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Thor M, Lee C, Sun L, Patel P, Apte A, Grkovski M, Shepherd AF, Gelblum DY, Wu AJ, Simone CB, Chaft JE, Rimner A, Gomez DR, Deasy JO, Shaverdian N. An 18F-FDG PET/CT and Mean Lung Dose Model to Predict Early Radiation Pneumonitis in Stage III Non-Small Cell Lung Cancer Patients Treated with Chemoradiation and Immunotherapy. J Nucl Med 2024; 65:520-526. [PMID: 38485270 PMCID: PMC10995528 DOI: 10.2967/jnumed.123.266965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 01/11/2024] [Indexed: 04/04/2024] Open
Abstract
Radiation pneumonitis (RP) that develops early (i.e., within 3 mo) (RPEarly) after completion of concurrent chemoradiation (cCRT) leads to treatment discontinuation and poorer survival for patients with stage III non-small cell lung cancer. Since no RPEarly risk model exists, we explored whether published RP models and pretreatment 18F-FDG PET/CT-derived features predict RPEarly Methods: One hundred sixty patients with stage III non-small cell lung cancer treated with cCRT and consolidative immunotherapy were analyzed for RPEarly Three published RP models that included the mean lung dose (MLD) and patient characteristics were examined. Pretreatment 18F-FDG PET/CT normal-lung SUV featured included the following: 10th percentile of SUV (SUVP10), 90th percentile of SUV (SUVP90), SUVmax, SUVmean, minimum SUV, and SD. Associations between models/features and RPEarly were assessed using area under the receiver-operating characteristic curve (AUC), P values, and the Hosmer-Lemeshow test (pHL). The cohort was randomly split, with similar RPEarly rates, into a 70%/30% derivation/internal validation subset. Results: Twenty (13%) patients developed RPEarly Predictors for RPEarly were MLD alone (AUC, 0.72; P = 0.02; pHL, 0.87), SUVP10, SUVP90, and SUVmean (AUC, 0.70-0.74; P = 0.003-0.006; pHL, 0.67-0.70). The combined MLD and SUVP90 model generalized in the validation subset and was deemed the final RPEarly model (RPEarly risk = 1/[1+e(- x )]; x = -6.08 + [0.17 × MLD] + [1.63 × SUVP90]). The final model refitted in the 160 patients indicated improvement over the published MLD-alone model (AUC, 0.77 vs. 0.72; P = 0.0001 vs. 0.02; pHL, 0.65 vs. 0.87). Conclusion: Patients at risk for RPEarly can be detected with high certainty by combining the normal lung's MLD and pretreatment 18F-FDG PET/CT SUVP90 This refined model can be used to identify patients at an elevated risk for premature immunotherapy discontinuation due to RPEarly and could allow for interventions to improve treatment outcomes.
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Affiliation(s)
- Maria Thor
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York;
| | - Chen Lee
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lian Sun
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Purvi Patel
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Aditya Apte
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Milan Grkovski
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Annemarie F Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; and
| | - Daphna Y Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; and
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; and
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; and
| | - Jamie E Chaft
- Thoracic Oncology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; and
| | - Daniel R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; and
| | - Joseph O Deasy
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Narek Shaverdian
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; and
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Rimner A, Ahmad U, Lobaugh SM, Zhang Z, Shepherd AF, Huang J, Antonicelli A, Girard N, Moser B, Filosso P, Lucchi M, Marom EM, Roden A, Detterbeck F, Ruffini E, Simone CB. Postoperative Radiation Therapy for Thymic Carcinoma: An Analysis of the International Thymic Malignancy Interest Group/European Society of Thoracic Surgeons Database. J Thorac Oncol 2024; 19:626-635. [PMID: 38070599 DOI: 10.1016/j.jtho.2023.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 11/28/2023] [Accepted: 12/04/2023] [Indexed: 01/06/2024]
Abstract
INTRODUCTION R0 resection and radiation therapy have been associated with improved overall survival (OS) in patients with thymic carcinoma (TC). Here, we analyzed which subgroups of patients derive the greatest benefit from postoperative radiation therapy (PORT). METHODS Clinical, pathologic, treatment, and survival information of 462 patients with TC from the International Thymic Malignancy Interest Group/European Society of Thoracic Surgeons database were analyzed. Variables included age, sex, continent of treatment, paraneoplastic syndrome, carcinoma subtype, tumor size, pathologic Masaoka stage, resection status, and use of chemotherapy. OS was the primary end point using the Kaplan-Meier method. Time to recurrence (TTR) was the secondary end point using a competing risk analysis. A 3-month landmark analysis was performed. RESULTS PORT was associated with a significant OS benefit (5-y OS 68% versus 53%, p = 0.002). In patients with R0 resection, PORT was associated with increased OS for advanced (stages III-IV, p = 0.04), but not early (stages I-II, p = 0.14) stage TC. In patients with an R1/2 resection of advanced-stage TC, PORT was associated with significantly longer OS (5-y OS 53% versus 38%; p < 0.001). Subset analyses did not reveal clear associations of PORT with TTR. On multivariable analysis, lower pathologic stage, PORT, and R0 resection status were associated with an OS benefit, whereas only higher age and lower pathologic stage had an association with longer TTR. CONCLUSIONS In the largest individual patient data set on patients with TC reported to date, PORT was associated with a meaningful OS benefit in patients with advanced-stage TC after an R0 or R1/2 resection.
