival based on fractionation. MF-SRS may be a preferred option for neoadjuvant radiation therapy of resected BMs. Additional confirmatory studies are needed. A phase 3 randomized trial of single-fraction preoperative versus postoperative SRS (NRG-BN012) is ongoing (NCT05438212).
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Affiliation(s)
- Roshan S Prabhu
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina; Southeast Radiation Oncology Group, Charlotte, North Carolina.
| | - Tobi Akinyelu
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Zachary K Vaslow
- Department of Radiation Oncology, Cone Health Cancer Center, Greensboro, North Carolina
| | - Jennifer K Matsui
- Department of Radiation Oncology, The Ohio State University College of Medicine, Columbus, Ohio
| | - Neda Haghighi
- Department of Radiation Oncology, Peter McCallum Cancer Centre, Melbourne Victoria, Australia; Department of Radiation Oncology, Icon Cancer Centre, Epworth Centre, Richmond Victoria, Australia
| | - Tu Dan
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mark V Mishra
- University of Maryland School of Medicine, Greenebaum Comprehensive Cancer Center, Baltimore, Maryland
| | - Erin S Murphy
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio
| | - Susan Boyles
- Department of Radiation Oncology, Cone Health Cancer Center, Greensboro, North Carolina
| | - Haley K Perlow
- Department of Radiation Oncology, The Ohio State University College of Medicine, Columbus, Ohio
| | - Joshua D Palmer
- Department of Radiation Oncology, The Ohio State University College of Medicine, Columbus, Ohio
| | - Cristian Udovicich
- Department of Radiation Oncology, Peter McCallum Cancer Centre, Melbourne Victoria, Australia
| | - Toral R Patel
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Zabi Wardak
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Graeme F Woodworth
- University of Maryland School of Medicine, Greenebaum Comprehensive Cancer Center, Baltimore, Maryland
| | - Alexander Ksendzovsky
- University of Maryland School of Medicine, Greenebaum Comprehensive Cancer Center, Baltimore, Maryland
| | - Kailin Yang
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio
| | - Samuel T Chao
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio
| | - Anthony L Asher
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina; Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina
| | - Stuart H Burri
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina; Southeast Radiation Oncology Group, Charlotte, North Carolina
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Heinzerling JH, Pen OV, Robinson M, Foster R, Kelly B, Mileham KF, Moeller B, Prabhu RS, Corso C, Ward MW, Sullivan CM, Burri S, Simone CB. Full Dose SBRT in Combination With Mediastinal Chemoradiation for Locally Advanced, Non-Small Cell Lung Cancer: A Practical Guide for Planning, Dosimetric Results From a Phase 2 Study, and a Treatment Planning Guide for the Phase 3 NRG Oncology LU-008 Trial. Pract Radiat Oncol 2023; 13:531-539. [PMID: 37406774 DOI: 10.1016/j.prro.2023.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 04/21/2023] [Accepted: 04/25/2023] [Indexed: 07/07/2023]
Abstract
PURPOSE Stereotactic body radiation therapy (SBRT) has been used with high effectiveness in early-stage non-small cell lung cancer (NSCLC) but has not been studied extensively in locally advanced NSCLC. We conducted a phase 2 study delivering SBRT to the primary tumor followed by conventionally fractionated chemoradiation to the involved lymph nodes for patients with node-positive locally advanced NSCLC. This manuscript serves as both a guide to planning techniques used on this trial and the subsequent phase 3 study, NRG Oncology LU-008, and to report patient dosimetry and toxicity results. METHODS AND MATERIALS We initiated a phase 2 multicenter single arm study evaluating SBRT to the primary tumor (50-54 Gy in 3-5 fractions) followed by conventionally fractionated chemoradiation to 60 Gy in 2 Gy fractions with doublet chemotherapy to the involved lymph nodes for patients with stage III or unresectable stage II NSCLC. Patients eligible for adjuvant immunotherapy received up to 12 months of durvalumab. We report a detailed guide for the entire treatment process from computed tomography simulation through treatment planning and delivery. The dosimetric outcomes from the 60 patients who completed therapy on study are reported both for target coverage and normal structure doses. We also report correlation between radiation-related toxicities and dosimetric parameters. RESULTS Sixty patients were enrolled between 2017 and 2022. Planning techniques used were primarily volumetric modulated arc therapy for SBRT to the primary tumor and conventionally fractionated radiation to the involved nodes, with a minority of cases using dynamic conformal arc technique or static dynamic multileaf collimator intensity modulated radiation therapy. Grade 2 or higher pneumonitis was associated with lung dose V5 Gy > 70% and grade 2 or higher pulmonary toxicity was associated with lung dose V10 Gy > 50%. Only 3 patients (5%) experienced grade 3 or higher pneumonitis. Grade 2 or higher esophagitis was associated with esophageal doses, including mean dose > 20 Gy, V60 Gy > 7%, and D1cc > 55 Gy. Only 1 patient (1.7%) experienced grade 3 esophagitis. CONCLUSIONS SBRT to the primary tumor followed by conventionally fractionated chemoradiation to the involved lymph nodes is feasible with planning techniques as described. Radiation-related toxicity on this phase 2 study was low. This manuscript serves as a guideline for the recently activated NRG Oncology LU-008 phase 3 trial evaluating this experimental regimen.
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Affiliation(s)
- John H Heinzerling
- Levine Cancer Institute, Atrium Health, Southeast Radiation Oncology, Charlotte, North Carolina.
| | - Olga V Pen
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Myra Robinson
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Ryan Foster
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Brian Kelly
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | | | - Benjamin Moeller
- Levine Cancer Institute, Atrium Health, Southeast Radiation Oncology, Charlotte, North Carolina
| | - Roshan S Prabhu
- Levine Cancer Institute, Atrium Health, Southeast Radiation Oncology, Charlotte, North Carolina
| | - Christopher Corso
- Levine Cancer Institute, Atrium Health, Southeast Radiation Oncology, Charlotte, North Carolina
| | - Matt W Ward
- Levine Cancer Institute, Atrium Health, Southeast Radiation Oncology, Charlotte, North Carolina
| | - Cara M Sullivan
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Stuart Burri
- Levine Cancer Institute, Atrium Health, Southeast Radiation Oncology, Charlotte, North Carolina
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; New York Proton Center, New York, New York
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Ward MC, Atlas JL, Carrizosa DR, Milas ZL, Brickman DS, Frenkel CH, Hong S, Heinzerling JH, Prabhu RS, Moeller BJ. Weekly vs. Bolus Cisplatin Concurrent with Definitive Radiotherapy for Squamous Carcinoma of the Head and Neck: A Systematic Review and Network Meta-Analysis. Int J Radiat Oncol Biol Phys 2023; 117:e632-e633. [PMID: 37785889 DOI: 10.1016/j.ijrobp.2023.06.2031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) The optimal schedule for cisplatin delivered concurrently with definitive radiation for squamous carcinoma of the head and neck remains controversial. Randomized data in the postoperative setting is mixed, and definitive studies are ongoing. Meanwhile, multiple trials have already compared cetuximab to cisplatin in the definitive setting. Across these trials, the cetuximab dosing was identical, but cisplatin dosing was variable and can be categorized as weekly (40 mg/m2 q1 week) or bolus (100 mg/m2 q3 weeks). We indirectly compared these two cisplatin schedules by performing a network meta-analysis of cetuximab trials. MATERIALS/METHODS We performed a PRISMA-concordant systematic review to identify randomized controlled trials comparing cisplatin to cetuximab for patients with non-metastatic squamous carcinoma of the head and neck treated with definitive radiation therapy. Trials of primary surgery, incorporating induction therapy, or mixing other therapeutics were excluded. The analysis was pre-registered with the Open Science Foundation. Individual patient survival data was extracted from the published overall survival curves using a digitizer, and outcomes were validated against published point-estimates and hazard ratios. A random effects Cox regression was used to perform the individual-patient analysis using a one-step approach under a frequentist framework. Random effects were applied to model heterogeneity in the baseline hazard function and treatment effect. Models were adjusted by HPV and smoking status, which were trial-level covariates. Alternative endpoints (DFS, LRF, DM, etc.) were analyzed qualitatively. IRB approval was not required. RESULTS Five randomized trials were identified, including 1,678 patients. Bolus cisplatin was delivered to 572 patients in 2 trials, and weekly to 271 in 3 trials. The risk of bias was low. Relative to cetuximab, both bolus and weekly cisplatin reduced the risk of death (adjusted HR 0.63, 95% CI 0.46-0.87, p = 0.004 & HR 0.56, 95% CI 0.37-0.86, p = 0.008 respectively). No interaction was identified between regimen and HPV or smoking status. Between-study heterogeneity (δ2) was 0.148 and treatment effect heterogeneity (τ2) was small (<0.0002). There was no statistical difference in OS between bolus vs. weekly regimens (weekly vs. bolus HR 0.90, 95% CI 0.53-1.52, p = 0.345). This Cox model therefore suggested that on average, the absolute difference in 5-year OS is <1.5% between the two regimens, which was not statistically significant. Secondary endpoints and toxicity were not obviously different by regimen, qualitatively. CONCLUSION Using cetuximab as a common reference, there was no significant difference in survival between weekly and bolus cisplatin schedules.
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Affiliation(s)
- M C Ward
- Levine Cancer Institute, Atrium Health and Southeast Radiation Oncology Group, Charlotte, NC
| | - J L Atlas
- Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - D R Carrizosa
- Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Z L Milas
- Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - D S Brickman
- Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - C H Frenkel
- Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - S Hong
- Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - J H Heinzerling
- Levine Cancer Institute, Atrium Health and Southeast Radiation Oncology Group, Charlotte, NC
| | - R S Prabhu
- Levine Cancer Institute, Atrium Health and Southeast Radiation Oncology Group, Charlotte, NC
| | - B J Moeller
- Levine Cancer Institute, Atrium Health and Southeast Radiation Oncology Group, Charlotte, NC
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Heinzerling JH, Mileham K, Robinson M, Symanowski JT, Induru R, Corso CD, Brouse G, Prabhu RS, Haggstrom D, Moeller BJ, Bobo WE, Fasola C, Thakkar VV, Gregory J, Burri SH, Simone CB. Prospective Phase II Trial of Primary Lung Tumor Stereotactic Body Radiation Therapy (SBRT) Followed By Concurrent Mediastinal Chemoradiation and Adjuvant Immunotherapy for Locally-Advanced Non-Small Cell Lung Cancer (LA NSCLC). Int J Radiat Oncol Biol Phys 2023; 117:S27-S28. [PMID: 37784465 DOI: 10.1016/j.ijrobp.2023.06.287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) To report the efficacy and toxicity outcomes of a prospective phase II trial of primary tumor SBRT followed by conventional chemoradiation to the lymph nodes and adjuvant immunotherapy in patients (pts) with unresectable LA NSCLC. MATERIALS/METHODS Eligible pts included stage II-III LA NSCLC with peripheral primary tumors ≤ 7cm or centrally based tumors that had at least 2 cm separation from involved nodal disease. Pts received SBRT to the primary tumor (50-54 Gy in 3-5 fractions) followed by standard radiation to 60 Gy in 30 fractions to the involved lymph nodes with concurrent platinum doublet chemotherapy. The trial was amended to allow pts without disease progression after chemoradiation to receive adjuvant durvalumab per the PACIFIC trial. The primary endpoint was 1 year progression free survival (PFS), evaluated as a binary variable. Frequencies and proportions were used for reporting this primary endpoint, in addition to adverse events and patterns of failure. Median PFS and OS were estimated using Kaplan Meier methods. RESULTS Safety and efficacy is reported on the first 50 pts enrolled in the trial with a median follow-up of 24 months (mos) (range, 1-54 mos). Pts were primarily stage IIIA (60%) or stage IIIB (34%), with 6% of pts stage IIB. Overall grade 3 or higher toxicity related to SBRT and/or mediastinal radiation was 8% with two pts (4%) developing grade 3 pneumonitis and one pt having a grade 5 lung infection possibly related to radiation. Overall grade 2 pneumonitis related to SBRT or mediastinal radiation was 20%. Only one pt (2%) developed grade 3 esophagitis. No late cardiac events have been observed. The one-year PFS for all pts was 62% with a median PFS of 26.3 mos and median overall survival of 40.8 mos. Of the 50 pts enrolled, 37 received at least one dose of adjuvant durvalumab. The one-year PFS for pts who received at least one dose of durvalumab was 70.3% with a median PFS not yet reached in this group (median follow-up 24 mos). Patterns of failure were mostly distant with 26% of pts experiencing distant failure, 6% regional, and 2% distant and regional. There was only one local failure (2%) after SBRT in all 50 pts. CONCLUSION SBRT to the primary tumor followed by conventional chemoradiation to the involved lymph nodes and adjuvant immunotherapy was well tolerated and showed improved 1-year PFS compared to prior conventional chemoradiation trials for locally advanced NSCLC. The results of this trial will be further evaluated in a randomized phase III study, NRG LU-008. Pts will receive either conventional chemoradiation vs. SBRT to the primary tumor followed by chemoradiation to the involved lymph nodes followed by consolidative immunotherapy to evaluate the possibility of utilization of SBRT as a new standard of care for LA NSCLC.
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Affiliation(s)
- J H Heinzerling
- Levine Cancer Institute, Atrium Health/Wake Forest School of Medicine and Southeast Radiation Oncology Group, Charlotte, NC
| | - K Mileham
- Levine Cancer Institute, Atrium Health/Wake Forest School of Medicine, Charlotte, NC
| | - M Robinson
- Levine Cancer Institute, Atrium Health, Charlotte, NC
| | | | - R Induru
- Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - C D Corso
- Levine Cancer Institute, Atrium Health and Southeast Radiation Oncology Group, Charlotte, NC
| | - G Brouse
- Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - R S Prabhu
- Levine Cancer Institute, Atrium Health and Southeast Radiation Oncology Group, Charlotte, NC
| | - D Haggstrom
- Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - B J Moeller
- Levine Cancer Institute, Atrium Health and Southeast Radiation Oncology Group, Charlotte, NC
| | - W E Bobo
- Levine Cancer Institute, Atrium Health and Southeast Radiation Oncology Group, Charlotte, NC
| | - C Fasola
- Levine Cancer Institute, Atrium Health and Southeast Radiation Oncology Group, Charlotte, NC
| | - V V Thakkar
- Levine Cancer Institute, Atrium Health and Southeast Radiation Oncology Group, Charlotte, NC
| | - J Gregory
- Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - S H Burri
- Levine Cancer Institute, Atrium Health and Southeast Radiation Oncology Group, Charlotte, NC
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Prabhu RS, Akinyelu T, Vaslow ZK, Matsui JK, Haghighi N, Dan T, Mishra MV, Murphy ES, Boyles S, Perlow HK, Palmer JD, Udovicich C, Patel TR, Wardak Z, Woodworth GF, Ksendzovsky A, Yang K, Chao ST, Asher AL, Burri SH. Risk Factors for Progression and Toxic Effects After Preoperative Stereotactic Radiosurgery for Patients With Resected Brain Metastases. JAMA Oncol 2023; 9:1066-1073. [PMID: 37289451 PMCID: PMC10251241 DOI: 10.1001/jamaoncol.2023.1629] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 03/14/2023] [Indexed: 06/09/2023]
Abstract
Importance Preoperative stereotactic radiosurgery (SRS) has been demonstrated as a feasible alternative to postoperative SRS for resectable brain metastases (BMs) with potential benefits in adverse radiation effects (AREs) and meningeal disease (MD). However, mature large-cohort multicenter data are lacking. Objective To evaluate preoperative SRS outcomes and prognostic factors from a large international multicenter cohort (Preoperative Radiosurgery for Brain Metastases-PROPS-BM). Design, Setting, and Participants This multicenter cohort study included patients with BMs from solid cancers, of which at least 1 lesion received preoperative SRS and a planned resection, from 8 institutions. Radiosurgery to synchronous intact BMs was allowed. Exclusion criteria included prior or planned whole-brain radiotherapy and no cranial imaging follow-up. Patients were treated between 2005 and 2021, with most treated between 2017 and 2021. Exposures Preoperative SRS to a median dose to 15 Gy in 1 fraction or 24 Gy in 3 fractions delivered at a median (IQR) of 2 (1-4) days before resection. Main Outcomes and Measures The primary end points were cavity local recurrence (LR), MD, ARE, overall survival (OS), and multivariable analysis of prognostic factors associated with these outcomes. Results The study cohort included 404 patients (214 women [53%]; median [IQR] age, 60.6 [54.0-69.6] years) with 416 resected index lesions. The 2-year cavity LR rate was 13.7%. Systemic disease status, extent of resection, SRS fractionation, type of surgery (piecemeal vs en bloc), and primary tumor type were associated with cavity LR risk. The 2-year MD rate was 5.8%, with extent of resection, primary tumor type, and posterior fossa location being associated with MD risk. The 2-year any-grade ARE rate was 7.4%, with target margin expansion greater than 1 mm and melanoma primary being associated with ARE risk. Median OS was 17.2 months (95% CI, 14.1-21.3 months), with systemic disease status, extent of resection, and primary tumor type being the strongest prognostic factors associated with OS. Conclusions and Relevance In this cohort study, the rates of cavity LR, ARE, and MD after preoperative SRS were found to be notably low. Several tumor and treatment factors were identified that are associated with risk of cavity LR, ARE, MD, and OS after treatment with preoperative SRS. A phase 3 randomized clinical trial of preoperative vs postoperative SRS (NRG BN012) has began enrolling (NCT05438212).