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Affiliation(s)
- Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Usman Ahmad
- Department of Thoracic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Stephanie M Lobaugh
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Zhigang Zhang
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Annemarie F Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - James Huang
- Department of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alberto Antonicelli
- Department of Thoracic Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Nicolas Girard
- Department of Thoracic Oncology, Institut Curie, Paris, France
| | - Bernhard Moser
- Department of Thoracic Surgery, University of Vienna, Vienna, Austria
| | | | - Marco Lucchi
- Division of Thoracic Surgery, Cardiac and Thoracic Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Edith M Marom
- Department of Diagnostic Imaging, Chaim Sheba Medical Center, Tel-Aviv University, Ramat Gan, Israel
| | - Anja Roden
- Department of Pathology, Mayo Clinic, Rochester, Minnesota
| | - Frank Detterbeck
- Department of Thoracic Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Enrico Ruffini
- Department of Thoracic Surgery, University of Torino, Turin, Italy
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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Shin JY, Offin M, Simone CB, Shepherd AF, Wu AJ, Shaverdian N, Gelblum DY, Gomez DR, Sauter JL, Ginsberg MS, Adusumilli PS, Rusch VW, Zauderer MG, Rimner A. Response letter to "Stereotactic body radiation therapy for pleural mesothelioma: Which goal, which patients". Radiother Oncol 2024; 193:110138. [PMID: 38342346 DOI: 10.1016/j.radonc.2024.110138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 02/01/2024] [Indexed: 02/13/2024]
Affiliation(s)
- Jacob Y Shin
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA.
| | - Michael Offin
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Annemarie F Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Narek Shaverdian
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Daphna Y Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Daniel R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Jennifer L Sauter
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Michelle S Ginsberg
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Prasad S Adusumilli
- Department of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Valerie W Rusch
- Department of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Marjorie G Zauderer
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
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Shin JY, Offin M, Simone CB, Zhang Z, Shepherd AF, Wu AJ, Shaverdian N, Gelblum DY, Gomez DR, Sauter JL, Ginsberg MS, Adusumilli PS, Rusch VW, Zauderer MG, Rimner A. Clinical outcomes of stereotactic body radiation therapy for malignant pleural mesothelioma. Radiother Oncol 2024; 191:110057. [PMID: 38104783 PMCID: PMC10923065 DOI: 10.1016/j.radonc.2023.110057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 12/07/2023] [Accepted: 12/11/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND The objective of this study is to determine the outcomes and toxicities of patients with malignant pleural mesothelioma (MPM) treated with stereotactic body radiotherapy (SBRT). MATERIALS AND METHODS Data were extracted from an institutional tumor registry for patients diagnosed with mesothelioma and treated with SBRT. Kaplan-Meier and Cox regression analyses were employed to determine local control (LC) and overall survival (OS). RESULTS Forty-four patients with 59 total treated tumors from December 2006 to April 2022 were identified. Fifty-one (86.4 %) cases had oligoprogressive disease (five sites or less). The median prescription dose delivered was 3000 cGy in 5 fractions (range: 2700-6000 cGy in 3-8 fractions). Fifty-one (86.4 %) tumors were in the pleura, 4 (6.8 %) spine, 2 (3.4 %) bone, 1 (1.7 %) brain, and 1 (1.7 %) pancreas. The median follow-up from SBRT completion for those alive at last follow-up was 28 months (range: 14-52 months). The most common toxicities were fatigue (50.8 %), nausea (22.0 %), pain flare (15.3 %), esophagitis (6.8 %), dermatitis (6.8 %), and pneumonitis (5.1 %). There were no grade ≥ 3 acute or late toxicities. There were 2 (3.4 %) local failures, one of the pleura and another of the spine. One-year LC was 92.9 % (95 % CI: 74.6-98.2 %) for all lesions and 96.3 % (95 % CI: 76.5-99.5 %) for pleural tumors. One-year LC was 90.9 % (95 % CI: 68.1-97.6 %) for epithelioid tumors and 92.1 % (95 % CI: 72.1-98.0 %) for oligoprogressive tumors. One-year OS from time of SBRT completion was 36.4 % (95 % CI: 22.6-50.3 %). On multivariable analysis, KPS was the lone significant predictor for OS (p = 0.029). CONCLUSIONS Our single-institutional experience on patients with MPM suggests that SBRT is safe with a low toxicity profile and potentially achieve good local control.
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Affiliation(s)
- Jacob Y Shin
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States.
| | - Michael Offin
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Annemarie F Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Narek Shaverdian
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Daphna Y Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Daniel R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Jennifer L Sauter
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Michelle S Ginsberg
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Prasad S Adusumilli
- Department of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Valerie W Rusch
- Department of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Marjorie G Zauderer
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
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Tsai CJ, Yang JT, Shaverdian N, Patel J, Shepherd AF, Eng J, Guttmann D, Yeh R, Gelblum DY, Namakydoust A, Preeshagul I, Modi S, Seidman A, Traina T, Drullinsky P, Flynn J, Zhang Z, Rimner A, Gillespie EF, Gomez DR, Lee NY, Berger M, Robson ME, Reis-Filho JS, Riaz N, Rudin CM, Powell SN. Standard-of-care systemic therapy with or without stereotactic body radiotherapy in patients with oligoprogressive breast cancer or non-small-cell lung cancer (Consolidative Use of Radiotherapy to Block [CURB] oligoprogression): an open-label, randomised, controlled, phase 2 study. Lancet 2024; 403:171-182. [PMID: 38104577 PMCID: PMC10880046 DOI: 10.1016/s0140-6736(23)01857-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/27/2023] [Accepted: 08/31/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Most patients with metastatic cancer eventually develop resistance to systemic therapy, with some having limited disease progression (ie, oligoprogression). We aimed to assess whether stereotactic body radiotherapy (SBRT) targeting oligoprogressive sites could improve patient outcomes. METHODS We did a phase 2, open-label, randomised controlled trial of SBRT in patients with oligoprogressive metastatic breast cancer or non-small-cell lung cancer (NSCLC) after having received at least first-line systemic therapy, with oligoprogression defined as five or less progressive lesions on PET-CT or CT. Patients aged 18 years or older were enrolled from a tertiary cancer centre in New York, NY, USA, and six affiliated regional centres in the states of New York and New Jersey, with a 1:1 randomisation between standard of care (standard-of-care group) and SBRT plus standard of care (SBRT group). Randomisation was done with a computer-based algorithm with stratification by number of progressive sites of metastasis, receptor or driver genetic alteration status, primary site, and type of systemic therapy previously received. Patients and investigators were not masked to treatment allocation. The primary endpoint was progression-free survival, measured up to 12 months. We did a prespecified subgroup analysis of the primary endpoint by disease site. All analyses were done in the intention-to-treat population. The study is registered with ClinicalTrials.gov, NCT03808662, and is complete. FINDINGS From Jan 1, 2019, to July 31, 2021, 106 patients were randomly assigned to standard of care (n=51; 23 patients with breast cancer and 28 patients with NSCLC) or SBRT plus standard of care (n=55; 24 patients with breast cancer and 31 patients with NSCLC). 