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Affiliation(s)
- Roshan S. Prabhu
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
- Southeast Radiation Oncology Group, Charlotte, North Carolina
| | - Tobi Akinyelu
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | | | | | - Neda Haghighi
- Peter McCallum Cancer Centre, Melbourne, Victoria, Australia
- Icon Cancer Centre, Epworth Centre, Richmond, Victoria, Australia
| | - Tu Dan
- University of Texas Southwestern Medical Center, Dallas
| | | | - Erin S. Murphy
- Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio
| | - Susan Boyles
- Cone Health Cancer Center, Greensboro, North Carolina
| | | | | | | | | | - Zabi Wardak
- University of Texas Southwestern Medical Center, Dallas
| | | | | | - Kailin Yang
- Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio
| | - Samuel T. Chao
- Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio
| | - Anthony L. Asher
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
- Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina
| | - Stuart H. Burri
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
- Southeast Radiation Oncology Group, Charlotte, North Carolina
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Jansen CS, Prabhu RS, Pagadala MS, Chappa P, Goyal S, Zhou C, Neill SG, Prokhnevska N, Cardenas M, Hoang KB, Zhong J, Torres M, Logan S, Olson JJ, Nduom EK, del Balzo L, Patel K, Burri SH, Asher AL, Wilkinson S, Lake R, Higgins KA, Patel P, Dhere V, Sowalsky AG, Khan MK, Kissick H, Buchwald ZS. Immune niches in brain metastases contain TCF1+ stem-like T cells, are associated with disease control and are modulated by preoperative SRS. Res Sq 2023:rs.3.rs-2722744. [PMID: 36993444 PMCID: PMC10055679 DOI: 10.21203/rs.3.rs-2722744/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
The CD8+ T-cell response is prognostic for survival outcomes in several tumor types. However, whether this extends to tumors in the brain, an organ with barriers to T cell entry, remains unclear. Here, we analyzed immune infiltration in 67 brain metastasis (BrM) and found high frequencies of PD1+ TCF1+ stem-like CD8+ T-cells and TCF1- effector-like cells. Importantly, the stem-like cells aggregate with antigen presenting cells in immune niches, and niches were prognostic for local disease control. Standard of care for BrM is resection followed by stereotactic radiosurgery (SRS), so to determine SRS's impact on the BrM immune response, we examined 76 BrM treated with pre-operative SRS (pSRS). pSRS acutely reduced CD8+ T cells at 3 days. However, CD8+ T cells rebounded by day 6, driven by increased frequency of effector-like cells. This suggests that the immune response in BrM can be regenerated rapidly, likely by the local TCF1+ stem-like population.
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Affiliation(s)
- Caroline S. Jansen
- Department of Urology and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Roshan S. Prabhu
- Southeast Radiation Oncology Group, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Meghana S. Pagadala
- Biomedical Science Program, University of California San Diego, La Jolla, CA, USA
| | - Prasanthi Chappa
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Subir Goyal
- Department of Biostatistics and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Chengjing Zhou
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Stewart G. Neill
- Department of Pathology and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Nataliya Prokhnevska
- Department of Urology and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Maria Cardenas
- Department of Urology and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Kimberly B. Hoang
- Department of Neurosurgery and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Jim Zhong
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Mylin Torres
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Suzanna Logan
- Department of Pathology, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Jeffrey J. Olson
- Department of Neurosurgery and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Edjah K. Nduom
- Department of Neurosurgery and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Luke del Balzo
- Department of Urology and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | | | - Stuart H. Burri
- Southeast Radiation Oncology Group, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | | | - Scott Wilkinson
- Laboratory of Genitourinary Cancer Pathogenesis, National Cancer Institute, Bethesda, MD, USA
| | - Ross Lake
- Laboratory of Genitourinary Cancer Pathogenesis, National Cancer Institute, Bethesda, MD, USA
| | - Kristin A. Higgins
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Pretesh Patel
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Vishal Dhere
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Adam G. Sowalsky
- Laboratory of Genitourinary Cancer Pathogenesis, National Cancer Institute, Bethesda, MD, USA
| | - Mohammad K. Khan
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Haydn Kissick
- Department of Urology and Winship Cancer Institute, Emory University, Atlanta, GA, USA
- Emory Vaccine Center, Department of Microbiology and Immunology, Emory University, Atlanta, GA, USA
| | - Zachary S. Buchwald
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, USA
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Trifiletti DM, Akinyelu T, Burri SH, Jeudy A, Quinones-Hinojosa A, Prabhu RS. Glioma inadvertently treated with preoperative stereotactic radiosurgery: focusing on safety. J Neurooncol 2023; 162:247-249. [PMID: 36877383 DOI: 10.1007/s11060-023-04278-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 02/24/2023] [Indexed: 03/07/2023]
Affiliation(s)
- Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL 32224, USA.
| | - Tobi Akinyelu
- Department of Radiation Oncology, Levine Cancer Institute Atrium Health, Charlotte, NC 28204, USA
| | - Stuart H Burri
- Department of Radiation Oncology, Levine Cancer Institute Atrium Health, Charlotte, NC 28204, USA
| | - Andjie Jeudy
- St. George's University School of Medicine, True-Blue, St. George's, West Indies, Grenada
| | | | - Roshan S Prabhu
- Department of Radiation Oncology, Levine Cancer Institute Atrium Health, Charlotte, NC 28204, USA
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Squires MH, Ethun CG, Donahue EE, Benbow JH, Anderson CJ, Jagosky MH, Manandhar M, Patt JC, Kneisl JS, Salo JC, Hill JS, Ahrens W, Prabhu RS, Livingston MB, Gower NL, Needham M, Trufan SJ, Fields RC, Krasnick BA, Bedi M, Votanopoulos K, Chouliaras K, Grignol V, Roggin KK, Tseng J, Poultsides G, Tran TB, Cardona K, Howard JH. ASO Visual Abstract: Extremity Soft Tissue Sarcoma-A Multi-institutional Validation of Prognostic Nomograms. Ann Surg Oncol 2022. [PMID: 35088171 DOI: 10.1245/s10434-021-11263-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
| | | | - Erin E Donahue
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | | | - Colin J Anderson
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA.,Musculoskeletal Institute, Atrium Health, Charlotte, NC, USA
| | | | | | - Joshua C Patt
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA.,Musculoskeletal Institute, Atrium Health, Charlotte, NC, USA
| | - Jeffrey S Kneisl
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA.,Musculoskeletal Institute, Atrium Health, Charlotte, NC, USA
| | | | - Joshua S Hill
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - William Ahrens
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | | | | | - Nicole L Gower
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | | | - Sally J Trufan
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Ryan C Fields
- Washington University School of Medicine, St. Louis, MO, USA
| | | | - Meena Bedi
- Medical College of Wisconsin, Milwaukee, WI, USA
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9
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Squires MH, Ethun CG, Donahue EE, Benbow JH, Anderson CJ, Jagosky MH, Manandhar M, Patt JC, Kneisl JS, Salo JC, Hill JS, Ahrens W, Prabhu RS, Livingston MB, Gower NL, Needham M, Trufan SJ, Fields RC, Krasnick BA, Bedi M, Votanopoulos K, Chouliaras K, Grignol V, Roggin KK, Tseng J, Poultsides G, Tran TB, Cardona K, Howard JH. Extremity Soft Tissue Sarcoma: A Multi-Institutional Validation of Prognostic Nomograms. Ann Surg Oncol 2022; 29:3291-3301. [PMID: 35015183 DOI: 10.1245/s10434-021-11205-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 11/15/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Prognostic nomograms for patients with resected extremity soft tissue sarcoma (STS) include the Sarculator and Memorial Sloan Kettering (MSKCC) nomograms. We sought to validate these two nomograms within a large, modern, multi-institutional cohort of resected primary extremity STS patients. METHODS Resected primary extremity STS patients from 2000 to 2017 were identified across nine high-volume U.S. institutions. Predicted 5- and 10-year overall survival (OS) and distant metastases cumulative incidence (DMCI), and 4-, 8-, and 12-year disease-specific survival (DSS) were calculated with Sarculator and MSKCC nomograms, respectively. Predicted survival probabilities stratified in quintiles were compared in calibration plots to observed survival assessed by Kaplan-Meier estimates. Cumulative incidence was estimated for DMCI. Harrell's concordance index (C-index) assessed discriminative ability of nomograms. RESULTS A total of 1326 patients underwent resection of primary extremity STS. Common histologies included: undifferentiated pleomorphic sarcoma (35%), fibrosarcoma (13%), and leiomyosarcoma (9%). Median tumor size was 8.0 cm (IQR 4.5-13.0). Tumor grade distribution was: Grade 1 (13%), Grade 2 (9%), Grade 3 (78%). Median OS was 172 months, with estimated 5- and 10-year OS of 70% and 58%. C-indices for 5- and 10-year OS (Sarculator) were 0.72 (95% CI 0.70-0.75) and 0.73 (95% CI 0.70-0.75), and 0.72 (95% CI 0.69-0.75) for 5- and 10-year DMCI. C-indices for 4-, 8-, and 12-year DSS (MSKCC) were 0.71 (95% CI 0.68-0.75). Calibration plots showed good prognostication across all outcomes. CONCLUSIONS Sarculator and MSKCC nomograms demonstrated good prognostic ability for survival and recurrence outcomes in a modern, multi-institutional validation cohort of resected primary extremity STS patients. External validation of these nomograms supports their ongoing incorporation into clinical practice.
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Affiliation(s)
| | | | - Erin E Donahue
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | | | - Colin J Anderson
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA.,Musculoskeletal Institute, Atrium Health, Charlotte, NC, USA
| | | | | | - Joshua C Patt
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA.,Musculoskeletal Institute, Atrium Health, Charlotte, NC, USA
| | - Jeffrey S Kneisl
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA.,Musculoskeletal Institute, Atrium Health, Charlotte, NC, USA
| | | | - Joshua S Hill
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - William Ahrens
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | | | | | - Nicole L Gower
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | | | - Sally J Trufan
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Ryan C Fields
- Washington University School of Medicine, St. Louis, MO, USA
| | | | - Meena Bedi
- Medical College of Wisconsin, Milwaukee, WI, USA
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10
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Prabhu RS, Dhakal R, Piantino M, Bahar N, Meaders KS, Fasola CE, Ward MC, Heinzerling JH, Sumrall AL, Burri SH. Volumetric Modulated Arc Therapy (VMAT) Craniospinal Irradiation (CSI) for Children and Adults: A Practical Guide for Implementation. Pract Radiat Oncol 2021; 12:e101-e109. [PMID: 34848379 DOI: 10.1016/j.prro.2021.11.005] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/28/2021] [Accepted: 11/08/2021] [Indexed: 11/19/2022]
Abstract
PURPOSE Volumetric modulated arc therapy (VMAT) craniospinal irradiation (CSI) has been shown to have significant dosimetric advantages compared to 3D-conformal therapy, but is a technically complex process. We sought to develop a guide for all aspects of the VMAT CSI process and report patient dosimetry results. METHODS AND MATERIALS We initiated VMAT CSI in 2017 and have regularly revised our standard operating procedure (SOP) for this process since then. Herein, we report a detailed template for the entire VMAT CSI process from initial patient setup and immobilization at time of CT simulation to contouring and treatment planning, quality assurance, and therapy delivery. The records of 12 patients who were treated with VMAT CSI were also retrospectively reviewed. RESULTS Patient age ranged from 2 to 59 years with 5 pediatric patients (age<18 years), 5 young adults (age 18-35 years) and 2 older adults (age>35 years). The majority of patients (67%) had medulloblastoma. CSI dose ranged from 21.6 Gy to 36 Gy, with a median of 36 Gy. The median CSI planning target volume (PTV) was 2383cc with a median V95% of 99.8% and median 0.03 cc hotspot of 112.5%. The average V107% was 7.4% and the average conformality index was 1.01. CONCLUSIONS VMAT CSI has potentially significant dosimetric and acute toxicity advantages compared to 3D-conformal. However, proper procedures need to be in place throughout the process in order to be able to realize these potential advantages. We herein describe our detailed SOP for VMAT CSI. Recognizing the scarcity of proton beam centers in many areas, VMAT CSI represents a feasible treatment with more widespread availability.
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Affiliation(s)
- Roshan S Prabhu
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina; Southeast Radiation Oncology Group, Charlotte, North Carolina.
| | - Reshika Dhakal
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Melanie Piantino
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Nina Bahar
- St. Peter's Health Partners, Albany, New York
| | | | - Carolina E Fasola
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina; Southeast Radiation Oncology Group, Charlotte, North Carolina
| | - Matthew C Ward
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina; Southeast Radiation Oncology Group, Charlotte, North Carolina
| | - John H Heinzerling
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina; Southeast Radiation Oncology Group, Charlotte, North Carolina
| | - Ashley L Sumrall
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Stuart H Burri
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina; Southeast Radiation Oncology Group, Charlotte, North Carolina
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11
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Squires MH, Gower N, Benbow JH, Donahue EE, Bohl CE, Prabhu RS, Hill JS, Salo JC. PET Imaging and Rate of Pathologic Complete Response in Esophageal Squamous Cell Carcinoma. Ann Surg Oncol 2021; 29:1327-1333. [PMID: 34625880 DOI: 10.1245/s10434-021-10644-4] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 07/30/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND For locally advanced esophageal squamous cell carcinoma (ESCC), chemoradiation (ChemoRT) followed by surgery offers the best chance of cure, with a 35-50% pathologic complete response (pCR) rate. Given the morbidity of esophagectomy and the possibility of pCR with ChemoRT, a 'watch and wait' strategy has been proposed, particularly for squamous cell carcinoma. The ability to accurately predict which patients will have pCR from ChemoRT is critical in treatment decision making. This study assessed positron emission tomography (PET) in predicting pCR after neoadjuvant ChemoRT for ESCC. METHODS ESCC patients treated with ChemoRT followed by surgery were identified. Maximum standard uptake value (SUV), metabolic tumor volume, total lesion glycolysis, and first-order textual features of standard deviation, kurtosis and skewness were measured from PET. Univariable and multivariable generalized linear method analyses were performed. A metabolic complete response (mCR) was defined as a post-therapy PET scan with maximum SUV < 4.0. RESULTS Twenty-seven patients underwent ChemoRT followed by surgery, with overall pCR seen in 11 (41%) patients and radiographic mCR seen in 12 (44%) patients. Final pathology for these 12 patients revealed pCR (ypT0N0M0) in 5 (42%) patients and persistent disease in 7 (58%) patients. Univariate analysis did not reveal PET parameters predictive of pCR. CONCLUSION Treatment of ESCC with ChemoRT often results in a robust clinical response. Among patients with an mCR after ChemoRT, disease persistence was found in 58%. The inability of PET to predict pCR is important in the context of a 'watch and wait' strategy for ESCC treated with ChemoRT.
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Affiliation(s)
- M Hart Squires
- Division of Surgical Oncology, Department of Surgery, Carolinas Medical Center, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Nicole Gower
- LCI Research Support, Clinical Trials Office, Levine Cancer Institute, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Jennifer H Benbow
- LCI Research Support, Clinical Trials Office, Levine Cancer Institute, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Erin E Donahue
- Department of Biostatistics, Carolinas Medical Center, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Casey E Bohl
- Charlotte Radiology, Atrium Health, Charlotte, NC, USA
| | - Roshan S Prabhu
- Southeast Radiation Oncology Group, Carolinas Medical Center, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Joshua S Hill
- Division of Surgical Oncology, Department of Surgery, Carolinas Medical Center, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Jonathan C Salo
- Division of Surgical Oncology, Department of Surgery, Carolinas Medical Center, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA.
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12
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Squires MH, Gower N, Benbow JH, Donahue EE, Bohl CE, Prabhu RS, Hill JS, Salo JC. ASO Visual Abstract: PET Imaging and Rate of Pathologic Complete Response in Esophageal Squamous Cell Carcinoma. Ann Surg Oncol 2021. [PMID: 34549361 DOI: 10.1245/s10434-021-10691-x] [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: 11/18/2022]
Affiliation(s)
- M Hart Squires
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Nicole Gower
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | | | - Erin E Donahue
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | | | - Roshan S Prabhu
- Southeast Radiation Oncology Group, Carolinas Medical Center, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Joshua S Hill
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
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13
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Squires MH, Ethun CG, Donahue EE, Benbow JH, Anderson CJ, Jagosky MH, Salo JC, Hill JS, Ahrens W, Prabhu RS, Livingston MB, Gower NL, Needham M, Trufan SJ, Fields RC, Krasnick BA, Bedi M, Abbott DE, Schwartz P, Votanopoulos K, Chouliaras K, Grignol V, Roggin KK, Tseng J, Poultsides G, Tran TB, Cardona K, Howard JH. A multi-institutional validation study of prognostic nomograms for retroperitoneal sarcoma. J Surg Oncol 2021; 124:829-837. [PMID: 34254691 DOI: 10.1002/jso.26586] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 06/12/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Prognostic nomograms for patients undergoing resection of retroperitoneal sarcoma (RPS) include the Sarculator and Memorial Sloan Kettering (MSK) sarcoma nomograms. We sought to validate the Sarculator and MSK nomograms within a large, modern multi-institutional cohort of patients with primary RPS undergoing resection. METHODS Patients who underwent resection of primary RPS between 2000 and 2017 across nine high-volume US institutions were identified. Predicted 7-year disease-free (DFS) and overall survival (OS) and 4-, 8-, and 12-year disease-specific survival (DSS) were calculated from the Sarculator and MSK nomograms, respectively. Nomogram-predicted survival probabilities were stratified in quintiles and compared in calibration plots to observed survival outcomes assessed by Kaplan-Meier estimates. Discriminative ability of nomograms was quantified by Harrell's concordance index (C-index). RESULTS Five hundred and two patients underwent resection of primary RPS. Histologies included leiomyosarcoma (30%), dedifferentiated liposarcoma (23%), and well-differentiated liposarcoma (15%). Median tumor size was 14.0 cm (interquartile range [IQR], 8.5-21.0 cm). Tumor grade distribution was: Grade 1 (27%), Grade 2 (17%), and Grade 3 (56%). Median DFS was 31.5 months; 7-year DFS was 29%. Median OS was 93.8 months; 7-year OS was 51%. C-indices for 7-year DFS, and OS by the Sarculator nomogram were 0.65 (95% confidence interval [CI]: 0.62-0.69) and 0.69 (95%CI: 0.65-0.73); plots demonstrated good calibration for predicting 7-year outcomes. The C-index for 4-, 8-, and 12-year DSS by the MSK nomogram was 0.71 (95%CI: 0.67-0.75); plots demonstrated similarly good calibration ability. CONCLUSIONS In a diverse, modern validation cohort of patients with resected primary RPS, both Sarculator and MSK nomograms demonstrated good prognostic ability, supporting their ongoing adoption into clinical practice.