16 (34%) of 47 patients with breast cancer had triple-negative disease, and 51 (86%) of 59 patients with NSCLC had no actionable driver mutation. The study was closed to accrual before reaching the targeted sample size, after the primary efficacy endpoint was met during a preplanned interim analysis. The median follow-up was 11·6 months for patients in the standard-of-care group and 12·1 months for patients in the SBRT group. The median progression-free survival was 3·2 months (95% CI 2·0-4·5) for patients in the standard-of-care group versus 7·2 months (4·5-10·0) for patients in the SBRT group (hazard ratio [HR] 0·53, 95% CI 0·35-0·81; p=0·0035). The median progression-free survival was higher for patients with NSCLC in the SBRT group than for those with NSCLC in the standard-of-care group (10·0 months [7·2-not reached] vs 2·2 months [95% CI 2·0-4·5]; HR 0·41, 95% CI 0·22-0·75; p=0·0039), but no difference was found for patients with breast cancer (4·4 months [2·5-8·7] vs 4·2 months [1·8-5·5]; 0·78, 0·43-1·43; p=0·43). Grade 2 or worse adverse events occurred in 21 (41%) patients in the standard-of-care group and 34 (62%) patients in the SBRT group. Nine (16%) patients in the SBRT group had grade 2 or worse toxicities related to SBRT, including gastrointestinal reflux disease, pain exacerbation, radiation pneumonitis, brachial plexopathy, and low blood counts. INTERPRETATION The trial showed that progression-free survival was increased in the SBRT plus standard-of-care group compared with standard of care only. Oligoprogression in patients with metastatic NSCLC could be effectively treated with SBRT plus standard of care, leading to more than a four-times increase in progression-free survival compared with standard of care only. By contrast, no benefit was observed in patients with oligoprogressive breast cancer. Further studies to validate these findings and understand the differential benefits are warranted. FUNDING National Cancer Institute.
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Affiliation(s)
- Chiaojung Jillian Tsai
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.
| | - Jonathan T Yang
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Narek Shaverdian
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Juber Patel
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Annemarie F Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Juliana Eng
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David Guttmann
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Randy Yeh
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daphna Y Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Azadeh Namakydoust
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Isabel Preeshagul
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Shanu Modi
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrew Seidman
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tiffany Traina
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Pamela Drullinsky
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jessica Flynn
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Erin F Gillespie
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Daniel R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nancy Y Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michael Berger
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mark E Robson
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jorge S Reis-Filho
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nadeem Riaz
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Charles M Rudin
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Simon N Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Li X, Yorke E, Jackson A, Yue Y, Simone CB, Apte AP, Rimner A, Gomez DR, Shaverdian N, Gelblum DY, Wu AJ, Shepherd AF. Clinical and Dosimetric Risk Factors Associated With Radiation-Induced Lung Toxicities After Multiple Courses of Lung Stereotactic Body Radiation Therapy. Adv Radiat Oncol 2024; 9:101284. [PMID: 38260213 PMCID: PMC10801636 DOI: 10.1016/j.adro.2023.101284] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 05/27/2023] [Indexed: 01/24/2024] Open
Abstract
Purpose Data are limited on radiation-induced lung toxicities (RILT) after multiple courses of lung stereotactic body radiation therapy (SBRT). We herein analyze a large cohort of patients to explore the clinical and dosimetric risk factors associated with RILT in such settings. Methods and Materials A single institutional database of patients treated with multiple courses of lung SBRT between January 2014 and December 2019 was analyzed. Grade 2 or higher (G2+) RILT after the last course of SBRT was the primary endpoint. Composite plans were generated with advanced algorithms including deformable registration and equivalent dose adjustment. Logistic regression analyses were performed to examine correlations between patient or treatment factors including dosimetry and G2+ RILT. Risk stratification of patients and lung constraints based on acceptable normal tissue complication probability were calculated based on risk factors identified. Results Among 110 eligible patients (56 female and 54 male), there were 64 synchronous (58.2%; defined as 2 courses of SBRT delivered within 30 days) and 46 metachronous (41.8%) courses of SBRT. The composite median lung V20, lung V5, and mean lung dose were 9.9% (interquartile range [IQR], 7.3%-12.4%), 32.2% (IQR, 25.5%-40.1%), and 7.0 Gy (IQR, 5.5 Gy-8.6 Gy), respectively. With a median follow-up of 21.1 months, 30 patients (27.3%) experienced G2+ RILT. Five patients (4.5%) developed G3 RILT, and 1 patient (0.9%) developed G4 RILT, and no patients developed G5 RILT. On multivariable regression analysis, female sex (odds ratio [OR], 4.35; 95% CI, 1.49%-14.3%; P = .01), synchronous SBRT (OR, 8.78; 95% CI, 2.27%-47.8%; P = .004), prior G2+ RILT (OR, 29.8; 95% CI, 2.93%-437%; P = .007) and higher composite lung V20 (OR, 1.18; 95% CI, 1.02%-1.38%; P = .030) were associated with significantly higher likelihood of G2+ RILT. Conclusions Our data suggest an acceptable incidence of G2+ RILT after multiple courses of lung SBRT. Female sex, synchronous SBRT, prior G2+ RILT, and higher composite lung V20 may be risk factors for G2+ RILT.
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Affiliation(s)
- Xingzhe Li
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, Texas
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew Jackson
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yujuan Yue
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Charles B. Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Aditya P. Apte
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel R. Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Narek Shaverdian
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daphna Y. Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Abraham J. Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Annemarie F. Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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7
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Rimner A, Gelblum DY, Wu AJ, Shepherd AF, Mueller B, Zhang S, Cuaron J, Shaverdian N, Flynn J, Fiasconaro M, Zhang Z, von Reibnitz D, Li H, McKnight D, McCune M, Gelb E, Gomez DR, Simone CB, Deasy JO, Yorke ED, Ng KK, Chaft JE. Stereotactic Body Radiation Therapy for Stage IIA to IIIA Inoperable Non-Small Cell Lung Cancer: A Phase 1 Dose-Escalation Trial. Int J Radiat Oncol Biol Phys 2023:S0360-3016(23)08252-4. [PMID: 38154510 DOI: 10.1016/j.ijrobp.2023.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 12/10/2023] [Accepted: 12/15/2023] [Indexed: 12/30/2023]
Abstract
PURPOSE Larger tumors are underrepresented in most prospective trials on stereotactic body radiation therapy (SBRT) for inoperable non-small cell lung cancer (NSCLC). We performed this phase 1 trial to specifically study the maximum tolerated dose (MTD) of SBRT for NSCLC >3 cm. METHODS AND MATERIALS A 3 + 3 dose-escalation design (cohort A) with an expansion cohort at the MTD (cohort B) was used. Patients with inoperable NSCLC >3 cm (T2-4) were eligible. Select ipsilateral hilar and single-station mediastinal nodes were permitted. The initial SBRT dose was 40 Gy in 5 fractions, with planned escalation to 50 and 60 Gy in 5 fractions. Adjuvant chemotherapy was mandatory for cohort A and optional for cohort B, but no patients in cohort B received chemotherapy. The primary endpoint was SBRT-related acute grade (G) 4+ or persistent G3 toxicities (Common Terminology Criteria for Adverse Events version 4.03). Secondary endpoints included local failure (LF), distant metastases, disease progression, and overall survival. RESULTS The median age was 80 years; tumor size was >3 cm and ≤5 cm in 20 (59%) and >5 cm in 14 patients (41%). In cohort A (n = 9), 3 patients treated to 50 Gy experienced G3 radiation pneumonitis (RP), thus defining the MTD. In the larger dose-expansion cohort B (n = 25), no radiation therapy-related G4+ toxicities and no G3 RP occurred; only 2 patients experienced G2 RP. The 2-year cumulative incidence of LF was 20.2%, distant failure was 34.7%, and disease progression was 54.4%. Two-year overall survival was 53%. A biologically effective dose (BED) <100 Gy was associated with higher LF (P = .006); advanced stage and higher neutrophil/lymphocyte ratio were associated with greater disease progression (both P = .004). CONCLUSIONS Fifty Gy in 5 fractions is the MTD for SBRT to tumors >3 cm. A higher BED is associated with fewer LFs even in larger tumors. Cohort B appears to have had less toxicity, possibly due to the omission of chemotherapy.
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Affiliation(s)
- Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Radiation Oncology, University of Freiburg, Robert-Koch-Strasse 3, 79106 Freiburg, Germany.
| | - Daphna Y Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Annemarie F Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Boris Mueller
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Siyuan Zhang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing, China
| | - John Cuaron
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Narek Shaverdian
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jessica Flynn
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Megan Fiasconaro
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York; Flatiron Health, New York, New York
| | - Zhigang Zhang
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Donata von Reibnitz
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Surgery, Stadtspital Waid, Zurich, Switzerland
| | - Henry Li
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Dominique McKnight
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Megan McCune
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Emily Gelb
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joseph O Deasy
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ellen D Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kenneth K Ng
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jamie E Chaft
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
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8
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Rimner A, Huang J, Pagano A, Ginsberg M, Chang J, Riely G, Simone CB, Gomez DR, Shepherd AF. Phase II Study of Hemithoracic Intensity-Modulated Pleural Radiation Therapy (IMPRINT) for Patients with Pleural Metastases from Thymic Malignancies. Int J Radiat Oncol Biol Phys 2023; 117:e56-e57. [PMID: 37785717 DOI: 10.1016/j.ijrobp.2023.06.771] [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) Pleural metastases are common sites for recurrence and progression in patients with thymic malignancies. The management of pleural metastases typically involves surgical resection with or without neoadjuvant or adjuvant systemic therapy. After surgical resection of pleural metastases, the 5-year progression-free survival (PFS) rate is about 29-45%. While radiation therapy (RT) is standardly used in the management of locally-advanced thymic malignancies, the role of RT in patients with pleural metastases in unclear. Intensity-modulated pleural radiation therapy (IMPRINT) is a RT technique currently being used to treat malignant pleural mesothelioma (MPM) patients with 2 intact lungs at centers that specialize in MPM treatment. This IMPRINT technique can potentially be extrapolated to thymic patients with pleural metastases. Because the risk of toxicity is of greater concern for thymic patients given their overall relatively favorable prognosis, the rate of toxicity, particularly radiation pneumonitis, needs to be established in the thymic patient population. MATERIALS/METHODS This is a single-arm, single institution Phase II study of hemithoracic IMPRINT for patients with pleural metastases from thymic malignancies. The primary endpoint of this study is grade 3 or higher radiation pneumonitis within 4 months of completing RT. Secondary endpoints include any toxicity, progression-free survival, patterns of failure and overall survival. Patients must have a pathologically confirmed diagnosis of a thymic malignancy with radiologic or pathologic evidence of pleural metastases. Thymoma or thymic carcinoma are allowed. Patients may have de novo stage IVA disease or recurrent disease in the pleura. There must be no evidence of extrathoracic metastatic disease or contralateral pleural/pericardial disease. Surgical resection of the pleural nodules (ex: pleurectomy/decortication, debulking/metastasectomy) are allowed. Extrapleural pneumonectomy is not allowed. Patients are excluded if they have undergone prior thoracic radiation therapy preventing hemithoracic pleural IMRT, whereas prior thymic bed radiation and/or prior pleural SBRT are allowed. RT will be administered to the ipsilateral pleura to 50.4 Gy in 28 fractions. An optional dose-painting boost to gross disease up to 60 Gy while respecting normal tissue constraints is allowed. Patients can be treated with photon or proton therapy. Simulation, contouring and RT planning guidelines have been developed. Patients will be followed per protocol at regular intervals for at least 12 months following RT. The expected accrual is 36 patients over 4 years. Further information can be found on clinicaltrials.gov (NCT05354570). RESULTS To be determined. CONCLUSION To be determined.