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Affiliation(s)
- Malcolm H Squires
- Division of Surgical Oncology, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Cecilia G Ethun
- Division of Surgical Oncology, Emory University, Atlanta, Georgia, USA
| | - Erin E Donahue
- Department of Cancer Biostatistics, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Jennifer H Benbow
- Department of Cancer Biostatistics, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Colin J Anderson
- Department of Orthopedic Oncology, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA.,Musculoskeletal Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Megan H Jagosky
- Department of Medical Oncology, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Jonathan C Salo
- Division of Surgical Oncology, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Joshua S Hill
- Division of Surgical Oncology, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - William Ahrens
- Department of Pathology, Atrium Health, Charlotte, North Carolina, USA
| | - Roshan S Prabhu
- Department of Radiation Oncology, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Michael B Livingston
- Department of Medical Oncology, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Nicole L Gower
- Department of Cancer Biostatistics, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Mckenzie Needham
- Department of Cancer Biostatistics, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Sally J Trufan
- Department of Cancer Biostatistics, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Bradley A Krasnick
- Department of Surgery, School of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Meena Bedi
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Daniel E Abbott
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - Patrick Schwartz
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | | | | | - Valerie Grignol
- Division of Surgical Oncology, The Ohio State University, Columbus, OH, USA
| | - Kevin K Roggin
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Jennifer Tseng
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - George Poultsides
- Department of Surgery, Stanford University, Palo Alto, California, USA
| | - Thuy B Tran
- Department of Surgery, Stanford University, Palo Alto, California, USA
| | - Kenneth Cardona
- Division of Surgical Oncology, Emory University, Atlanta, Georgia, USA
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Prabhu RS, Dhakal R, Vaslow ZK, Dan T, Mishra MV, Murphy ES, Patel TR, Asher AL, Yang K, Manning MA, Stern JD, Patel AR, Wardak Z, Woodworth GF, Chao ST, Mohammadi A, Burri SH. Preoperative Radiosurgery for Resected Brain Metastases: The PROPS-BM Multicenter Cohort Study. Int J Radiat Oncol Biol Phys 2021; 111:764-772. [PMID: 34058254 DOI: 10.1016/j.ijrobp.2021.05.124] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 05/13/2021] [Accepted: 05/20/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Preoperative radiosurgery (SRS) is a feasible alternative to postoperative SRS, with potential benefits in adverse radiation effect (ARE) and leptomeningeal disease (LMD) relapse. However, previous studies are limited by small patient numbers and single-institution designs. Our aim was to evaluate preoperative SRS outcomes and prognostic factors from a large multicenter cohort (Preoperative Radiosurgery for Brain Metastases [PROPS-BM]). METHODS AND MATERIALS Patients with brain metastases (BM) from solid cancers who had at least 1 lesion treated with preoperative SRS and underwent a planned resection were included from 5 institutions. SRS to synchronous intact BM was allowed. Radiographic meningeal disease (MD) was categorized as either nodular or classical "sugarcoating" (cLMD). RESULTS The cohort included 242 patients with 253 index lesions. Most patients (62.4%) had a single BM, 93.7% underwent gross total resection, and 98.8% were treated with a single fraction to a median dose of 15 Gray to a median gross tumor volume of 9.9 cc. Cavity local recurrence (LR) rates at 1 and 2 years were 15% and 17.9%, respectively. Subtotal resection (STR) was a strong independent predictor of LR (hazard ratio, 9.1; P < .001). One and 2-year rates of MD were 6.1% and 7.6% and of any grade ARE were 4.7% and 6.8% , respectively. The median overall survival (OS) duration was 16.9 months and the 2-year OS rate was 38.4%. The majority of MD was cLMD (13 of 19 patients with MD; 68.4%). Of 242 patients, 10 (4.1%) experienced grade ≥3 postoperative surgical complications. CONCLUSIONS To our knowledge, this multicenter study represents the largest cohort treated with preoperative SRS. The favorable outcomes previously demonstrated in single-institution studies, particularly the low rates of MD and ARE, are confirmed in this expanded multicenter analysis, without evidence of an excessive postoperative surgical complication risk. STR, though infrequent, is associated with significantly worse cavity LR. A randomized trial between preoperative and postoperative SRS is warranted and is currently being designed.
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Affiliation(s)
- Roshan S Prabhu
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina; Southeast Radiation Oncology Group, Charlotte, North Carolina.
| | - Reshika Dhakal
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | | | - Tu Dan
- Department of Radiation Oncology, University of Texas Southwestern, Dallas, Texas
| | - Mark V Mishra
- Department of Radiation Oncology, University of Maryland, Baltimore, Maryland
| | - Erin S Murphy
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Toral R Patel
- Department of Neurosurgery, University of Texas Southwestern, Dallas, Texas
| | - Anthony L Asher
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina; Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina
| | - Kailin Yang
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
| | | | - Joseph D Stern
- Cone Health, Greensboro, North Carolina; Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina
| | - Ankur R Patel
- Department of Neurosurgery, Baylor University, Dallas, Texas
| | - Zabi Wardak
- Department of Radiation Oncology, University of Texas Southwestern, Dallas, Texas
| | | | - Samuel T Chao
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
| | | | - Stuart H Burri
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina; Southeast Radiation Oncology Group, Charlotte, North Carolina
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15
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Dhakal R, Moeller BJ, Prabhu RS, Frenkel CH, Carrizosa DR, Sumrall AL, Milas ZL, Brickman DS, Ward MC. Pattern of distant metastasis in oropharyngeal carcinoma - Do they differ by HPV status? Oral Oncol 2021; 120:105286. [PMID: 33883078 DOI: 10.1016/j.oraloncology.2021.105286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 03/27/2021] [Accepted: 03/31/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Reshika Dhakal
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA.
| | - Benjamin J Moeller
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA; Southeast Radiation Oncology (SERO), Charlotte, NC, USA
| | - Roshan S Prabhu
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA; Southeast Radiation Oncology (SERO), Charlotte, NC, USA
| | | | | | | | | | | | - Matthew C Ward
- Levine Cancer Institute, Atrium Health, Charlotte, NC, USA; Southeast Radiation Oncology (SERO), Charlotte, NC, USA.
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16
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Prabhu RS, Ward MC, Heinzerling JH, Corso CD, Buchwald ZS, Dhakal R, Asher AL, Sumrall AL, Burri SH. The Association Between Radiation Therapy Dose and Overall Survival in Patients With Intracranial Infiltrative Low-Grade Glioma Treated With Concurrent and/or Adjuvant Chemotherapy. Adv Radiat Oncol 2021; 6:100577. [PMID: 33665485 PMCID: PMC7897756 DOI: 10.1016/j.adro.2020.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 08/30/2020] [Accepted: 09/22/2020] [Indexed: 11/19/2022] Open
Abstract
Purpose Previous trials have shown no benefit for radiation therapy (RT) dose escalation when RT is given as adjuvant monotherapy for infiltrative low-grade glioma (LGG). However, the current standard of care for high-risk LGG is RT with concurrent and/or adjuvant chemotherapy. The effect of RT dose escalation on overall survival (OS) in the setting of concurrent and/or adjuvant chemotherapy is not well established. Methods and Materials We used the National Cancer Database to select records for adult patients with intracranial grade 2 LGG diagnosed between 2004 and 2015. Patients must have received adjuvant external beam RT with concurrent and/or adjuvant chemotherapy. RT dose level was categorized as standard (45-54 Gy) or high (>54-65 Gy). Multivariable and propensity score matched analyses were used. Results The study cohort consisted of 1043 patients, of whom 644 (62%) received standard dose (median, 54 Gy) and 399 (38%) received high-dose RT (median, 60 Gy). RT dose level was not associated with OS (hazard ratio, 1.2; P = .1) in multivariable analysis. Propensity score matching yielded 380 matched pairs (n = 760). There was no difference in OS for high-dose versus standard-dose RT in the matched cohort (5-year OS 64% vs 69%; P = .14) or in the 2 prespecified subgroups of astrocytoma histology and 1p/19q noncodeleted. Conclusions Adjuvant RT dose escalation above 54 Gy in the setting of concurrent and/or adjuvant chemotherapy was not associated with improved OS for patients with infiltrative LGG in this National Cancer Database retrospective study. This was also true for the subgroups with less chemotherapy-sensitive disease, including astrocytoma histology and 1p/19q noncodeleted, although these analyses were limited by small size. Methods to improve OS other than RT dose escalation in the setting of concurrent and/or adjuvant chemotherapy should be considered for patients with poor-prognosis LGG.
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Affiliation(s)
- Roshan S. Prabhu
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
- Southeast Radiation Oncology Group, Charlotte, North Carolina
- Corresponding author: Roshan S. Prabhu, MD, MS
| | - Matthew C. Ward
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
- Southeast Radiation Oncology Group, Charlotte, North Carolina
| | - John H. Heinzerling
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
- Southeast Radiation Oncology Group, Charlotte, North Carolina
| | - Christopher D. Corso
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
- Southeast Radiation Oncology Group, Charlotte, North Carolina
| | | | - Reshika Dhakal
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Anthony L. Asher
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
- Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina
| | | | - Stuart H. Burri
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
- Southeast Radiation Oncology Group, Charlotte, North Carolina
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Prabhu RS, Dhakal R, Hicks AS, McBride J, Patrick AL, Corso CD, Murphy T, Thonen M, Lipford EH, Raghavan D, Burri SH. Implementation, adherence, and results of systematic SARS-CoV-2 testing for asymptomatic patients treated at a tertiary care regional radiation oncology network. Radiat Oncol 2021; 16:28. [PMID: 33541359 PMCID: PMC7861151 DOI: 10.1186/s13014-021-01760-2] [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: 12/13/2020] [Accepted: 01/28/2021] [Indexed: 11/10/2022] Open
Abstract
Background Coronavirus disease 2019 (COVID-19) caused by the SARS-CoV-2 virus is a current pandemic. We initiated a program of systematic SARS-CoV-2 polymerase chain reaction (PCR) testing in all asymptomatic patients receiving radiotherapy (RT) at a large radiation oncology network in the Charlotte, NC metropolitan region and report adherence and results of the testing program. Methods Patients undergoing simulation for RT between May 18, 2020 and July 10, 2020 within the Levine Cancer Institute radiation oncology network who were asymptomatic for COVID-19 associated symptoms, without previous positive SARS-CoV-2 testing, and without recent high-risk contacts were included. PCR testing was performed on nasal cavity or nasopharyngeal swab samples. Testing was performed within 2 weeks of RT start (pre-RT) and at least every 4 weeks during RT for patients with prolonged RT courses (intra-RT). An automated task based process using the oncology electronic medical record (EMR) was developed specifically for this purpose. Results A total of 604 unique patients were included in the cohort. Details on testing workflow and implementation are described herein. Pre-RT PCR testing was performed in 573 (94.9%) patients, of which 4 (0.7%) were positive. The adherence rate to intra-RT testing overall was 91.6%. Four additional patients (0.7%) tested positive during their RT course, of whom 3 were tested due to symptom development and 1 was asymptomatic and identified via systematic testing. A total of 8 (1.3%) patients tested positive overall. There were no known cases of SARS-CoV-2 transmission from infected patients to clinic staff and/or other patients. Conclusions We detailed the workflows used to implement systematic SARS-CoV-2 for asymptomatic patients at a large radiation oncology network. Adherence rates for pre-RT and intra-RT testing were high using this process. This information allowed for appropriate delay in initiating RT, minimizing the occurrence of RT treatment interruptions, and no known cases of transmission from infected patients to clinic staff and/or other patients.
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Affiliation(s)
- Roshan S Prabhu
- Levine Cancer Institute, Atrium Health, 1021 Morehead Medical Drive, Suite 1000, Charlotte, NC, 28204, USA. .,Southeast Radiation Oncology Group, Charlotte, NC, USA.
| | - Reshika Dhakal
- Levine Cancer Institute, Atrium Health, 1021 Morehead Medical Drive, Suite 1000, Charlotte, NC, 28204, USA
| | - Amy S Hicks
- Levine Cancer Institute, Atrium Health, 1021 Morehead Medical Drive, Suite 1000, Charlotte, NC, 28204, USA
| | - James McBride
- Levine Cancer Institute, Atrium Health, 1021 Morehead Medical Drive, Suite 1000, Charlotte, NC, 28204, USA
| | - Alicia L Patrick
- Levine Cancer Institute, Atrium Health, 1021 Morehead Medical Drive, Suite 1000, Charlotte, NC, 28204, USA
| | - Christopher D Corso
- Levine Cancer Institute, Atrium Health, 1021 Morehead Medical Drive, Suite 1000, Charlotte, NC, 28204, USA.,Southeast Radiation Oncology Group, Charlotte, NC, USA
| | - Tomain Murphy
- Levine Cancer Institute, Atrium Health, 1021 Morehead Medical Drive, Suite 1000, Charlotte, NC, 28204, USA
| | - Melissa Thonen
- Levine Cancer Institute, Atrium Health, 1021 Morehead Medical Drive, Suite 1000, Charlotte, NC, 28204, USA
| | - Edward H Lipford
- Levine Cancer Institute, Atrium Health, 1021 Morehead Medical Drive, Suite 1000, Charlotte, NC, 28204, USA
| | - Derek Raghavan
- Levine Cancer Institute, Atrium Health, 1021 Morehead Medical Drive, Suite 1000, Charlotte, NC, 28204, USA
| | - Stuart H Burri
- Levine Cancer Institute, Atrium Health, 1021 Morehead Medical Drive, Suite 1000, Charlotte, NC, 28204, USA.,Southeast Radiation Oncology Group, Charlotte, NC, USA
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Burri SH, Ward MC, Prabhu RS. Hobgoblins, Iron Lungs, and Surgical Perturbation Failure? Int J Radiat Oncol Biol Phys 2020; 108:996-998. [DOI: 10.1016/j.ijrobp.2020.06.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 06/12/2020] [Accepted: 06/17/2020] [Indexed: 01/17/2023]
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Prabhu RS, Corso CD, Ward MC, Heinzerling JH, Dhakal R, Buchwald ZS, Patel KR, Asher AL, Sumrall AL, Burri SH. The effect of adjuvant radiotherapy on overall survival in adults with intracranial ependymoma. Neurooncol Pract 2020; 7:391-399. [PMID: 32765890 PMCID: PMC7393282 DOI: 10.1093/nop/npz070] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Adult intracranial ependymoma is rare, and the role for adjuvant radiotherapy (RT) is not well defined. METHODS We used the National Cancer Database (NCDB) to select adults (age ≥ 22 years) with grade 2 to 3 intracranial ependymoma status postresection between 2004 and 2015 and treated with adjuvant RT vs observation. Four cohorts were generated: (1) all patients, (2) grade 2 only, (3) grade 2 status post-subtotal resection only, (4) and grade 3 only. The association between adjuvant RT use and overall survival (OS) was assessed using multivariate Cox and propensity score matched analyses. RESULTS A total of 1787 patients were included in cohort 1, of which 856 patients (48%) received adjuvant RT and 931 (52%) were observed. Approximately two-thirds of tumors were supratentorial and 80% were grade 2. Cohorts 2, 3, and 4 included 1471, 345, and 316 patients, respectively. There was no significant association between adjuvant RT use and OS in multivariate or propensity score matched analysis in any of the cohorts. Older age, male sex, urban location, higher comorbidity score, earlier year of diagnosis, and grade 3 were associated with increased risk of death. CONCLUSIONS This large NCDB study did not demonstrate a significant association between adjuvant RT use and OS for adults with intracranial ependymoma, including for patients with grade 2 ependymoma status post-subtotal resection. The conflicting results regarding the efficacy of adjuvant RT in this patient population highlight the need for high-quality studies to guide therapy recommendations in adult ependymoma.
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Affiliation(s)
- Roshan S Prabhu
- Levine Cancer Institute, Atrium Health, Charlotte, NC
- Southeast Radiation Oncology Group, Charlotte, NC
| | - Christopher D Corso
- Levine Cancer Institute, Atrium Health, Charlotte, NC
- Southeast Radiation Oncology Group, Charlotte, NC
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20
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Buchwald ZS, Tian S, Rossi M, Smith GH, Switchenko J, Hauenstein JE, Moreno CS, Press RH, Prabhu RS, Zhong J, Saxe DF, Neill SG, Olson JJ, Crocker IR, Curran WJ, Shu HKG. Genomic copy number variation correlates with survival outcomes in WHO grade IV glioma. Sci Rep 2020; 10:7355. [PMID: 32355162 PMCID: PMC7192941 DOI: 10.1038/s41598-020-63789-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 08/12/2019] [Accepted: 04/06/2020] [Indexed: 12/12/2022] Open
Abstract
Allele-specific copy number analysis of tumors (ASCAT) assesses copy number variations (CNV) while accounting for aberrant cell fraction and tumor ploidy. We evaluated if ASCAT-assessed CNV are associated with survival outcomes in 56 patients with WHO grade IV gliomas. Tumor data analyzed by Affymetrix OncoScan FFPE Assay yielded the log ratio (R) and B-allele frequency (BAF). Input into ASCAT quantified CNV using the segmentation function to measure copy number inflection points throughout the genome. Quantified CNV was reported as log R and BAF segment counts. Results were confirmed on The Cancer Genome Atlas (TCGA) glioblastoma dataset. 25 (44.6%) patients had MGMT hyper-methylated tumors, 6 (10.7%) were IDH1 mutated. Median follow-up was 36.4 months. Higher log R segment counts were associate with longer progression-free survival (PFS) [hazard ratio (HR) 0.32, p < 0.001], and overall survival (OS) [HR 0.45, p = 0.01], and was an independent predictor of PFS and OS on multivariable analysis. Higher BAF segment counts were linked to longer PFS (HR 0.49, p = 0.022) and OS (HR 0.49, p = 0.052). In the TCGA confirmation cohort, longer 12-month OS was seen in patients with higher BAF segment counts (62.3% vs. 51.9%, p = 0.0129) and higher log R (63.6% vs. 55.2%, p = 0.0696). Genomic CNV may be a novel prognostic biomarker for WHO grade IV glioma patient outcomes.