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Affiliation(s)
- A Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - J Huang
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - A Pagano
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - M Ginsberg
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - J Chang
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - G Riely
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - D R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - A F Shepherd
- Memorial Sloan Kettering Cancer Center, New York, NY
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9
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Kratochvil LB, Lebow ES, Eichholz J, Gelblum D, Simone CB, Shepherd AF, Wu AJ, Shin JY, Rimner A, Isbell J, Li BT, Shaverdian N, Gomez DR. Prospective, Cell-Free Circulating Tumor DNA (ctDNA) Profiling in Locally Advanced Lung Cancer Treated with Chemoradiation. Int J Radiat Oncol Biol Phys 2023; 117:e31. [PMID: 37785120 DOI: 10.1016/j.ijrobp.2023.06.716] [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) Liquid biopsy for cell-free circulating tumor DNA (ctDNA) allows for non-invasive, comprehensive genomic profiling. We explored the utility prospective liquid biopsy for (ctDNA) in among non-small cell lung cancer (NSCLC) patients treated with definitive chemoradiation. MATERIALS/METHODS This prospective clinical cohort consists of unresectable, locally advanced NSCLC patients who had liquid biopsy testing prior to initiation of cancer therapy. Liquid biopsy testing was performed using a next-generation sequencing assay (MSK-ACCESS) which includes 129 genes and paired white blood cell sequencing. An FDA-recognized database (OncoKB) was utilized to classify alterations associated with radiation resistance (including KEAP1, NFE2L2, STK11, and PIK3CA) and radiation sensitivity (including ATM, ATR, BRCA1/2, ARID1A, MLH1 and other DNA Damage Repair Pathway alterations). We evaluated progression-free survival (PFS) from the completion of chemoradiation using the Log-rank test. RESULTS Among 25 patients with prospective ctDNA testing prior to therapy initiation, 17 patients had stage III disease (68%), 8 patients had stage II disease (32%), 18 patients had adenocarcinoma (72%), 7 patients had squamous cell carcinoma (28%), and 23 (92%) were former or current smokers. The median radiation dose was 60 Gy in 30 fractions (range: 55 to 66 Gy in 20 to 33 fractions). 76% of patients (n = 18) had one or more alterations detected (median: 3 alterations, range: 1 - 8) including genomic markers of radiation response in 2 patients in BRCA1/2 (n = 2) and radiation resistance in 1 patient in KEAP1. The most common driver alteration detected was KRAS in 24% of the cohort (n = 6). Among patients with baseline detectable ctDNA, the median PFS was 21.3 months and was not reached among patients without baseline ctDNA detection (HR 4.54, p = 0.04). CONCLUSION Using an institutional assay, the presence of baseline cell-free ctDNA appeared prognostic in patients with unresectable, locally advanced NSCLC treated with definitive chemoradiation. We also detected driver alterations and potential markers of radiation resistance and response using ctDNA testing. Prospective cell-free ctDNA profiling may offer pathways to therapy personalization among patients with locally advanced unresectable lung cancer.
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Affiliation(s)
| | - E S Lebow
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - J Eichholz
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - D Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - A F Shepherd
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - A J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - J Y Shin
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - A Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - J Isbell
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - B T Li
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - N Shaverdian
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - D R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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10
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Lin H, Yu F, Gorovets D, Kabarriti R, Alektiar KM, Ohri N, Hasan S, Tsai P, Shim A, Kang M, Barker CA, Wolden SL, Hajj C, Mehta KJ, Lee NY, Chhabra AM, Shepherd AF, Choi IJ, Yamada Y, Simone CB. Pencil Beam Scanning Proton Stereotactic Body Radiation Therapy (SBRT): A Robust Single Institution Experience. Int J Radiat Oncol Biol Phys 2023; 117:e686-e687. [PMID: 37786018 DOI: 10.1016/j.ijrobp.2023.06.2155] [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 describe the feasibility of treating a complex and diverse group of patients using pencil beam scanning (PBS) proton stereotactic body radiation therapy (SBRT: 5 or fewer fractions, with a fraction size of at least 5 Gy). MATERIALS/METHODS Our center treats on average 105-120 PBS proton treatments daily, of which 9.5% of treatment courses are proton SBRT. Statistics of disease sites, treatment planning parameters (target volume, prescriptions, number of fields, SFO vs. MFO), and treatment efficiencies (scheduled time slots, actual treatment time) are presented for 305 consecutive SBRT patients receiving 1507 fractions in the past three years. Thermoplastic masks or Vacuum-lock bags are used to immobilize SBRT patients and index the patients' treatment position. Imaging guidance of orthogonal kV images and volumetric cone-beam CT is routinely used for patient setup. RESULTS SBRT patients are grouped based on the target locations: pelvis (31%), liver (17%), thoracic (13%), spine (8%), abdominal (8%), brain (7%), non-spine bone (7%), ocular (6%), and head and neck (2%). Only 112 patients (37%) were receiving their 1st RT course, whereas 113 (37%) had one prior in-field RT course, and 80 (26%) had multiple prior in-field RT courses. The median [IQR] target volume was 65.4 [29.3, 168] cc (range: 0.3-2475 cc). 72% of cases were planned with SFO and 28% with MFO. On average, 3.76 fields (range: 2 to 12) were planned for each treatment. 44% of the treatments were planned with three or fewer fields, and 10% received more than five fields, most of which involved repainting for moving targets. Over 97% of treatments were delivered in 5 fractions, with ∼3% delivered in 3 fractions. The median [IQR] prescription per treatment was 8 [7, 10] Gy (range: 5-18 Gy per treatment). 85% (84%) of the SBRT treatments were scheduled (delivered) in a 45-minute or shorter slot, and 6% (7%) of treatments were scheduled (delivered) in over a one-hour slot, most commonly for multiple isocenter treatments. 93% of treatments were delivered within 15 minutes of the planned treatment time or shorter. Deep-inspiration breath-hold (DIBH) was applied to 45% of liver SBRT cases, with the remaining 55% planned on 4D CT with (14%) or without (86%) abdominal compression. DIBH was applied in 13% of lung SBRT cases. The application of other motion mitigation approaches, such as volumetric repainting, was determined by the target motion amplitude and whether the patient could tolerate DIBH. CONCLUSION In the most diverse and largest proton SBRT experience delivered in the world over the past 3 years, over 300 patients were treated, demonstrating the feasibility and efficiency of delivering proton SBRT in a very busy center. The planning and treatment parameter statistics reported serve as a helpful reference for the proton community.
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Affiliation(s)
- H Lin
- New York Proton Center, New York, NY; Memorial Sloan Kettering Cancer Center, New York, NY
| | - F Yu
- New York Proton Center, New York, NY
| | - D Gorovets
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - R Kabarriti
- Department of Radiation Oncology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
| | - K M Alektiar
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - N Ohri
- Department of Radiation Oncology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
| | - S Hasan
- New York Proton Center, New York, NY; Department of Radiation Oncology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
| | - P Tsai
- New York Proton Center, New York, NY
| | - A Shim
- New York Proton Center, New York, NY
| | - M Kang
- New York Proton Center, New York, NY
| | - C A Barker
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - S L Wolden
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - C Hajj
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - K J Mehta
- Department of Radiation Oncology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
| | - N Y Lee
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - A M Chhabra
- New York Proton Center, New York, NY; Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - A F Shepherd
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - I J Choi
- New York Proton Center, New York, NY; Memorial Sloan Kettering Cancer Center, New York, NY
| | - Y Yamada
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - C B Simone
- New York Proton Center, New York, NY; Memorial Sloan Kettering Cancer Center, New York, NY
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11
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Lebow ES, Lobaugh SM, Zhang Z, Dickson MA, Rosenbaum E, D'Angelo SP, Nacev BA, Shepherd AF, Shaverdian N, Wolden S, Wu AJ, Gelblum DY, Simone CB, Gomez DR, Alektiar K, Tap WD, Rimner A. Stereotactic body radiation therapy for sarcoma pulmonary metastases. Radiother Oncol 2023; 187:109824. [PMID: 37532104 DOI: 10.1016/j.radonc.2023.109824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/20/2023] [Accepted: 07/20/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND/PURPOSE Stereotactic body radiation therapy (SBRT) is standard for patients with inoperable early-stage NSCLC. We hypothesized that SBRT for sarcoma pulmonary metastases would achieve high rates of local control with acceptable toxicity and that patients with oligometastatic disease may achieve prolonged survival following SBRT. MATERIALS/METHODS This retrospective review included consecutive patients at our institution treated with SBRT for sarcoma pulmonary metastases. Cumulative incidence of local failure (LF) was estimated using a competing risks framework. RESULTS We identified 66 patients treated to 95 pulmonary metastases with SBRT. The median follow-up from the time of SBRT was 36 months (95% CI 34 - 53 months). The cumulative incidence of LF at 12 and 24 months was 3.1% (95% CI 0.9 - 10.6%) and 7.4% (95% CI 4.0% - 13.9%), respectively. The 12- and 24-month overall survival was 74% (95% CI 64 - 86%) and 49% (38 - 63%), respectively. Oligometastatic disease, intrathoracic only disease, and performance status were associated with improved survival on univariable analysis. Three patients had grade 2 pneumonitis, and one patient had grade 2 esophagitis. No patients had ≥ grade 3+ toxicities. CONCLUSION To the best of our knowledge, this is the largest series of patients treated with SBRT for pulmonary sarcoma metastases. We observed that SBRT offers an effective alternative to surgical resection with excellent local control and low proportions of toxicity.
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Affiliation(s)
- Emily S Lebow
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Stephanie M Lobaugh
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States.
| | - Zhigang Zhang
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Mark A Dickson
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Evan Rosenbaum
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Sandra P D'Angelo
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Benjamin A Nacev
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Annemarie F Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Narek Shaverdian
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Suzanne Wolden
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Daphna Y Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Daniel R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Kaled Alektiar
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - William D Tap
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States.
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12
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Thor M, Shepherd AF, Apte A, Gelblum D, Wu AJ, Simone CB, Chaft J, Rimner A, Gomez DR, Deasy JO, Shaverdian N. A Novel FDG PET and Mean Lung Dose Model to Identify Stage III NSCLC Patients at High Risk of Developing Early Radiation Pneumonitis. Int J Radiat Oncol Biol Phys 2023; 117:S169. [PMID: 37784422 DOI: 10.1016/j.ijrobp.2023.06.271] [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) Early radiation pneumonitis (RPEarly) is a primary reason for the premature discontinuation of durvalumab consolidation and can lead to poor survival in patients with stage III non-small cell lung cancer (NSCLC). Currently, there are no RP risk models specifically tested for RPEarly. Here, we tested the applicability of published RP models for predicting RPEarly and explored the value of integrating pretreatment FDG-PET parameters. MATERIALS/METHODS The cohort consisted of all 178 LA-NSCLC patients treated with concurrent chemoradiation (cCRT) and durvalumab between May 2017 and December 2021. RPEarly was defined as RP occurring within three months of cCRT completion; late RP (RPLate) was defined as any later occurring RP. The three published RP models analyzed included: 1) Mean lung dose (MLD), 2) MLD, age, pulmonary comorbidity, smoking status, and tumor location, and 3) MLD, age and pulmonary comorbidity. In addition, pretreatment FDG PET-CT scans were used to calculate SUV parameters from auto-segmented normal lung contours: 10th- and 90th percentile (SUVP10, SUVP90), maximum, mean (SUVmean), minimum, and standard deviation. The RP models were fit to RPEarly, RPLate, and RPEarly+Late in the 178 patients. To assess the association between FDG PET parameters and RP unbiasedly, the cohort was then randomly split, but enforcing similar RP rates, into a two-thirds derivation and a one-third validation subset. Model performance was assessed by AUC, p-values and the Hosmer-Lemeshow test (pHL; ideally ∼0.50). RESULTS The rates of RPEarly, RPLate, and RPEarly+Late were 12%, 11%, and 23%, respectively (corresponding to 21, 20, and 41 events). Only the MLD model significantly predicted RPEarly (AUC = 0.70; p = 0.04; pHL = 0.84); none of the three models predicted RPLate or RPEarly+Late. Among the FDG PET parameters, SUVP10, SUVP90 and SUVmean predicted RPEarly with similar performance (AUC = 0.69-0.73; p = 0.005-0.01; pHL = 0.68-0.72), and, therefore, bivariate models were built between MLD and each of SUVP10, SUVP90 and SUVmean. Only the MLD + SUVP90 model generalized in the validation subset (AUC = 0.63; p = 0.03; pHL = 0.89) and was thus deemed the final model for RPEarly. A final re-fitting of all model coefficients to the whole cohort indicated improvement over using the published MLD alone model (AUC = 0.75 vs. 0.70; p-value = 0.0006 vs. 0.04; pHL = 0.67 vs. 0.84). Risk of RPEarly is thus estimated as: RPEarly = 1/(1 = e-x); x = -5.79 + (1.57*MLD) + (0.14* SUVP90). CONCLUSION Patients at risk for RPEarly can be accurately identified prior to treatment by combining a re-fitted version of the published Mean Lung Dose model and pre-treatment FDG PET SUVP90 of the normal lung. This refined model can be used to identify patients with an exacerbated risk for premature durvalumab discontinuation due to RPEarly and could allow for interventions and/or the generation of "RPEarly sparing" treatment plans to improve overall treatment outcomes.