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Affiliation(s)
- Zachary S Buchwald
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA.
| | - Sibo Tian
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | | | - Geoffrey H Smith
- Pathology & Laboratory Medicine, Emory University, Atlanta, GA, USA
| | - Jeffrey Switchenko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Carlos S Moreno
- Pathology & Laboratory Medicine, Emory University, Atlanta, GA, USA
| | - Robert H Press
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Roshan S Prabhu
- Southeast Radiation Oncology Group, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC, USA
| | - Jim Zhong
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Debra F Saxe
- Pathology & Laboratory Medicine, Emory University, Atlanta, GA, USA
| | - Stewart G Neill
- Pathology & Laboratory Medicine, Emory University, Atlanta, GA, USA
| | - Jeffrey J Olson
- Department of Neurosurgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Ian R Crocker
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Walter J Curran
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Hui-Kuo G Shu
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
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21
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Press RH, Zhang C, Chowdhary M, Prabhu RS, Ferris MJ, Xu KM, Olson JJ, Eaton BR, Shu HKG, Curran WJ, Crocker IR, Patel KR. Hemorrhagic and Cystic Brain Metastases Are Associated With an Increased Risk of Leptomeningeal Dissemination After Surgical Resection and Adjuvant Stereotactic Radiosurgery. Neurosurgery 2020; 85:632-641. [PMID: 30335175 DOI: 10.1093/neuros/nyy436] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 08/19/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Brain metastases (BM) treated with surgical resection and focal postoperative radiotherapy have been associated with an increased risk of subsequent leptomeningeal dissemination (LMD). BMs with hemorrhagic and/or cystic features contain less solid components and may therefore be at higher risk for tumor spillage during resection. OBJECTIVE To investigate the association between hemorrhagic and cystic BMs treated with surgical resection and stereotactic radiosurgery and the risk of LMD. METHODS One hundred thirty-four consecutive patients with a single resected BM treated with adjuvant stereotactic radiosurgery from 2008 to 2016 were identified. Intracranial outcomes including LMD were calculated using the cumulative incidence model with death as a competing risk. Univariable analysis and multivariable analysis were assessed using the Fine & Gray model. Overall survival was analyzed using the Kaplan-Meier method. RESULTS Median imaging follow-up was 14.2 mo (range 2.5-132 mo). Hemorrhagic and cystic features were present in 46 (34%) and 32 (24%) patients, respectively. The overall 12- and 24-mo cumulative incidence of LMD with death as a competing risk was 11.0 and 22.4%, respectively. On multivariable analysis, hemorrhagic features (hazard ratio [HR] 2.34, P = .015), cystic features (HR 2.34, P = .013), breast histology (HR 3.23, P = .016), and number of brain metastases >1 (HR 2.09, P = .032) were independently associated with increased risk of LMD. CONCLUSION Hemorrhagic and cystic features were independently associated with increased risk for postoperative LMD. Patients with BMs containing these intralesion features may benefit from alternative treatment strategies to mitigate this risk.
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Affiliation(s)
- Robert H Press
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Chao Zhang
- Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Mudit Chowdhary
- Department of Radiation Oncology, Rush University, Chicago, Illinois
| | - Roshan S Prabhu
- Southeast Radiation Oncology Group, Levine Cancer Institute, Charlotte, North Carolina
| | - Matthew J Ferris
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Karen M Xu
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Jeffrey J Olson
- Department of Neurological Surgery, Emory University, Atlanta, Georgia
| | - Bree R Eaton
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Hui-Kuo G Shu
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Walter J Curran
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Ian R Crocker
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Kirtesh R Patel
- Department of Therapeutic Radiology, Smilow Cancer Center, Yale University, New Haven, Connecticut
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Ryken TC, Kuo JS, Prabhu RS, Sherman JH, Kalkanis SN, Olson JJ. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Role of Steroids in the Treatment of Adults With Metastatic Brain Tumors. Neurosurgery 2019; 84:E189-E191. [PMID: 30629207 DOI: 10.1093/neuros/nyy546] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [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: 08/02/2018] [Accepted: 10/31/2018] [Indexed: 12/15/2022] Open
Abstract
QUESTION Do steroids improve neurological symptoms and/or quality of life in patients with metastatic brain tumors compared to supportive care only or other treatment options? If steroids are given, what dose should be used? TARGET POPULATION These recommendations apply to adults diagnosed with brain metastases. RECOMMENDATIONS STEROID THERAPY VERSUS NO STEROID THERAPYAsymptomatic brain metastases patients without mass effectInsufficient evidence exists to make a treatment recommendation for this clinical scenario.Brain metastases patients with mild symptoms related to mass effect Level 3: Corticosteroids are recommended to provide temporary symptomatic relief of symptoms related to increased intracranial pressure and edema secondary to brain metastases. It is recommended for patients who are symptomatic from metastatic disease to the brain that a starting dose of 4 to 8 mg/d of dexamethasone be considered.Brain metastases patients with moderate to severe symptoms related to mass effect Level 3: Corticosteroids are recommended to provide temporary symptomatic relief of symptoms related to increased intracranial pressure and edema secondary to brain metastases. If patients exhibit severe symptoms consistent with increased intracranial pressure, it is recommended that higher doses such as 16 mg/d or more be considered. CHOICE OF STEROID Level 3: If corticosteroids are given, dexamethasone is the best drug choice given the available evidence.Duration of Corticosteroid Administration Level 3: Corticosteroids, if given, should be tapered as rapidly as possible but no faster than clinically tolerated, based upon an individualized treatment regimen and a full understanding of the long-term sequelae of corticosteroid therapy.Given the very limited number of studies (2) which met the eligibility criteria for the systematic review, these are the only recommendations that can be offered based on this methodology.The full guideline can be found at https://www.cns.org/guidelines/guidelines-treatment-adults-metastatic-brain-tumors/chapter_7.
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Affiliation(s)
- Timothy C Ryken
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - John S Kuo
- Department of Neurosurgery and Mulva Clinic for the Neurosciences, Dell Medical School, University of Texas at Austin, Austin, Texas
| | - Roshan S Prabhu
- Southeast Radiation Oncology Group, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, North Carolina
| | - Jonathan H Sherman
- Department of Neurosurgery, The George Washington University, Washington, District of Columbia
| | - Steven N Kalkanis
- Department of Neurosurgery, Henry Ford Health System, Detroit, Michigan
| | - Jeffrey J Olson
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
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Gaspar LE, Prabhu RS, Hdeib A, McCracken DJ, Lasker GF, McDermott MW, Kalkanis SN, Olson JJ. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Role of Whole Brain Radiation Therapy in Adults With Newly Diagnosed Metastatic Brain Tumors. Neurosurgery 2019; 84:E159-E162. [PMID: 30629211 DOI: 10.1093/neuros/nyy541] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 10/18/2018] [Indexed: 11/13/2022] Open
Abstract
TARGET POPULATION Adult patients (older than 18 yr of age) with newly diagnosed brain metastases. QUESTION If whole brain radiation therapy (WBRT) is used, is there an optimal dose/fractionation schedule? RECOMMENDATIONS Level 1: A standard WBRT dose/fractionation schedule (ie, 30 Gy in 10 fractions or a biological equivalent dose [BED] of 39 Gy10) is recommended as altered dose/fractionation schedules do not result in significant differences in median survival or local control. Level 3: Due to concerns regarding neurocognitive effects, higher dose per fraction schedules (such as 20 Gy in 5 fractions) are recommended only for patients with poor performance status or short predicted survival. Level 3: WBRT can be recommended to improve progression-free survival for patients with more than 4 brain metastases. QUESTION What impact does tumor histopathology or molecular status have on the decision to use WBRT, the dose fractionation scheme to be utilized, and its outcomes? RECOMMENDATIONS There is insufficient evidence to support the choice of any particular dose/fractionation regimen based on histopathology. Molecular status may have an impact on the decision to delay WBRT in subgroups of patients, but there is not sufficient data to make a more definitive recommendation. QUESTION Separate from survival outcomes, what are the neurocognitive consequences of WBRT, and what steps can be taken to minimize them? RECOMMENDATIONS Level 2: Due to neurocognitive toxicity, local therapy (surgery or SRS) without WBRT is recommended for patients with ≤4 brain metastases amenable to local therapy in terms of size and location. Level 2: Given the association of neurocognitive toxicity with increasing total dose and dose per fraction of WBRT, WBRT doses exceeding 30 Gy given in 10 fractions, or similar biologically equivalent doses, are not recommended, except in patients with poor performance status or short predicted survival. Level 2: If prophylactic cranial irradiation (PCI) is given to prevent brain metastases for small cell lung cancer, the recommended WBRT dose/fractionation regimen is 25 Gy in 10 fractions, and because this can be associated with neurocognitive decline, patients should be told of this risk at the same time they are counseled about the possible survival benefits. Level 3: Patients having WBRT (given for either existing brain metastases or as PCI) should be offered 6 mo of memantine to potentially delay, lessen, or prevent the associated neurocognitive toxicity. QUESTION Does the addition of WBRT after surgical resection or radiosurgery improve progression-free or overall survival outcomes when compared to surgical resection or radiosurgery alone? RECOMMENDATIONS Level 2: WBRT is not recommended in WHO performance status 0 to 2 patients with up to 4 brain metastases because, compared to surgical resection or radiosurgery alone, the addition of WBRT improves intracranial progression-free survival but not overall survival. Level 2: In WHO performance status 0 to 2 patients with up to 4 brain metastases where the goal is minimizing neurocognitive toxicity, as opposed to maximizing progression-free survival and overall survival, local therapy (surgery or radiosurgery) without WBRT is recommended. Level 3: Compared to surgical resection or radiosurgery alone, the addition of WBRT is not recommended for patients with more than 4 brain metastases unless the metastases' volume exceeds 7 cc, or there are more than 15 metastases, or the size or location of the metastases are not amenable to surgical resection or radiosurgery.The full guideline can be found at: https://www.cns.org/guidelines/guidelines-treatment-adults-metastatic-brain-tumors/chapter_3.
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Affiliation(s)
- Laurie E Gaspar
- Department of Radiation Oncology, University of Colorado Denver School of Medicine, Aurora, Colorado
| | - Roshan S Prabhu
- Southeast Radiation Oncology Group and Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Alia Hdeib
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - D Jay McCracken
- Department of Neurosurgery, Emory University, Atlanta, Georgia
| | - George F Lasker
- Departments of Neurological Surgery, Radiation Oncology, Otolaryngology, University of California San Francisco, San Francisco, California
| | - Michael W McDermott
- Departments of Neurological Surgery, Radiation Oncology, Otolaryngology, University of California San Francisco, San Francisco, California
| | - Steven N Kalkanis
- Department of Neurosurgery, Henry Ford Health System, Detroit, Michigan
| | - Jeffrey J Olson
- Department of Neurosurgery, Emory University, Atlanta, Georgia
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24
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Turner BE, Prabhu RS, Burri SH, Brown PD, Pollom EL, Milano MT, Weiss SE, Iv M, Fischbein N, Soliman H, Lo SS, Chao ST, Cox BW, Murphy JD, Li G, Gephart MH, Nagpal S, Atalar B, Azoulay M, Thomas R, Tillman G, Durkee BY, Shah JL, Soltys SG. Nodular Leptomeningeal Disease-A Distinct Pattern of Recurrence After Postresection Stereotactic Radiosurgery for Brain Metastases: A Multi-institutional Study of Interobserver Reliability. Int J Radiat Oncol Biol Phys 2019; 106:579-586. [PMID: 31605786 DOI: 10.1016/j.ijrobp.2019.10.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 09/25/2019] [Accepted: 10/01/2019] [Indexed: 12/21/2022]
Abstract
PURPOSE For brain metastases, surgical resection with postoperative stereotactic radiosurgery is an emerging standard of care. Postoperative cavity stereotactic radiosurgery is associated with a specific, underrecognized pattern of intracranial recurrence, herein termed nodular leptomeningeal disease (nLMD), which is distinct from classical leptomeningeal disease. We hypothesized that there is poor consensus regarding the definition of LMD, and that a formal, self-guided training module will improve interrater reliability (IRR) and validity in diagnosing LMD. METHODS AND MATERIALS Twenty-two physicians at 16 institutions, including 15 physicians with central nervous system expertise, completed a 2-phase survey that included magnetic resonance imaging and treatment information for 30 patients. In the "pretraining" phase, physicians labeled cases using 3 patterns of recurrence commonly reported in prospective studies: local recurrence (LR), distant parenchymal recurrence (DR), and LMD. After a self-directed training module, participating physicians completed the "posttraining" phase and relabeled the 30 cases using the 4 following labels: LR, DR, classical leptomeningeal disease, and nLMD. RESULTS IRR increased 34% after training (Fleiss' Kappa K = 0.41 to K = 0.55, P < .001). IRR increased most among non-central nervous system specialists (+58%, P < .001). Before training, IRR was lowest for LMD (K = 0.33). After training, IRR increased across all recurrence subgroups and increased most for LMD (+67%). After training, ≥27% of cases initially labeled LR or DR were later recognized as nLMD. CONCLUSIONS This study highlights the large degree of inconsistency among clinicians in recognizing nLMD. Our findings demonstrate that a brief self-guided training module distinguishing nLMD can significantly improve IRR across all patterns of recurrence, and particularly in nLMD. To optimize outcomes reporting, prospective trials in brain metastases should incorporate central imaging review and investigator training.
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Affiliation(s)
- Brandon E Turner
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, California
| | - Roshan S Prabhu
- Southeast Radiation Oncology Group, Charlotte, North Carolina; Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Stuart H Burri
- Southeast Radiation Oncology Group, Charlotte, North Carolina; Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Erqi L Pollom
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, California
| | | | | | - Michael Iv
- Department of Neuroimaging and Neurointervention, Stanford University, Stanford, California
| | - Nancy Fischbein
- Department of Neuroimaging and Neurointervention, Stanford University, Stanford, California
| | - Hany Soliman
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Samuel T Chao
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Brett W Cox
- Department of Radiation Medicine, Northwell Health, New York, New York
| | - James D Murphy
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, California
| | - Gordon Li
- Department of Neurosurgery, Stanford School of Medicine, Stanford, California
| | | | - Seema Nagpal
- Department of Neurology, Stanford University, Stanford, California
| | - Banu Atalar
- Department of Radiation Oncology, Acibadem University School of Medicine, Istanbul, Turkey
| | - Melissa Azoulay
- Department of Radiation Oncology, McGill University Health Center, Montreal, Canada
| | - Reena Thomas
- Department of Neurology, Stanford University, Stanford, California
| | - Gayle Tillman
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Ben Y Durkee
- Department of Radiation Oncology, SwedishAmerican, Rockford, Illinois
| | - Jennifer L Shah
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, California.
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25
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Prabhu RS, Turner BE, Asher AL, Marcrom SR, Fiveash JB, Foreman PM, Press RH, Patel KR, Curran WJ, Breen WG, Brown PD, Jethwa KR, Grills IS, Arden JD, Foster LM, Manning MA, Stern JD, Soltys SG, Burri SH. A multi-institutional analysis of presentation and outcomes for leptomeningeal disease recurrence after surgical resection and radiosurgery for brain metastases. Neuro Oncol 2019; 21:1049-1059. [PMID: 30828727 PMCID: PMC6682204 DOI: 10.1093/neuonc/noz049] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [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] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Radiographic leptomeningeal disease (LMD) develops in up to 30% of patients following postoperative stereotactic radiosurgery (SRS) for brain metastases. However, the clinical relevancy of this finding and outcomes after various salvage treatments are not known. METHODS Patients with brain metastases, of which 1 was resected and treated with adjunctive SRS, and who subsequently developed LMD were combined from 7 tertiary care centers. LMD pattern was categorized as nodular (nLMD) or classical ("sugarcoating," cLMD). RESULTS The study cohort was 147 patients. Most patients (60%) were symptomatic at LMD presentation, with cLMD more likely to be symptomatic than nLMD (71% vs. 51%, P = 0.01). Salvage therapy was whole brain radiotherapy (WBRT) alone (47%), SRS (27%), craniospinal radiotherapy (RT) (10%), and other (16%), with 58% receiving a WBRT-containing regimen. WBRT was associated with lower second LMD recurrence compared with focal RT (40% vs 68%, P = 0.02). Patients with nLMD had longer median overall survival (OS) than those with cLMD (8.2 vs 3.3 mo, P < 0.001). On multivariable analysis for OS, pattern of initial LMD (nodular vs classical) was significant, but type of salvage RT (WBRT vs focal) was not. CONCLUSIONS Nodular LMD is a distinct pattern of LMD associated with postoperative SRS that is less likely to be symptomatic and has better OS outcomes than classical "sugarcoating" LMD. Although focal RT demonstrated increased second LMD recurrence compared with WBRT, there was no associated OS detriment. Focal cranial RT for nLMD recurrence after surgery and SRS for brain metastases may be a reasonable alternative to WBRT.