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Affiliation(s)
- M Thor
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - A F Shepherd
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - A Apte
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - D Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - A J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - J Chaft
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - A Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - D R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - J O Deasy
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - N Shaverdian
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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13
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Lebow ES, Shaverdian N, Eichholz JE, Kratochvil LB, McCune M, Murciano-Goroff YR, Jee J, Eng J, Chaft JE, Kris MG, Kalashnikova E, Feeney J, Scalise CB, Sudhaman S, Palsuledesai CC, Malhotra M, Krainock M, Sethi H, Aleshin A, Liu MC, Shepherd AF, Wu AJ, Simone CB, Gelblum DY, Johnson KA, Rudin CM, Gomez DR, Razavi P, Reis-Filho JS, Isbell JM, Li BT, Rimner A. ctDNA-based detection of molecular residual disease in stage I-III non-small cell lung cancer patients treated with definitive radiotherapy. Front Oncol 2023; 13:1253629. [PMID: 37795442 PMCID: PMC10546425 DOI: 10.3389/fonc.2023.1253629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 08/24/2023] [Indexed: 10/06/2023] Open
Abstract
Background Sensitive and reliable biomarkers for early detection of recurrence are needed to improve post-definitive radiation risk stratification, disease management, and outcomes for patients with unresectable early-stage or locally advanced non-small cell lung cancer (NSCLC) who are treated with definitive radiation therapy (RT). This prospective, multistate single-center, cohort study investigated the association of circulating tumor DNA (ctDNA) status with recurrence in patients with unresectable stage I-III NSCLC who underwent definitive RT. Methods A total of 70 serial plasma samples from 17 NSCLC patients were collected before, during, and after treatment. A personalized, tumor-informed ctDNA assay was used to track a set of up to 16 somatic, single nucleotide variants in the associated patient's plasma samples. Results Pre-treatment ctDNA detection rate was 82% (14/17) and varied based on histology and stage. ctDNA was detected in 35% (6/17) of patients at the first post-RT timepoint (median of 1.66 months following the completion of RT), all of whom subsequently developed clinical progression. At this first post-RT time point, patients with ctDNA-positivity had significantly worse progression-free survival (PFS) [hazard ratio (HR): 24.2, p=0.004], and ctDNA-positivity was the only significant prognostic factor associated with PFS (HR: 13.4, p=0.02) in a multivariate analysis. All patients who developed clinical recurrence had detectable ctDNA with an average lead time over radiographic progression of 5.4 months, and post-RT ctDNA positivity was significantly associated with poor PFS (p<0.0001). Conclusion Personalized, longitudinal ctDNA monitoring can detect recurrence early in patients with unresectable NSCLC patients undergoing curative radiation and potentially risk-stratify patients who might benefit most from treatment intensification.