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Affiliation(s)
- Roshan S Prabhu
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
- Southeast Radiation Oncology Group, Charlotte, North Carolina
| | - Brandon E Turner
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Anthony L Asher
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
- Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina
| | | | - John B Fiveash
- University of Alabama at Birmingham, Birmingham, Alabama
| | - Paul M Foreman
- University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert H Press
- Winship Cancer Institute of Emory University, Atlanta, Georgia
| | | | - Walter J Curran
- Winship Cancer Institute of Emory University, Atlanta, Georgia
| | | | | | | | | | | | - Lauren M Foster
- Oakland University William Beaumont School of Medicine, Auburn Hills, Michigan
| | | | - Joseph D Stern
- Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina
- Cone Health Cancer Center, Greensboro, North Carolina
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Stuart H Burri
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
- Southeast Radiation Oncology Group, Charlotte, North Carolina
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Jairam V, Kann BH, Park HS, Miccio JA, Beckta JM, Yu JB, Prabhu RS, Gao SJ, Mehta MP, Curran WJ, Bindra RS, Contessa JN, Patel KR. Defining an Intermediate-risk Group for Low-grade Glioma: A National Cancer Database Analysis. Anticancer Res 2019; 39:2911-2918. [PMID: 31177129 DOI: 10.21873/anticanres.13420] [Citation(s) in RCA: 5] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 05/07/2019] [Accepted: 05/08/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND RTOG 9802 identified a cohort of patients with age less than 40 years and undergoing gross total resection as having low-risk, low-grade glioma (LR-LGG). European Organization for Research and Treatment of Cancer studies have demonstrated additional prognostic features in this group. The aim of this study was to analyze clinical factors associated with overall survival (OS), identify a potentially higher risk group within LR-LGG, and investigate patterns of care for adjuvant therapy. MATERIALS AND METHODS Patients with LR-LGG diagnosed between 2010 to 2013 were identified in the National Cancer Database. Kaplan-Meier method was used to analyze OS. Propensity score matching and multivariate analysis were utilized to adjust for differences in cohorts. RESULTS A total of 1,032 patients with LR-LGG were identified. Histological breakdown was 42.0% astrocytoma, 33.2% oligodendroglioma, and 25.8% mixed. Median follow-up was 3.9 years; median pre-operative tumor size was 4.0 cm. Overall, 834 (80.8%) underwent observation and 198 (19.2%) received adjuvant therapy. Tumor size >5 cm predicted for receipt of adjuvant therapy on regression analyses (OR=2.02, p=0.001). On multivariate analysis, tumor size >5 cm (hazard ratio=1.95) and non-oligodendroglioma histology (hazard ratio=2.50) were associated with inferior OS (both p<0.05). For patients with both poor prognostic features (a subset we consider "intermediate-risk"), 5-year OS was 78.4%, compared to 94.1% for all other low-risk patients (p<0.001). After propensity score matching, the intermediate-risk group continued to be associated with worse 5-year OS: 80.5% vs. 94.0%, p=0.004. CONCLUSION Due to inferior OS for patients with LR-LGG with >5 cm, non-oligodendroglioma tumors, we propose an 'intermediate-risk' clinical classification for this subset.
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Affiliation(s)
- Vikram Jairam
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, U.S.A.
| | - Benjamin H Kann
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, U.S.A
| | - Henry S Park
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, U.S.A
| | - Joseph A Miccio
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, U.S.A
| | - Jason M Beckta
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, U.S.A
| | - James B Yu
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, U.S.A
| | - Roshan S Prabhu
- Southeast Radiation Oncology Group, Levine Cancer Institute, Charlotte, NC, U.S.A
| | - Sarah J Gao
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, U.S.A
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, U.S.A
| | - Walter J Curran
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, U.S.A
| | - Ranjit S Bindra
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, U.S.A
| | - Joseph N Contessa
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, U.S.A
| | - Kirtesh R Patel
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, U.S.A
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Lorimer PD, Motz BM, Watson M, Trufan SJ, Prabhu RS, Hill JS, Salo JC. Enteral Feeding Access Has an Impact on Outcomes for Patients with Esophageal Cancer Undergoing Esophagectomy: An Analysis of SEER-Medicare. Ann Surg Oncol 2019; 26:1311-1319. [PMID: 30783851 DOI: 10.1245/s10434-019-07230-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Optimal nutrition after esophagectomy is challenging due to alterations in eating, both from the tumor and during surgical recovery. Enteral nutrition via feeding tube is commonly used. The impact of feeding tubes on post-esophagectomy outcomes was examined in a large national data set. METHODS Patients with esophageal cancer (1998-2013) undergoing esophagectomy were extracted from the Surveillance Epidemiology and End Results-Medicare database. Chi-square and t tests were used to compare categorical and continuous variables. Time trend analyses were performed with Cochran-Armitage survival using log-rank and multivariable analysis with generalized linear modeling. RESULTS The study examined 2495 patients. The majority had enteral feeding access (71%, n = 1794) during the perioperative period. Mortality among the patients with feeding tubes was lower at 30 days (5.4% vs 8.4%), 60 days (9.0% vs 13.0%), and 90 days (12.2% vs 15.8%). In the multivariable analysis, the patients with feeding tubes had improved short-term survival at 30 days (odds ratio [OR], 0.65, 95% confidence interval [CI], 0.46-0.93), 60 days (OR, 0.64; 95% CI, 0.49-0.85), and 90 days (OR, 0.70; 95% CI, 0.54-0.90). The hospital stay was shorter for the patients undergoing enteral feeding tube placement (17.9 vs 19.5 days; p = 0.04). Discharge destination (home vs health care facility) showed no difference. CONCLUSIONS Feeding tubes in patients undergoing esophagectomy were associated with an increase in short-term survival up to 90 days after surgery. Feeding tube placement was not associated with higher rates of non-home discharges and did not prolong the hospital stay.
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Affiliation(s)
- Patrick D Lorimer
- Division of Surgical Oncology, Department of Surgery, Carolinas Medical Center, Levine Cancer Institute, Charlotte, NC, USA
| | - Benjamin M Motz
- Division of Surgical Oncology, Department of Surgery, Carolinas Medical Center, Levine Cancer Institute, Charlotte, NC, USA
| | - Michael Watson
- Division of Surgical Oncology, Department of Surgery, Carolinas Medical Center, Levine Cancer Institute, Charlotte, NC, USA
| | - Sally J Trufan
- Department of Biostatistics, Carolinas Medical Center, Levine Cancer Institute, Charlotte, NC, USA
| | | | - Joshua S Hill
- Division of Surgical Oncology, Department of Surgery, Carolinas Medical Center, Levine Cancer Institute, Charlotte, NC, USA
| | - Jonathan C Salo
- Division of Surgical Oncology, Department of Surgery, Carolinas Medical Center, Levine Cancer Institute, Charlotte, NC, USA.
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Prabhu RS, Miller KR, Asher AL, Heinzerling JH, Moeller BJ, Lankford SP, McCammon RJ, Fasola CE, Patel KR, Press RH, Sumrall AL, Ward MC, Burri SH. Preoperative stereotactic radiosurgery before planned resection of brain metastases: updated analysis of efficacy and toxicity of a novel treatment paradigm. J Neurosurg 2018; 131:1-8. [PMID: 30554174 DOI: 10.3171/2018.7.jns181293] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 07/16/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEPreoperative stereotactic radiosurgery (SRS) is a feasible alternative to postoperative SRS and may lower the risk of radiation necrosis (RN) and leptomeningeal disease (LMD) recurrence. The study goal was to report the efficacy and toxicity of preoperative SRS in an expanded patient cohort with longer follow-up period relative to prior reports.METHODSThe records for patients with brain metastases treated with preoperative SRS and planned resection were reviewed. Patients with classically radiosensitive tumors, planned adjuvant whole brain radiotherapy, or no cranial imaging at least 1 month after surgery were excluded. Preoperative SRS dose was based on lesion size and was reduced approximately 10-20% from standard dosing. Surgery generally followed within 48 hours.RESULTSThe study cohort consisted of 117 patients with 125 lesions treated with single-fraction preoperative SRS and planned resection. Of the 117 patients, 24 patients were enrolled in an initial prospective trial; the remaining 93 cases were consecutively treated patients who were retrospectively reviewed. Most patients had a single brain metastasis (70.1%); 42.7% had non-small cell lung cancer, 18.8% had breast cancer, 15.4% had melanoma, and 11.1% had renal cell carcinoma. Gross total resection was performed in 95.2% of lesions. The median time from SRS to surgery was 2 days, the median SRS dose was 15 Gy, and the median gross tumor volume was 8.3 cm3. Event cumulative incidence at 2 years was as follows: cavity local recurrence (LR), 25.1%; distant brain failure, 60.2%; LMD, 4.3%; and symptomatic RN, 4.8%. The median overall survival (OS) and 2-year OS rate were 17.2 months and 36.7%, respectively. Subtotal resection (STR, n = 6) was significantly associated with increased risk of cavity LR (hazard ratio [HR] 6.67, p = 0.008) and worsened OS (HR 2.63, p = 0.05) in multivariable analyses.CONCLUSIONSThis expanded and updated analysis confirms that single-fraction preoperative SRS confers excellent cavity local control with very low risk of RN or LMD. Preoperative SRS has several potential advantages compared to postoperative SRS, including reduced risk of RN due to smaller irradiated volume without need for cavity margin expansion and reduced risk of LMD due to sterilization of tumor cells prior to spillage at the time of surgery. Subtotal resection, though infrequent, is associated with significantly worse cavity LR and OS. Based on these results, a randomized trial of preoperative versus postoperative SRS is being designed.
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Affiliation(s)
- Roshan S Prabhu
- 1Levine Cancer Institute, Atrium Health
- 2Southeast Radiation Oncology Group; and
| | | | - Anthony L Asher
- 1Levine Cancer Institute, Atrium Health
- 3Carolina Neurosurgical and Spine Associates, Charlotte, North Carolina
| | - John H Heinzerling
- 1Levine Cancer Institute, Atrium Health
- 2Southeast Radiation Oncology Group; and
| | - Benjamin J Moeller
- 1Levine Cancer Institute, Atrium Health
- 2Southeast Radiation Oncology Group; and
| | - Scott P Lankford
- 1Levine Cancer Institute, Atrium Health
- 2Southeast Radiation Oncology Group; and
| | - Robert J McCammon
- 1Levine Cancer Institute, Atrium Health
- 2Southeast Radiation Oncology Group; and
| | - Carolina E Fasola
- 1Levine Cancer Institute, Atrium Health
- 2Southeast Radiation Oncology Group; and
| | - Kirtesh R Patel
- 4Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut; and
| | - Robert H Press
- 5Department of Radiation Oncology, Emory University and Winship Cancer Institute, Atlanta, Georgia
| | | | - Matthew C Ward
- 1Levine Cancer Institute, Atrium Health
- 2Southeast Radiation Oncology Group; and
| | - Stuart H Burri
- 1Levine Cancer Institute, Atrium Health
- 2Southeast Radiation Oncology Group; and
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Prabhu RS, Patel KR, Press RH, Soltys SG, Brown PD, Mehta MP, Asher AL, Burri SH. Preoperative Vs Postoperative Radiosurgery For Resected Brain Metastases: A Review. Neurosurgery 2018; 84:19-29. [DOI: 10.1093/neuros/nyy146] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 03/25/2018] [Indexed: 01/27/2023] Open
Affiliation(s)
- Roshan S Prabhu
- Southeast Radiation Oncology Group, Charlotte, North Carolina
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Kirtesh R Patel
- Department of Radiation Oncology, Yale University, New Haven, Connecticut
| | - Robert H Press
- Department of Radiation Oncology, Emory University and Winship Cancer Institute, Atlanta, Georgia
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Anthony L Asher
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
- Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina
| | - Stuart H Burri
- Southeast Radiation Oncology Group, Charlotte, North Carolina
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
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Patel KR, Burri SH, Asher AL, Crocker IR, Fraser RW, Zhang C, Chen Z, Kandula S, Zhong J, Press RH, Olson JJ, Oyesiku NM, Wait SD, Curran WJ, Shu HKG, Prabhu RS. Comparing Preoperative With Postoperative Stereotactic Radiosurgery for Resectable Brain Metastases: A Multi-institutional Analysis. Neurosurgery 2017; 79:279-85. [PMID: 26528673 DOI: 10.1227/neu.0000000000001096] [Citation(s) in RCA: 133] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Stereotactic radiosurgery (SRS) is an increasingly common modality used with surgery for resectable brain metastases (BM). OBJECTIVE To present a multi-institutional retrospective comparison of outcomes and toxicities of preoperative SRS (Pre-SRS) and postoperative SRS (Post-SRS). METHODS We reviewed the records of patients who underwent resection of BM and either Pre-SRS or Post-SRS alone between 2005 and 2013 at 2 institutions. Pre-SRS used a dose-reduction strategy based on tumor size, with planned resection within 48 hours. Cumulative incidence with competing risks was used to determine estimated rates. RESULTS A total of 180 patients underwent surgical resection for 189 BM: 66 (36.7%) underwent Pre-SRS and 114 (63.3%) underwent Post-SRS. Baseline patient characteristics were balanced except for higher rates of performance status 0 (62.1% vs 28.9%, P < .001) and primary breast cancer (27.2% vs 10.5%, P = .010) for Pre-SRS. Pre-SRS had lower median planning target volume margin (0 mm vs 2 mm) and peripheral dose (14.5 Gy vs 18 Gy), but similar gross tumor volume (8.3 mL vs 9.2 mL, P = .85). The median imaging follow-up period was 24.6 months for alive patients. Multivariable analyses revealed no difference between groups for overall survival (P = .1), local recurrence (P = .24), and distant brain recurrence (P = .75). Post-SRS was associated with significantly higher rates of leptomeningeal disease (2 years: 16.6% vs 3.2%, P = .010) and symptomatic radiation necrosis (2 years: 16.4% vs 4.9%, P = .010). CONCLUSION Pre-SRS and Post-SRS for resected BM provide similarly favorable rates of local recurrence, distant brain recurrence, and overall survival, but with significantly lower rates of symptomatic radiation necrosis and leptomeningeal disease in the Pre-SRS cohort. A prospective clinical trial comparing these treatment approaches is warranted. ABBREVIATIONS BM, brain metastasesCI, confidence intervalCTV, clinical target volumeDBR, distant brain recurrenceGTV, gross tumor volumeLC, local controlLMD, leptomeningeal diseaseLR, local recurrenceMVA, multivariable analysisOS, overall survivalPost-SRS, postoperative stereotactic radiosurgeryPre-SRS, preoperative stereotactic radiosurgeryPTV, planning target volumeRN, radiation necrosisSRN, symptomatic radiation necrosisSRS, stereotactic radiosurgeryWBRT, whole-brain radiation therapy.
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Affiliation(s)
- Kirtesh R Patel
- *Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia; ‡Southeast Radiation Oncology Group, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, North Carolina; §Carolina Neurosurgery and Spine Associates, Levine Cancer Institute, Charlotte, North Carolina; ¶Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, Georgia; ‖Department of Neurological Surgery, Emory University, Atlanta, Georgia
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Lorimer PD, Motz BM, Kirks RC, Boselli DM, Walsh KK, Prabhu RS, Hill JS, Salo JC. Pathologic Complete Response Rates After Neoadjuvant Treatment in Rectal Cancer: An Analysis of the National Cancer Database. Ann Surg Oncol 2017; 24:2095-2103. [PMID: 28534080 DOI: 10.1245/s10434-017-5873-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Pathologic complete response (pCR) of rectal cancer following neoadjuvant therapy is associated with decreased local recurrence and increased overall survival. This study utilizes a national dataset to identify predictors of pCR in patients with rectal cancer. METHODS The National Cancer Database was queried for patients with nonmetastatic rectal cancer (2004-2014) who underwent neoadjuvant therapy and surgical resection. Unadjusted associations were assessed using rank-sum tests and χ 2 tests where appropriate. Backward elimination and forward selection multivariable logistic regression models were created to determine the relationship of annual surgical volume with pCR rate, adjusting for preoperative characteristics and radiation-surgery interval. Statistical tests were two-sided, with a significance level of p ≤ 0.05. Analyses were performed using SAS version 9.4. RESULTS A total of 27,532 patients from 1179 participating hospitals met the inclusion criteria. Generalized linear mixed models demonstrated that the odds of achieving pCR was independently associated with more recent diagnosis, female sex, private insurance, lower grade, lower clinical T classification, lower clinical N classification, increasing interval between the end of radiation and surgery, and treatment at higher-volume institutions. CONCLUSIONS pCR was associated with favorable tumor factors, insurance status, time between radiation and surgery, and institutional volume. It is not clear what is driving the higher rates of pCR at high-volume institutions. Research targeted at understanding processes that are associated with pCR in high-volume institutions is needed so that similar results can be achieved across the spectrum of facilities caring for patients in this population.
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Affiliation(s)
- Patrick D Lorimer
- Division of Surgical Oncology, Department of Surgery, Carolinas Medical Center, Levine Cancer Institute, Charlotte, NC, USA
| | - Benjamin M Motz
- Division of Surgical Oncology, Department of Surgery, Carolinas Medical Center, Levine Cancer Institute, Charlotte, NC, USA
| | - Russell C Kirks
- Division of Surgical Oncology, Department of Surgery, Carolinas Medical Center, Levine Cancer Institute, Charlotte, NC, USA
| | - Danielle M Boselli
- Department of Biostatistics, Carolinas Medical Center, Levine Cancer Institute, Charlotte, NC, USA
| | - Kendall K Walsh
- Division of Surgical Oncology, Department of Surgery, Carolinas Medical Center, Levine Cancer Institute, Charlotte, NC, USA
| | - Roshan S Prabhu
- Department of Radiation Oncology, Carolinas Medical Center, Levine Cancer Institute, Charlotte, NC, USA
| | - Joshua S Hill
- Division of Surgical Oncology, Department of Surgery, Carolinas Medical Center, Levine Cancer Institute, Charlotte, NC, USA
| | - Jonathan C Salo
- Division of Surgical Oncology, Department of Surgery, Carolinas Medical Center, Levine Cancer Institute, Charlotte, NC, USA.
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32
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Prabhu RS, Press RH, Patel KR, Boselli DM, Symanowski JT, Lankford SP, McCammon RJ, Moeller BJ, Heinzerling JH, Fasola CE, Asher AL, Sumrall AL, Buchwald ZS, Curran WJ, Shu HKG, Crocker I, Burri SH. Single-Fraction Stereotactic Radiosurgery (SRS) Alone Versus Surgical Resection and SRS for Large Brain Metastases: A Multi-institutional Analysis. Int J Radiat Oncol Biol Phys 2017; 99:459-467. [PMID: 28871997 DOI: 10.1016/j.ijrobp.2017.04.006] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 02/22/2017] [Accepted: 04/03/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE Stereotactic radiosurgery (SRS) dose is limited by brain metastasis (BM) size. The study goal was to retrospectively determine whether there is a benefit for intracranial outcomes and overall survival (OS) for gross total resection with single-fraction SRS versus SRS alone for patients with large BMs. METHODS AND MATERIALS A large BM was defined as ≥4 cm3 (2 cm in diameter) prior to the study. We reviewed the records of consecutive patients treated with single-fraction SRS alone or surgery with preoperative or postoperative SRS between 2005 and 2013 from 2 institutions. RESULTS Overall, 213 patients with 223 treated large BMs were included; 66 BMs (30%) were treated with SRS alone and 157 (70%) with surgery and SRS (63 preoperatively and 94 postoperatively). The groups (SRS vs surgery and SRS) were well balanced except regarding lesion volume (median, 5.9 cm3 vs 9.6 cm3; P<.001), median number of BMs (1.5 vs 1, P=.002), median SRS dose (18 Gy vs 15 Gy, P<.001), and prior whole-brain radiation therapy (33% vs 5%, P<.001). The local recurrence (LR) rate was significantly lower with surgery and SRS (1-year LR rate, 36.7% vs 20.5%; P=.007). There was no difference in radiation necrosis (RN) by resection status, but there was a significantly increased RN rate with postoperative SRS versus with preoperative SRS and with SRS alone (1-year RN rate, 22.6% vs 5% and 12.3%, respectively; P<.001). OS was significantly higher with surgery and SRS (2-year OS rate, 38.9% vs 19.8%; P=.01). Both multivariate adjusted analyses and propensity score-matched analyses demonstrated similar results. CONCLUSIONS In this retrospective study, gross total resection with SRS was associated with significantly reduced LR compared with SRS alone for patients with large BMs. Postoperative SRS was associated with the highest rate of RN. Surgical resection with SRS may improve outcomes in patients with a limited number of large BMs compared with SRS alone. Further studies are warranted.
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Affiliation(s)
- Roshan S Prabhu
- Southeast Radiation Oncology Group, Levine Cancer Institute, Charlotte, North Carolina.
| | - Robert H Press
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Kirtesh R Patel
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Danielle M Boselli
- Department of Cancer Biostatistics, Levine Cancer Institute, Carolinas HealthCare System, Charlotte, North Carolina
| | - James T Symanowski
- Department of Cancer Biostatistics, Levine Cancer Institute, Carolinas HealthCare System, Charlotte, North Carolina
| | - Scott P Lankford
- Southeast Radiation Oncology Group, Levine Cancer Institute, Charlotte, North Carolina
| | - Robert J McCammon
- Southeast Radiation Oncology Group, Levine Cancer Institute, Charlotte, North Carolina
| | - Benjamin J Moeller
- Southeast Radiation Oncology Group, Levine Cancer Institute, Charlotte, North Carolina
| | - John H Heinzerling
- Southeast Radiation Oncology Group, Levine Cancer Institute, Charlotte, North Carolina
| | - Carolina E Fasola
- Southeast Radiation Oncology Group, Levine Cancer Institute, Charlotte, North Carolina
| | - Anthony L Asher
- Carolina Neurosurgery and Spine Associates, Levine Cancer Institute, Charlotte, North Carolina
| | - Ashley L Sumrall
- Department of Oncology, Levine Cancer Institute, Carolinas HealthCare System, Charlotte, North Carolina
| | - Zachary S Buchwald
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Walter J Curran
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Hui-Kuo G Shu
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Ian Crocker
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Stuart H Burri
- Southeast Radiation Oncology Group, Levine Cancer Institute, Charlotte, North Carolina
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Abstract
Biliary tract carcinomas are relatively rare, but are increasingly diagnosed. They comprise several anatomically contiguous sites, so are often grouped together, but they do appear to represent distinct diseases, in part because of anatomical and surgical considerations. Complete upfront surgical resection is generally difficult because these cancers are often diagnosed at relatively advanced stages of disease. Thus, adjuvant therapy is often considered. This paper will review the evidence underpinning current recommendations for adjuvant therapy in biliary carcinomas.
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Affiliation(s)
- Roshan S Prabhu
- Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC, USA
| | - Jimmy Hwang
- Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC, USA
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34
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Patel KR, Prabhu RS, Switchenko JM, Chowdhary M, Craven C, Mendoza P, Danish H, Grossniklaus HE, Aaberg TM, Aaberg T, Reddy S, Butker E, Bergstrom C, Crocker IR. Visual acuity, oncologic, and toxicity outcomes with 103Pd vs. 125I plaque treatment for choroidal melanoma. Brachytherapy 2017; 16:646-653. [PMID: 28262517 DOI: 10.1016/j.brachy.2017.01.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 01/09/2017] [Accepted: 01/09/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE To evaluate outcomes of choroidal melanoma patients treated with 125I or 103Pd plaque brachytherapy. METHODS AND MATERIALS From 1993 to 2012, our institution treated 160 patients with 103Pd (56.1%) and 125 patients with 125I (43.9%) plaque brachytherapy. Tumor outcomes, visual acuity (VA), and toxicity were compared. Multivariate analyses (MVAs) and propensity score analysis were used to help address differences in baseline characteristics. RESULTS Median followup was longer for 125I patients, 52.7 vs. 43.5 months (p < 0.01). At baseline, 103Pd patients had lower rates of VA worse than 20/200 (4.4% vs. 16%, p = 0.002), T3-T4 tumors (17.5% vs. 32.8%, p = 0.03), and transpupillary thermotherapy use (3.1% vs. 9.6%, p = 0.001). Both 103Pd and 125I provided >90% 3-year overall survival and >93% 5-year secondary enucleation-free survival. On MVA, radionuclide was not predictive for tumor outcomes. A higher percentage maintained vision better than 20/40 with 103Pd (63% vs. 35%, p = 0.007) at 3 years. MVA demonstrated 103Pd radionuclide (odds ratio [OR]: 2.12, p = 0.028) and tumor height ≤5 mm (OR: 2.78, p = 0.017) were associated with VA better than 20/40. Propensity score analysis matched 23 125I with 107 103Pd patients. 103Pd continued to predict better VA at 3 years (OR: 8.10, p = 0.014). On MVA for the development of VA worse than 20/200 or degree of vision loss, radionuclide was not significant. Lower rates of radiation retinopathy were seen with 103Pd than 125I (3 years: 47.3% vs. 63.9%, p = 0.016), with radionuclide significant in MVA. CONCLUSIONS Both 125I and 103Pd achieve excellent tumor control. An increased probability of long-term VA better than 20/40 and reduced risk of radiation retinopathy is associated with 103Pd.
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Affiliation(s)
- Kirtesh R Patel
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA.
| | - Roshan S Prabhu
- Southeast Radiation Oncology Group, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC
| | - Jeffrey M Switchenko
- Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Mudit Chowdhary
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA; Department of Radiation Oncology, Rush University Medical Center, Chicago, IL
| | - Caroline Craven
- Department of Ophthalmology and Winship Cancer Institute, Emory University, Atlanta, GA
| | - Pia Mendoza
- Department of Ophthalmology and Winship Cancer Institute, Emory University, Atlanta, GA
| | - Hasan Danish
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA
| | - Hans E Grossniklaus
- Department of Ophthalmology and Winship Cancer Institute, Emory University, Atlanta, GA
| | - Thomas M Aaberg
- Department of Ophthalmology and Winship Cancer Institute, Emory University, Atlanta, GA
| | - Thomas Aaberg
- Department of Ophthalmology and Winship Cancer Institute, Emory University, Atlanta, GA
| | - Sahitya Reddy
- Department of Ophthalmology and Winship Cancer Institute, Emory University, Atlanta, GA
| | - Elizabeth Butker
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA
| | - Chris Bergstrom
- Department of Ophthalmology and Winship Cancer Institute, Emory University, Atlanta, GA
| | - Ian R Crocker
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA
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Abstract
Mentorship can be the cornerstone of professional development and career satisfaction. There is literature to support that mentorship not only improves job satisfaction, but also improves productivity, facilitates personal growth, and can rekindle our passion while lessening the risk of compassion fatigue. Mentorship is a developmental relationship that changes as the relationship evolves. There are two broad categories of mentorship: traditional and transformational. There are four subtypes within each of those areas: formal, informal, spot, or peer. Mentorship is critical to the professional development of junior colleagues. Good mentorship is guiding and steering younger partners and other colleagues toward paths of success. As a mentor, one should be looking for opportunities for formal professional development and engagement of mentees. Self-motivation is the hallmark of the successful mentee. The mentee should be able to set his or her own goals, strive to actively seek feedback, ask questions, and keep an accurate record of progress. Although the onus is on the mentee to reach out, mentorship has bidirectional value directly related to the efforts of both parties. There are many benefits to mentorship, such as the promotion of learning, personal development, improved job satisfaction, and improved job performance. Barriers exist, including the rapidly changing landscape of oncology, time constraints, lack of self-awareness, and generational differences. Through a career, mentoring needs will change, as will mentors.
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Affiliation(s)
- Kelly J Cooke
- From the UW Cancer Center at ProHealth Care, Waukesha, WI; The US Oncology Network/McKesson Specialty Health, Austin, TX; Southeast Radiation Oncology Group/Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC
| | - Debra A Patt
- From the UW Cancer Center at ProHealth Care, Waukesha, WI; The US Oncology Network/McKesson Specialty Health, Austin, TX; Southeast Radiation Oncology Group/Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC
| | - Roshan S Prabhu
- From the UW Cancer Center at ProHealth Care, Waukesha, WI; The US Oncology Network/McKesson Specialty Health, Austin, TX; Southeast Radiation Oncology Group/Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC
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Patel KR, Burri SH, Boselli D, Symanowski JT, Asher AL, Sumrall A, Fraser RW, Press RH, Zhong J, Cassidy RJ, Olson JJ, Curran WJ, Shu HKG, Crocker IR, Prabhu RS. Comparing pre-operative stereotactic radiosurgery (SRS) to post-operative whole brain radiation therapy (WBRT) for resectable brain metastases: a multi-institutional analysis. J Neurooncol 2016; 131:611-618. [PMID: 28000105 DOI: 10.1007/s11060-016-2334-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 11/12/2016] [Indexed: 12/11/2022]
Abstract
Pre-operative stereotactic radiosurgery (pre-SRS) has been shown as a viable treatment option for resectable brain metastases (BM). The aim of this study is to compare oncologic outcomes and toxicities for pre-SRS and post-operative WBRT (post-WBRT) for resectable BM. We reviewed records of consecutive patients who underwent resection of BM and either pre-SRS or post-WBRT between 2005 and 2013 at two institutions. Overall survival (OS) was calculated using the Kaplan-Meier method. Cumulative incidence was used for intracranial outcomes. Multivariate analysis (MVA) was performed using the Cox and Fine and Gray models, respectively. Overall, 102 patients underwent surgical resection of BM; 66 patients with 71 lesions received pre-SRS while 36 patients with 42 cavities received post-WBRT. Baseline characteristics were similar except for the pre-SRS cohort having more single lesions (65.2% vs. 38.9%, p = 0.001) and smaller median lesion volume (8.3 cc vs. 15.3 cc, p = 0.006). 1-year OS was similar between cohorts (58% vs. 56%, respectively) (p = 0.43). Intracranial outcomes were also similar (2-year outcomes, pre-SRS vs. post-WBRT): local recurrence: 24.5% vs. 25% (p = 0.81), distant brain failure (DBF): 53.2% vs. 45% (p = 0.66), and leptomeningeal disease (LMD) recurrence: 3.5% vs. 9.0% (p = 0.66). On MVA, radiation cohort was not independently associated with OS or any intracranial outcome. Crude rates of symptomatic radiation necrosis were 5.6 and 0%, respectively. OS and intracranial outcomes were similar for patients treated with pre-SRS or post-WBRT for resected BM. Pre-SRS is a viable alternative to post-WBRT for resected BM. Further confirmatory studies with neuro-cognitive outcomes comparing these two treatment paradigms are needed.
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Affiliation(s)
- Kirtesh R Patel
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Rd NE, Room AT225, Atlanta, GA, 30322, USA.
| | - Stuart H Burri
- Southeast Radiation Oncology Group, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC, USA
| | - Danielle Boselli
- Department of Cancer Biostatistics, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC, USA
| | - James T Symanowski
- Department of Cancer Biostatistics, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC, USA
| | - Anthony L Asher
- Carolina Neurosurgery and Spine Associates, Levine Cancer Institute, Charlotte, NC, USA
| | - Ashley Sumrall
- Department of Oncology, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC, USA
| | - Robert W Fraser
- Southeast Radiation Oncology Group, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC, USA
| | - Robert H Press
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Rd NE, Room AT225, Atlanta, GA, 30322, USA
| | - Jim Zhong
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Rd NE, Room AT225, Atlanta, GA, 30322, USA
| | - Richard J Cassidy
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Rd NE, Room AT225, Atlanta, GA, 30322, USA
| | - Jeffrey J Olson
- Department of Neurosurgery and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Walter J Curran
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Rd NE, Room AT225, Atlanta, GA, 30322, USA
| | - Hui-Kuo G Shu
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Rd NE, Room AT225, Atlanta, GA, 30322, USA
| | - Ian R Crocker
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Rd NE, Room AT225, Atlanta, GA, 30322, USA
| | - Roshan S Prabhu
- Southeast Radiation Oncology Group, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC, USA
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Abstract
Glioblastoma (GBM) remains an almost universally fatal diagnosis. The current therapeutic mainstay consists of maximal safe surgical resection followed by radiation therapy (RT) with concomitant temozolomide (TMZ), followed by monthly TMZ (the "Stupp regimen"). Several chemotherapeutic agents have been shown to have modest efficacy in the treatment of high-grade glioma (HGG), but blood-brain barrier impermeability remains a major delivery obstacle. Polymeric drug-delivery systems, developed to allow controlled local release of biologically active substances for a variety of conditions, can achieve high local concentrations of active agents while limiting systemic toxicities. Polymerically delivered carmustine (BCNU) wafers, placed on the surface of the tumor-resection cavity, can potentially provide immediate chemotherapy to residual tumor cells during the standard delay between surgery and chemoradiotherapy. BCNU wafer implantation as monochemotherapy (with RT) in newly diagnosed HGG has been investigated in 2 phase III studies that reported significant increases in median overall survival. A number of studies have investigated the tumoricidal synergies of combination chemotherapy with BCNU wafers in newly diagnosed or recurrent HGG, and a primary research focus has been the integration of BCNU wafers into multimodality therapy with the standard Stupp regimen. Overall, the results of these studies have been encouraging in terms of safety and efficacy. However, the data must be qualified by the nature of the studies conducted. Currently, there are no phase III studies of BCNU wafers with the standard Stupp regimen. We review the rationale, biochemistry, pharmacokinetics, and research history (including toxicity profile) of this modality.
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Affiliation(s)
- Scott D Wait
- Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina (S.D.W., A.L.A.); Levine Children's Hospital, Carolinas Medical Center, Charlotte, North Carolina (S.D.W.); Department of Neurosurgery, Levine Cancer Institute, and Neuroscience Institute, Carolinas Medical Center, Charlotte, North Carolina (S.D.W., T.G.A., A.L.A.); Southeast Radiation Oncology, Charlotte, North Carolina (R.S.P., S.H.B.); Department of Radiation Oncology, Levine Cancer Institute, Carolinas Medical Center, Charlotte, North Carolina (R.S.P., S.H.B.)
| | - Roshan S Prabhu
- Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina (S.D.W., A.L.A.); Levine Children's Hospital, Carolinas Medical Center, Charlotte, North Carolina (S.D.W.); Department of Neurosurgery, Levine Cancer Institute, and Neuroscience Institute, Carolinas Medical Center, Charlotte, North Carolina (S.D.W., T.G.A., A.L.A.); Southeast Radiation Oncology, Charlotte, North Carolina (R.S.P., S.H.B.); Department of Radiation Oncology, Levine Cancer Institute, Carolinas Medical Center, Charlotte, North Carolina (R.S.P., S.H.B.)
| | - Stuart H Burri
- Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina (S.D.W., A.L.A.); Levine Children's Hospital, Carolinas Medical Center, Charlotte, North Carolina (S.D.W.); Department of Neurosurgery, Levine Cancer Institute, and Neuroscience Institute, Carolinas Medical Center, Charlotte, North Carolina (S.D.W., T.G.A., A.L.A.); Southeast Radiation Oncology, Charlotte, North Carolina (R.S.P., S.H.B.); Department of Radiation Oncology, Levine Cancer Institute, Carolinas Medical Center, Charlotte, North Carolina (R.S.P., S.H.B.)
| | - Tyler G Atkins
- Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina (S.D.W., A.L.A.); Levine Children's Hospital, Carolinas Medical Center, Charlotte, North Carolina (S.D.W.); Department of Neurosurgery, Levine Cancer Institute, and Neuroscience Institute, Carolinas Medical Center, Charlotte, North Carolina (S.D.W., T.G.A., A.L.A.); Southeast Radiation Oncology, Charlotte, North Carolina (R.S.P., S.H.B.); Department of Radiation Oncology, Levine Cancer Institute, Carolinas Medical Center, Charlotte, North Carolina (R.S.P., S.H.B.)
| | - Anthony L Asher
- Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina (S.D.W., A.L.A.); Levine Children's Hospital, Carolinas Medical Center, Charlotte, North Carolina (S.D.W.); Department of Neurosurgery, Levine Cancer Institute, and Neuroscience Institute, Carolinas Medical Center, Charlotte, North Carolina (S.D.W., T.G.A., A.L.A.); Southeast Radiation Oncology, Charlotte, North Carolina (R.S.P., S.H.B.); Department of Radiation Oncology, Levine Cancer Institute, Carolinas Medical Center, Charlotte, North Carolina (R.S.P., S.H.B.)
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Press RH, Prabhu RS, Nickleach DC, Liu Y, Shu HKG, Kandula S, Patel KR, Curran WJ, Crocker I. Novel risk stratification score for predicting early distant brain failure and salvage whole-brain radiotherapy after stereotactic radiosurgery for brain metastases. Cancer 2015; 121:3836-43. [PMID: 26242475 DOI: 10.1002/cncr.29590] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 05/27/2015] [Accepted: 06/25/2015] [Indexed: 11/05/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate predictors of early distant brain failure (DBF) and salvage whole-brain radiotherapy (WBRT) after treatment with stereotactic radiosurgery (SRS) for brain metastases and create a clinically relevant risk score to stratify patients' risk for these events. METHODS The records of 270 patients with brain metastases who were treated with SRS between 2003 and 2012 were reviewed. Pretreatment patient and tumor characteristics were analyzed with univariate and multivariate analyses. The cumulative incidences of first DBF and salvage WBRT were calculated. Significant factors were used to create a score for stratifying early (6-month) DBF risk. RESULTS No prior WBRT, a total lesion volume < 1.3 cm(3), primary breast cancer or malignant melanoma histology, and multiple metastases (≥2) were found to be significant predictors of early DBF. Each factor was ascribed 1 point because of similar hazard ratios. Scores of 0 to 1, 2, and 3 to 4 were considered to indicate low, intermediate, and high risk, respectively. This correlated with 6-month cumulative incidences of DBF of 16.6%, 28.8%, and 54.4%, respectively (P < .001). For patients without prior WBRT, the 6-month cumulative incidence of salvage WBRT was 2%, 17.7%, and 25.7%, respectively (P < .001). CONCLUSIONS Early DBF after SRS requiring salvage WBRT remains a significant clinical problem. Patient stratification for early DBF can better inform the decision for the initial treatment strategy for brain metastases. The provided risk score may help to predict early DBF and subsequent salvage WBRT if SRS is initially used. External validation is needed before clinical implementation.
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Affiliation(s)
- Robert H Press
- Department of Radiation Oncology, Emory University, Atlanta, Georgia.,Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Roshan S Prabhu
- Southeast Radiation Oncology Group, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, North Carolina
| | - Dana C Nickleach
- Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Yuan Liu
- Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Hui-Kuo G Shu
- Department of Radiation Oncology, Emory University, Atlanta, Georgia.,Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Shravan Kandula
- Department of Radiation Oncology, Emory University, Atlanta, Georgia.,Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Kirtesh R Patel
- Department of Radiation Oncology, Emory University, Atlanta, Georgia.,Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Walter J Curran
- Department of Radiation Oncology, Emory University, Atlanta, Georgia.,Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Ian Crocker
- Department of Radiation Oncology, Emory University, Atlanta, Georgia.,Winship Cancer Institute, Emory University, Atlanta, Georgia
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Jegadeesh N, Liu Y, Prabhu RS, Magliocca KR, Marcus DM, Higgins KA, Vainshtein JM, Trad Wadsworth J, Beitler JJ. Outcomes and prognostic factors in modern era management of major salivary gland cancer. Oral Oncol 2015; 51:770-7. [PMID: 26033470 PMCID: PMC4515354 DOI: 10.1016/j.oraloncology.2015.05.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 05/11/2015] [Accepted: 05/12/2015] [Indexed: 01/19/2023]
Abstract
OBJECTIVES There is a dearth of prospective evidence regarding cancer of the major salivary glands. Outcomes and management of major salivary gland are based largely on retrospective series spanning many decades and changes in surgical, radiation, imaging and systemic therapy strategies and technique. We sought to report contemporary patterns of relapse and prognostic factors for major salivary gland cancer. MATERIALS AND METHODS 112 patients with major salivary gland cancers underwent resection with or without adjuvant therapy between January 1997 and September 2010. Outcomes were documented with follow-up until December 2014. Survival was calculated by the Kaplan-Meier method. Log-rank test and Cox proportional hazards regression were performed with locoregional control (LRC), distant control (DC) and overall survival (OS) as the primary outcome variables. RESULTS Median follow-up was 55.1 months. Rates of LRC for stage I/II and III/IV at five years were 95.7% and 61.9% respectively. Rates of DC at five years for stage I/II and III/IV were 93% and 56.9% respectively. Multivariate analysis identified larger tumor size, clinical nerve involvement and in parotid cancers, advanced T stage, no adjuvant radiation, and older age at diagnosis to be associated with increased risk of locoregional recurrence (all p<0.05). Distant metastasis was associated with sublingual site, degree of clinical nerve involvement, high grade, tumor size and in parotid tumors additionally deep lobe involvement on multivariate analysis (all p<0.05). CONCLUSION Several prognostic factors were identified that may help guide decisions regarding adjuvant therapy. DM remains a significant concern in the management of this disease.
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Affiliation(s)
- Naresh Jegadeesh
- Departments of Radiation Oncology, Emory University, Atlanta, GA, United States; Winship Cancer Institute, Emory University, Atlanta, GA, United States.
| | - Yuan Liu
- Departments of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, United States; Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Roshan S Prabhu
- Southeast Radiation Oncology Group, Levine Cancer Institute, Charlotte, NC, United States
| | - Kelly R Magliocca
- Departments of Pathology and Laboratory Medicine, Emory University, Atlanta, GA, United States; Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - David M Marcus
- Valley View Hospital, Glenwood Springs, CO, United States
| | - Kristin A Higgins
- Departments of Radiation Oncology, Emory University, Atlanta, GA, United States; Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Jeffrey M Vainshtein
- Departments of Radiation Oncology, Emory University, Atlanta, GA, United States; Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - J Trad Wadsworth
- Departments of Otolaryngology, Emory University, Atlanta, GA, United States; Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Jonathan J Beitler
- Departments of Radiation Oncology, Emory University, Atlanta, GA, United States; Winship Cancer Institute, Emory University, Atlanta, GA, United States
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Kandula S, Sutter A, Prabhu RS, Jegadeesh N, Esiashvili N. Reassessing dose constraints of organs at risk in children with abdominal neuroblastoma treated with definitive radiation therapy: a correlation with late toxicity. Pediatr Blood Cancer 2015; 62:970-5. [PMID: 25545501 DOI: 10.1002/pbc.25372] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Accepted: 10/29/2014] [Indexed: 12/25/2022]
Abstract
BACKGROUND In children treated with definitive radiation therapy (RT) for abdominal neuroblastoma, normal tissue constraints for organs at risk (OARs) are not well-standardized or evidence-based. In this study, we analyze dosimetric data of principal abdominal OARs, reassess existing RT planning constraints, and examine corresponding acute and late toxicity to OARs. PROCEDURE The treatment plans of 30 consecutive children who underwent definitive RT for high-risk abdominal neuroblastoma were reviewed. Dose-volume histogram (DVH) statistics were recorded for the ipsilateral kidney (if unresected), contralateral kidney, and liver. DVH data were analyzed to determine if OAR constraints from recent protocols were met and correlated with the development of toxicity. RESULTS The median follow-up period was 53.0 months. Ten, thirteen, and ten percent of patients' RT plans did not meet OAR DVH constraints for the liver, ipsilateral kidney, and contralateral kidney, respectively. Of the three patients whose plans did not achieve ipsilateral kidney DVH constraint(s), two developed evidence of late ipsilateral kidney hypoplasia, but maintained normal laboratory kidney function. No patient experienced late toxicity of the contralateral kidney nor developed RT-related late hepatic complications. CONCLUSIONS In children treated for abdominal neuroblastoma, the risk of developing clinically significant RT-related late toxicity of the kidney and liver is not appreciable, even when current DVH parameters for OARs are not achieved in planning. Toxicity outcomes did not necessarily correlate with present-day OAR dose constraints. Currently utilized DVH constraints are highly variable, and must be further studied and supported by toxicity outcomes to more accurately characterize risk of complications.
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Affiliation(s)
- Shravan Kandula
- Department of Radiation Oncology, Emory University, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia
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41
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Burri SH, Prabhu RS, Sumrall AL, Brick W, Blaker BD, Heideman BE, Boltes P, Kelly R, Symanowski JT, Wiggins WF, Ashby L, Norton HJ, Judy K, Asher AL. BCNU wafer placement with temozolomide (TMZ) in the immediate postoperative period after tumor resection followed by radiation therapy with TMZ in patients with newly diagnosed high grade glioma: final results of a prospective, multi-institutional, phase II trial. J Neurooncol 2015; 123:259-66. [DOI: 10.1007/s11060-015-1793-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 04/25/2015] [Indexed: 12/20/2022]
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Landry JC, Feng Y, Prabhu RS, Cohen SJ, Staley CA, Whittington R, Sigurdson ER, Nimeiri H, Verma U, Benson AB. Phase II Trial of Preoperative Radiation With Concurrent Capecitabine, Oxaliplatin, and Bevacizumab Followed by Surgery and Postoperative 5-Fluorouracil, Leucovorin, Oxaliplatin (FOLFOX), and Bevacizumab in Patients With Locally Advanced Rectal Cancer: 5-Year Clinical Outcomes ECOG-ACRIN Cancer Research Group E3204. Oncologist 2015; 20:615-6. [PMID: 25926352 DOI: 10.1634/theoncologist.2015-0106] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [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: 03/17/2015] [Accepted: 03/18/2015] [Indexed: 12/13/2022] Open
Abstract
LESSONS LEARNED The 5-year oncologic outcomes from the trial regimen were excellent. However, the neoadjuvant and surgical toxicity of this regimen was significant and was the primary reason for the low compliance with adjuvant systemic therapy.Due to the lack of an improvement in the pathologic complete response rate, the substantial associated toxicity, and the negative phase III trials of adjuvant bevacizumab in colon cancer, this regimen will not be pursued for further study. BACKGROUND The addition of bevacizumab to chemotherapy improves overall survival for metastatic colorectal cancer. We initiated a phase II trial to evaluate preoperative capecitabine, oxaliplatin, and bevacizumab with radiation therapy (RT) followed by surgery and postoperative 5-fluorouracil, leucovorin, oxaliplatin (FOLFOX), and bevacizumab for locally advanced rectal cancer. The purpose of this report is to describe the 5-year oncologic outcomes of this regimen. METHODS In a phase II Simon two-stage design study, we evaluated preoperative treatment with capecitabine (825 mg/m(2) b.i.d. Monday-Friday), oxaliplatin (50 mg/m(2) weekly), bevacizumab (5 mg/kg on days 1, 15, and 29), and RT (50.4 Gy). Surgery was performed by 8 weeks after RT. Beginning 8-12 weeks after surgery, patients received FOLFOX plus bevacizumab (5 mg/kg) every 2 weeks for 12 cycles (oxaliplatin stopped after 9 cycles). The primary endpoint was a pathologic complete response (path-CR) rate of 30%. Fifty-seven patients with resectable T3/T4 rectal adenocarcinoma were enrolled between 2006 and 2010. RESULTS Of 57 enrolled patients, 53 were eligible and included in the analysis. Forty-eight (91%) patients completed preoperative therapy, all of whom underwent curative surgical resection. Nine patients (17%) achieved path-CR. There were 29 worst grade 3 events, 8 worst grade 4 events, and 2 patient deaths, 1 of which was attributed to study therapy. Twenty-six patients (54%) began adjuvant chemotherapy. After a median follow-up period of 41 months, the 5-year overall survival (OS) rate for all patients was 80%. Only 2 patients experienced cancer recurrence: 1 distant (liver) and 1 loco-regional (pelvic lymph nodes), respectively. Both of these patients are still alive. The 5-year relapse-free survival rate was 81%. CONCLUSION Despite the path-CR primary endpoint of this trial not being reached, the 5-year OS and recurrence-free survival rates were excellent. However, the neoadjuvant and surgical toxicity of this regimen was significant and was the primary reason for the low compliance with adjuvant systemic therapy. Because of the lack of an improvement in the path-CR rate, the substantial associated toxicity, and the negative phase III trials of adjuvant bevacizumab in colon cancer, this regimen will not be pursued for further study.
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Affiliation(s)
- Jerome C Landry
- Emory University, Winship Cancer Institute, Atlanta, Georgia, USA;
| | - Yang Feng
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Roshan S Prabhu
- Southeast Radiation Oncology Group, Levine Cancer Institute, Charlotte, North Carolina, USA
| | - Steven J Cohen
- Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - Charles A Staley
- Emory University, Winship Cancer Institute, Atlanta, Georgia, USA
| | | | | | | | - Udit Verma
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Jegadeesh NK, Kim S, Prabhu RS, Oprea GM, Yu DS, Godette KG, Zelnak AB, Mister D, Switchenko JM, Torres MA. The 21-gene recurrence score and locoregional recurrence in breast cancer patients. Ann Surg Oncol 2015; 22:1088-94. [PMID: 25472643 PMCID: PMC4869872 DOI: 10.1245/s10434-014-4252-y] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Indexed: 12/18/2022]
Abstract
PURPOSE Although the 21-gene recurrence score (RS) assay has been validated to assess the risk of distant recurrence in hormone receptor-positive breast cancer patients, the relationship between RS and the risk of locoregional recurrence (LRR) remains unclear. The purpose of this study was to determine if RS is associated with LRR in breast cancer patients and whether this relationship varies based on the type of local treatment [mastectomy or breast-conserving therapy (BCT)]. METHODS 163 consecutive estrogen receptor-positive breast cancer patients at our institution had an RS generated from the primary breast tumor between August 2006 and October 2009. Patients were treated with lumpectomy and radiation (BCT) (n = 110) or mastectomy alone (n = 53). Patients were stratified using a pre-determined RS of 25 and then grouped according to local therapy type. RESULTS Median follow-up was 68.2 months. Patients who developed an LRR had stage I or IIA disease, >2 mm surgical margins, and received chemotherapy as directed by RS. While an RS > 25 did not predict for a higher rate of LRR, an RS > 24 was associated with LRR in our subjects. Among mastectomy patients, the 5-year LRR rate was 27.3 % in patients with an RS > 24 versus 10.7 % (p = 0.04) in those whose RS was ≤ 24. RS was not associated with LRR in patients who received BCT. CONCLUSIONS Breast cancer patients treated with mastectomy for tumors that have an RS > 24 are at high risk of LRR and may benefit from post-mastectomy radiation.
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Affiliation(s)
- Naresh K. Jegadeesh
- Department of Radiation Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA
| | - Sunjin Kim
- Department of Biostatistics and Bioinformatics, Winship Cancer Institute, Emory University, Atlanta, GA
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Roshan S. Prabhu
- Department of Radiation Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA
| | - Gabriela M. Oprea
- Department of Pathology and Laboratory Medicine, Winship Cancer Institute, Emory University, Atlanta, GA
| | - David S. Yu
- Department of Radiation Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA
| | - Karen G. Godette
- Department of Radiation Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA
| | - Amelia B. Zelnak
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Donna Mister
- Department of Radiation Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA
| | - Jeffrey M. Switchenko
- Department of Biostatistics and Bioinformatics, Winship Cancer Institute, Emory University, Atlanta, GA
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Mylin A. Torres
- Department of Radiation Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA
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Kandula S, Saindane AM, Prabhu RS, Hanasoge S, Patel KR, Shu HK, Curran WJ, Crocker IR. Patterns of presentation and failure in patients with gliomatosis cerebri treated with partial-brain radiation therapy. Cancer 2014; 120:2713-20. [PMID: 24845411 DOI: 10.1002/cncr.28785] [Citation(s) in RCA: 6] [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] [Received: 01/25/2014] [Revised: 03/27/2014] [Accepted: 04/22/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND The patterns of lobar involvement, optimal treatment, and disease course among patients with gliomatosis cerebri (GC) have not been fully characterized. The current study evaluates the clinical presentations and outcomes for patients with GC treated with radiation therapy (RT) at our institution. METHODS A total of 26 patients (25 with follow-up) with GC were diagnosed and treated between January 2004 and June 2012. Inclusion criteria consisted of brain magnetic resonance imaging and neuroradiology confirmation of contiguous involvement of ≥ 3 lobes/lobar equivalents with preservation of neural architecture. Patients were treated with either partial-brain RT to involved tumor (25 patients) or whole-brain RT (1 patient). The median RT dose was 54.0 Gray. The median follow-up was 17.3 months. RESULTS The median age of the patients at the time of diagnosis was 57 years. Twenty-one patients (81%) and 5 patients (19%) had 3 to 6 and ≥ 7 involved lobes/lobar equivalents, respectively. The median progression-free survival and overall survival were 7.4 months and 14.9 months, respectively. Fifteen patients experienced radiographic disease progression after partial-brain RT, 14 of whom (93%) developed infield disease recurrence. On univariate analysis, higher tumor grade and type II GC (with focal mass) were associated with a poorer progression-free survival. The extent of lobar involvement and chemotherapy were not associated with overall survival. CONCLUSIONS Even with partial-brain RT, nearly all disease recurrences were infield and clinical outcomes were similar to previous GC series, thereby suggesting that whole-brain RT is not necessary for this patient population. A greater number of involved lobes did not correlate with inferior outcomes. Further studies are necessary to establish more uniform and optimal treatments for this rare disease.
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Affiliation(s)
- Shravan Kandula
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
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Prabhu RS, Beitler JJ. In reply to Branstetter et al. Int J Radiat Oncol Biol Phys 2014; 89:435-6. [PMID: 24837897 DOI: 10.1016/j.ijrobp.2014.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 02/06/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Roshan S Prabhu
- Southeast Radiation Oncology Group, Charlotte, North Carolina
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Press RH, Prabhu RS, Appin CL, Brat DJ, Shu HKG, Hadjipanayis C, Olson JJ, Oyesiku NM, Curran WJ, Crocker I. Outcomes and patterns of failure for grade 2 meningioma treated with reduced-margin intensity modulated radiation therapy. Int J Radiat Oncol Biol Phys 2014; 88:1004-10. [PMID: 24661652 DOI: 10.1016/j.ijrobp.2013.12.037] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 12/20/2013] [Accepted: 12/21/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE The purpose of this study was to evaluate intracranial control and patterns of local recurrence (LR) for grade 2 meningiomas treated with intensity modulated radiation therapy (IMRT) with limited total margin expansions of ≤1 cm. METHODS AND MATERIALS We reviewed records of patients with a neuropathological diagnosis of grade 2 meningioma who underwent IMRT at our institution between 2002 and 2012. Actuarial rates were determined by the Kaplan-Meier method from the end of RT. LR was defined as in-field if ≥90% of the recurrence was within the prescription isodose, out-of-field (marginal) if ≥90% was outside of the prescription isodose, and both if neither criterion was met. RESULTS Between 2002 and 2012, a total of 54 consecutive patients underwent IMRT for grade 2 meningioma. Eight of these patients had total initial margins >1 cm and were excluded, leaving 46 patients for analysis. The median imaging follow-up period was 26.2 months (range, 7-107 months). The median dose for fractionated IMRT was 59.4 Gy (range, 49.2-61.2 Gy). Median clinical target volume (CTV), planning target volume (PTV), and total margin expansion were 0.5 cm, 0.3 cm, and 0.8 cm, respectively. LR occurred in 8 patients (17%), with 2-year and 3-year actuarial local control (LC) of 92% and 74%, respectively. Six of 8 patients (85%) had a known pattern of failure. Five patients (83%) had in-field LR; no patients had marginal LR; and 1 patient (17%) had both. CONCLUSIONS The use of IMRT to treat grade 2 meningiomas with total initial margins (CTV + PTV) ≤1 cm did not appear to compromise outcomes or increase marginal failures compared with other modern retrospective series. Of the 46 patients who had margins ≤1 cm, none experienced marginal failure only. These results demonstrate efficacy and low risk of marginal failure after IMRT treatment of grade 2 meningiomas with reduced margins, warranting study within a prospective clinical trial.
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Affiliation(s)
- Robert H Press
- Department of Radiation Oncology, Emory University, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Roshan S Prabhu
- Department of Radiation Oncology, Emory University, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia.
| | - Christina L Appin
- Department of Pathology, Emory University, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Daniel J Brat
- Department of Pathology, Emory University, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Hui-Kuo G Shu
- Department of Radiation Oncology, Emory University, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Constantinos Hadjipanayis
- Department of Neurosurgery, Emory University, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Jeffrey J Olson
- Department of Neurosurgery, Emory University, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Nelson M Oyesiku
- Department of Neurosurgery, Emory University, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Walter J Curran
- Department of Radiation Oncology, Emory University, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Ian Crocker
- Department of Radiation Oncology, Emory University, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia
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Prabhu RS, Hanasoge S, Magliocca KR, Hall WA, Chen SA, Higgins KA, Saba NF, El-Deiry M, Grist W, Wadsworth JT, Chen AY, Beitler JJ. Lymph node ratio influence on risk of head and neck cancer locoregional recurrence after initial surgical resection: implications for adjuvant therapy. Head Neck 2014; 37:777-82. [PMID: 24596123 DOI: 10.1002/hed.23662] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 12/14/2013] [Accepted: 03/02/2014] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND The purpose of this study was to determine if lymph node ratio is associated with locoregional recurrence for patients with oral cavity or laryngeal cancer treated with initial surgical management. METHODS The study included 350 patients with oral cavity (73%) or laryngeal cancer (27%) who underwent initial surgery. All analyses were multivariable, adjusting for primary site, pathologic prognostic factors, and adjuvant therapy. RESULTS Lymph node ratio was significantly associated with locoregional recurrence, in which each 1% increase in lymph node ratio had an adjusted hazard ratio (HR) for locoregional recurrence of 1.02 (95% confidence interval [CI], 1.002-1.042; p = .05). Lymph node ratio was also associated with OS, in which each 1% increase in lymph node ratio had an adjusted HR for death of 1.028 (95% CI, 1.012-1.045; p = .001). CONCLUSION Adjusting for pathologic factors and adjuvant therapy, lymph node ratio was found to be an independent prognostic factor for locoregional recurrence and overall survival (OS). Patients with lymph node ratio ≥20% are at high risk of locoregional recurrence and death, and may be considered for adjuvant chemoradiation.
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Affiliation(s)
- Roshan S Prabhu
- Department of Radiation Oncology, Emory University, Atlanta, Georgia.,Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Sheela Hanasoge
- Department of Radiation Oncology, Emory University, Atlanta, Georgia.,Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Kelly R Magliocca
- Department of Pathology, Emory University, Atlanta, Georgia.,Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - William A Hall
- Department of Radiation Oncology, Emory University, Atlanta, Georgia.,Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Susie A Chen
- Department of Radiation Oncology, University of Texas Southwestern, Dallas, Texas
| | - Kristin A Higgins
- Department of Radiation Oncology, Emory University, Atlanta, Georgia.,Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Nabil F Saba
- Department of Hematology and Medical Oncology, Emory University, Atlanta, Georgia.,Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Mark El-Deiry
- Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, Georgia.,Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - William Grist
- Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, Georgia.,Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - J Trad Wadsworth
- Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, Georgia.,Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Amy Y Chen
- Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, Georgia.,Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Jonathan J Beitler
- Department of Radiation Oncology, Emory University, Atlanta, Georgia.,Winship Cancer Institute, Emory University, Atlanta, Georgia
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Hall WA, Colbert LE, Nickleach D, Switchenko J, Liu Y, Gillespie T, Lipscomb J, Hardy C, Kooby DA, Prabhu RS, Kauh J, Landry JC. The influence of radiation therapy dose escalation on overall survival in unresectable pancreatic adenocarcinoma. J Gastrointest Oncol 2014; 5:77-85. [PMID: 24772334 DOI: 10.3978/j.issn.2078-6891.2014.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2014] [Accepted: 02/19/2014] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Radiation therapy (RT) dose escalation in unresectable pancreatic adenocarcinoma (PAC) remains investigational. We examined the association between total RT dose and overall survival (OS) in patients with unresectable PAC. METHODS AND MATERIALS National cancer data base (NCDB) data were obtained for patients who underwent definitive chemotherapy and RT (chemo-RT) for unresectable PAC. Univariate (UV) and multivariate (MV) survival analysis were performed along with Kaplan-Meier (KM) estimates for incremental RT dose levels. RESULTS A total of 977 analyzable patients met inclusion criteria. Median tumor size was 4.0 cm (0.3-40 cm) and median RT dose was 45 Gy. Median OS was 10 months (95% CI, 9-10 months). On MV analysis RT dose <30 Gy [HR, 2.38 (95% CI, 1.85-3.07); P<0.001] and RT dose ≥30 to <40 Gy [HR, 1.41 (95% CI, 1.04-1.91); P=0.026] were associated with lower OS when compared with dose ≥55 Gy. Patients receiving RT doses from 40 to <45, 45 to <50, 50 to <55, and ≥55 Gy did not differ in OS. CONCLUSIONS Lack of benefit to OS with conventionally delivered RT above 40 Gy is shown. Optimal RT dose escalation methods in unresectable PAC remain an important subject for investigation in prospective clinical trials.
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Affiliation(s)
- William A Hall
- 1 Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, USA ; 2 Biostatistics & Bioinformatics Shared Resource at Winship Cancer Institute, Atlanta, GA, USA ; 3 Department of Surgery and Winship Cancer Institute, Emory University, Atlanta, GA, USA ; 4 Atlanta Veterans Affairs Medical Center, Atlanta, GA, USA ; 5 Rollins School of Public Health and Winship Cancer Institute, Atlanta, GA, USA ; 6 Department of Medical Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Lauren E Colbert
- 1 Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, USA ; 2 Biostatistics & Bioinformatics Shared Resource at Winship Cancer Institute, Atlanta, GA, USA ; 3 Department of Surgery and Winship Cancer Institute, Emory University, Atlanta, GA, USA ; 4 Atlanta Veterans Affairs Medical Center, Atlanta, GA, USA ; 5 Rollins School of Public Health and Winship Cancer Institute, Atlanta, GA, USA ; 6 Department of Medical Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Dana Nickleach
- 1 Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, USA ; 2 Biostatistics & Bioinformatics Shared Resource at Winship Cancer Institute, Atlanta, GA, USA ; 3 Department of Surgery and Winship Cancer Institute, Emory University, Atlanta, GA, USA ; 4 Atlanta Veterans Affairs Medical Center, Atlanta, GA, USA ; 5 Rollins School of Public Health and Winship Cancer Institute, Atlanta, GA, USA ; 6 Department of Medical Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Jeffrey Switchenko
- 1 Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, USA ; 2 Biostatistics & Bioinformatics Shared Resource at Winship Cancer Institute, Atlanta, GA, USA ; 3 Department of Surgery and Winship Cancer Institute, Emory University, Atlanta, GA, USA ; 4 Atlanta Veterans Affairs Medical Center, Atlanta, GA, USA ; 5 Rollins School of Public Health and Winship Cancer Institute, Atlanta, GA, USA ; 6 Department of Medical Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Yuan Liu
- 1 Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, USA ; 2 Biostatistics & Bioinformatics Shared Resource at Winship Cancer Institute, Atlanta, GA, USA ; 3 Department of Surgery and Winship Cancer Institute, Emory University, Atlanta, GA, USA ; 4 Atlanta Veterans Affairs Medical Center, Atlanta, GA, USA ; 5 Rollins School of Public Health and Winship Cancer Institute, Atlanta, GA, USA ; 6 Department of Medical Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Theresa Gillespie
- 1 Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, USA ; 2 Biostatistics & Bioinformatics Shared Resource at Winship Cancer Institute, Atlanta, GA, USA ; 3 Department of Surgery and Winship Cancer Institute, Emory University, Atlanta, GA, USA ; 4 Atlanta Veterans Affairs Medical Center, Atlanta, GA, USA ; 5 Rollins School of Public Health and Winship Cancer Institute, Atlanta, GA, USA ; 6 Department of Medical Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Joseph Lipscomb
- 1 Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, USA ; 2 Biostatistics & Bioinformatics Shared Resource at Winship Cancer Institute, Atlanta, GA, USA ; 3 Department of Surgery and Winship Cancer Institute, Emory University, Atlanta, GA, USA ; 4 Atlanta Veterans Affairs Medical Center, Atlanta, GA, USA ; 5 Rollins School of Public Health and Winship Cancer Institute, Atlanta, GA, USA ; 6 Department of Medical Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Claire Hardy
- 1 Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, USA ; 2 Biostatistics & Bioinformatics Shared Resource at Winship Cancer Institute, Atlanta, GA, USA ; 3 Department of Surgery and Winship Cancer Institute, Emory University, Atlanta, GA, USA ; 4 Atlanta Veterans Affairs Medical Center, Atlanta, GA, USA ; 5 Rollins School of Public Health and Winship Cancer Institute, Atlanta, GA, USA ; 6 Department of Medical Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - David A Kooby
- 1 Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, USA ; 2 Biostatistics & Bioinformatics Shared Resource at Winship Cancer Institute, Atlanta, GA, USA ; 3 Department of Surgery and Winship Cancer Institute, Emory University, Atlanta, GA, USA ; 4 Atlanta Veterans Affairs Medical Center, Atlanta, GA, USA ; 5 Rollins School of Public Health and Winship Cancer Institute, Atlanta, GA, USA ; 6 Department of Medical Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Roshan S Prabhu
- 1 Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, USA ; 2 Biostatistics & Bioinformatics Shared Resource at Winship Cancer Institute, Atlanta, GA, USA ; 3 Department of Surgery and Winship Cancer Institute, Emory University, Atlanta, GA, USA ; 4 Atlanta Veterans Affairs Medical Center, Atlanta, GA, USA ; 5 Rollins School of Public Health and Winship Cancer Institute, Atlanta, GA, USA ; 6 Department of Medical Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - John Kauh
- 1 Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, USA ; 2 Biostatistics & Bioinformatics Shared Resource at Winship Cancer Institute, Atlanta, GA, USA ; 3 Department of Surgery and Winship Cancer Institute, Emory University, Atlanta, GA, USA ; 4 Atlanta Veterans Affairs Medical Center, Atlanta, GA, USA ; 5 Rollins School of Public Health and Winship Cancer Institute, Atlanta, GA, USA ; 6 Department of Medical Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Jerome C Landry
- 1 Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, USA ; 2 Biostatistics & Bioinformatics Shared Resource at Winship Cancer Institute, Atlanta, GA, USA ; 3 Department of Surgery and Winship Cancer Institute, Emory University, Atlanta, GA, USA ; 4 Atlanta Veterans Affairs Medical Center, Atlanta, GA, USA ; 5 Rollins School of Public Health and Winship Cancer Institute, Atlanta, GA, USA ; 6 Department of Medical Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, USA
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Prabhu RS, Hanasoge S, Magliocca KR, Moeller BJ, Milas ZL, Hall WA, El-Deiry M, Wadsworth JT, Higgins KA, Beitler JJ. Extent of pathologic extracapsular extension and outcomes in patients with nonoropharyngeal head and neck cancer treated with initial surgical resection. Cancer 2014; 120:1499-506. [DOI: 10.1002/cncr.28596] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2013] [Revised: 12/27/2013] [Accepted: 01/13/2014] [Indexed: 12/24/2022]
Affiliation(s)
- Roshan S. Prabhu
- Southeast Radiation Oncology Group; Levine Cancer Institute; Charlotte North Carolina
| | - Sheela Hanasoge
- Department of Radiation Oncology; Emory University; Atlanta Georgia
- Winship Cancer Institute; Emory University; Atlanta Georgia
| | - Kelly R. Magliocca
- Winship Cancer Institute; Emory University; Atlanta Georgia
- Department of Pathology; Emory University; Atlanta Georgia
| | - Benjamin J. Moeller
- Southeast Radiation Oncology Group; Levine Cancer Institute; Charlotte North Carolina
| | - Zvonimir L. Milas
- Department of Oncology; Levine Cancer Institute; Charlotte North Carolina
| | - William A. Hall
- Department of Radiation Oncology; Emory University; Atlanta Georgia
- Winship Cancer Institute; Emory University; Atlanta Georgia
| | - Mark El-Deiry
- Winship Cancer Institute; Emory University; Atlanta Georgia
- Department of Otolaryngology-Head & Neck Surgery; Emory University; Atlanta Georgia
| | - J. Trad Wadsworth
- Winship Cancer Institute; Emory University; Atlanta Georgia
- Department of Otolaryngology-Head & Neck Surgery; Emory University; Atlanta Georgia
| | - Kristen A. Higgins
- Department of Radiation Oncology; Emory University; Atlanta Georgia
- Winship Cancer Institute; Emory University; Atlanta Georgia
| | - Jonathan J. Beitler
- Department of Radiation Oncology; Emory University; Atlanta Georgia
- Winship Cancer Institute; Emory University; Atlanta Georgia
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Prabhu RS, Won M, Shaw EG, Hu C, Brachman DG, Buckner JC, Stelzer KJ, Barger GR, Brown PD, Gilbert MR, Mehta MP. Effect of the addition of chemotherapy to radiotherapy on cognitive function in patients with low-grade glioma: secondary analysis of RTOG 98-02. J Clin Oncol 2014; 32:535-41. [PMID: 24419119 DOI: 10.1200/jco.2013.53.1830] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The addition of PCV (procarbazine, lomustine, and vincristine) chemotherapy to radiotherapy (RT) for patients with WHO grade 2 glioma improves progression-free survival (PFS). The effect of therapy intensification on cognitive function (CF) remains a concern in this population with substantial long-term survival. PATIENTS AND METHODS A total of 251 patients with WHO grade 2 glioma age ≥ 40 years with any extent of resection or age < 40 years with subtotal resection/biopsy were randomly assigned to RT (54 Gy) or RT plus PCV. We observed 111 patients age < 40 years with gross total resection. CF was assessed by Mini-Mental State Examination (MMSE) at baseline and years 1, 2, 3, and 5. RESULTS Overall, few patients experienced significant decline in MMSE score. There were no significant differences in the proportion of patients experiencing MMSE score decline between the randomized study arms at any time point. Both study arms experienced a significant gain in average MMSE score longitudinally over time, with no difference between arms. CONCLUSION The MMSE is a relatively insensitive tool, and subtle changes in CF may have been missed. However, the addition of PCV to RT did not result in significantly higher rates of MMSE score decline than RT alone through 5 years of follow-up. Patients in both randomly assigned arms experienced a statistically significant average MMSE score increase over time, with no difference between arms. The addition of PCV chemotherapy to RT improves PFS without excessive CF detriment over RT alone for patients with low-grade glioma.
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Affiliation(s)
- Roshan S Prabhu
- Roshan S. Prabhu, Southeast Radiation Oncology Group; Levine Cancer Institute, Charlotte; Edward G. Shaw, Wake Forest University School of Medicine, Winston-Salem, NC; Minhee Won and Chen Hu, Radiation Therapy Oncology Group, Philadelphia, PA; David G. Brachman, Arizona Oncology Services Foundation and Barrows Neurologic Institute, Phoenix, AZ; Jan C. Buckner, Mayo Clinic, Rochester, MN; Keith J. Stelzer, Mid-Columbia Medical Center, Celilo Cancer Center, The Dalles, OR; Geoffrey R. Barger, Wayne State University School of Medicine, Detroit, MI; Paul D. Brown and Mark R. Gilbert, MD Anderson Cancer Center, Houston, TX; and Minesh P. Mehta, University of Maryland School of Medicine, Baltimore, MD
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