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Affiliation(s)
- Emily S. Lebow
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
- The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Narek Shaverdian
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | | | | | - Megan McCune
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Yonina R. Murciano-Goroff
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Weill Cornell Medicine, Cornell University, New York, NY, United States
| | - Justin Jee
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Weill Cornell Medicine, Cornell University, New York, NY, United States
| | - Juliana Eng
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Weill Cornell Medicine, Cornell University, New York, NY, United States
| | - Jamie E. Chaft
- Weill Cornell Medicine, Cornell University, New York, NY, United States
| | - Mark G. Kris
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Weill Cornell Medicine, Cornell University, New York, NY, United States
| | | | | | | | | | | | | | | | | | | | | | | | - Abraham J. Wu
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | | | | | | | - Charles M. Rudin
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Weill Cornell Medicine, Cornell University, New York, NY, United States
| | - Daniel R. Gomez
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Pedram Razavi
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Weill Cornell Medicine, Cornell University, New York, NY, United States
| | | | - James M. Isbell
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Weill Cornell Medicine, Cornell University, New York, NY, United States
| | - Bob T. Li
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Weill Cornell Medicine, Cornell University, New York, NY, United States
| | - Andreas Rimner
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
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14
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Rimner A, Moore ZR, Lobaugh S, Geyer A, Gelblum DY, Abdulnour REE, Shepherd AF, Shaverdian N, Wu AJ, Cuaron J, Chaft JE, Zauderer MG, Eng J, Riely GJ, Rudin CM, Vander Els N, Chawla M, McCune M, Li H, Jones DR, Sopka DM, Simone CB, Mak R, Weinhouse GL, Liao Z, Gomez DR, Zhang Z, Paik PK. Randomized Phase 2 Placebo-Controlled Trial of Nintedanib for the Treatment of Radiation Pneumonitis. Int J Radiat Oncol Biol Phys 2023; 116:1091-1099. [PMID: 36889516 PMCID: PMC10751877 DOI: 10.1016/j.ijrobp.2023.02.030] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 01/08/2023] [Accepted: 02/15/2023] [Indexed: 03/09/2023]
Abstract
PURPOSE Radiation pneumonitis (RP) is the most common dose-limiting toxicity for thoracic radiation therapy. Nintedanib is used for the treatment of idiopathic pulmonary fibrosis, which shares pathophysiological pathways with the subacute phase of RP. Our goal was to investigate the efficacy and safety of nintedanib added to a prednisone taper compared with a prednisone taper alone in reducing pulmonary exacerbations in patients with grade 2 or higher (G2+) RP. METHODS AND MATERIALS In this phase 2, randomized, double-blinded, placebo-controlled trial, patients with newly diagnosed G2+ RP were randomized 1:1 to nintedanib or placebo in addition to a standard 8-week prednisone taper. The primary endpoint was freedom from pulmonary exacerbations at 1 year. Secondary endpoints included patient-reported outcomes and pulmonary function tests. Kaplan-Meier analysis was used to estimate the probability of freedom from pulmonary exacerbations. The study was closed early due to slow accrual. RESULTS Thirty-four patients were enrolled between October 2015 and February 2020. Of 30 evaluable patients, 18 were randomized to the experimental Arm A (nintedanib + prednisone taper) and 12 to the control Arm B (placebo + prednisone taper). Freedom from exacerbation at 1 year was 72% (confidence interval, 54%-96%) in Arm A and 40% (confidence interval, 20%-82%) in Arm B (1-sided, P = .037). In Arm A, there were 16 G2+ adverse events possibly or probably related to treatment compared with 5 in the placebo arm. There were 3 deaths during the study period in Arm A due to cardiac failure, progressive respiratory failure, and pulmonary embolism. CONCLUSIONS There was an improvement in pulmonary exacerbations by the addition of nintedanib to a prednisone taper. Further investigation is warranted for the use of nintedanib for the treatment of RP.
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Affiliation(s)
- Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center New York, NY, USA
| | - Zachary R. Moore
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center New York, NY, USA
| | - Stephanie Lobaugh
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center New York, NY, USA
| | - Alexander Geyer
- Department of Medicine, Memorial Sloan Kettering Cancer Center New York, NY, USA
- Department of Medicine, Weill Cornell Medical Center New York, NY, USA
| | - Daphna Y. Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center New York, NY, USA
| | - Raja-Elie E. Abdulnour
- Department of Pulmonary and Critical Care, Brigham and Women’s Hospital/Dana-Farber Cancer Institute Boston, MA, USA
| | - Annemarie F. Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center New York, NY, USA
| | - Narek Shaverdian
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center New York, NY, USA
| | - Abraham J. Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center New York, NY, USA
| | - John Cuaron
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center New York, NY, USA
| | - Jamie E. Chaft
- Department of Medicine, Memorial Sloan Kettering Cancer Center New York, NY, USA
- Department of Medicine, Weill Cornell Medical Center New York, NY, USA
| | - Marjorie G. Zauderer
- Department of Medicine, Memorial Sloan Kettering Cancer Center New York, NY, USA
- Department of Medicine, Weill Cornell Medical Center New York, NY, USA
| | - Juliana Eng
- Department of Medicine, Memorial Sloan Kettering Cancer Center New York, NY, USA
| | - Gregory J. Riely
- Department of Medicine, Memorial Sloan Kettering Cancer Center New York, NY, USA
- Department of Medicine, Weill Cornell Medical Center New York, NY, USA
| | - Charles M. Rudin
- Department of Medicine, Memorial Sloan Kettering Cancer Center New York, NY, USA
- Department of Medicine, Weill Cornell Medical Center New York, NY, USA
| | - Nicholas Vander Els
- Department of Medicine, Memorial Sloan Kettering Cancer Center New York, NY, USA
- Department of Medicine, Weill Cornell Medical Center New York, NY, USA
| | - Mohit Chawla
- Department of Medicine, Memorial Sloan Kettering Cancer Center New York, NY, USA
- Department of Medicine, Weill Cornell Medical Center New York, NY, USA
| | - Megan McCune
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center New York, NY, USA
| | - Henry Li
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center New York, NY, USA
| | - David R. Jones
- Department of Surgery Memorial Sloan Kettering Cancer Center New York, NY, USA
| | - Dennis M. Sopka
- Department of Radiation Oncology Lehigh Valley Health Network, MSK Alliance Allentown, PA, USA
| | - Charles B. Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center New York, NY, USA
| | - Raymond Mak
- Department of Radiation Oncology Brigham and Women’s Hospital/Dana-Farber Cancer Institute Boston, MA, USA
| | - Gerald L. Weinhouse
- Department of Pulmonary and Critical Care, Brigham and Women’s Hospital/Dana-Farber Cancer Institute Boston, MA, USA
| | - Zhongxing Liao
- Department of Radiation Oncology MD Anderson Cancer Center Houston, TX, USA
| | - Daniel R. Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center New York, NY, USA
| | - Zhigang Zhang
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center New York, NY, USA
| | - Paul K. Paik
- Department of Medicine, Memorial Sloan Kettering Cancer Center New York, NY, USA
- Department of Medicine, Weill Cornell Medical Center New York, NY, USA
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15
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Kang M, Choi JI, Souris K, Zhou J, Yu G, Shepherd AF, Ohri N, Lazarev S, Lin L, Lin H, Simone CB. Advances in treatment planning and management for the safety and accuracy of lung stereotactic body radiation therapy using proton pencil beam scanning: Simulation, planning, quality assurance, and delivery recommendations. J Radiosurg SBRT 2023; 9:53-62. [PMID: 38029008 PMCID: PMC10681141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 08/09/2023] [Indexed: 12/01/2023]
Abstract
This study presents the clinical experiences of the New York Proton Center in employing proton pencil beam scanning (PBS) for the treatment of lung stereotactic body radiation therapy. It encompasses a comprehensive examination of multiple facets, including patient simulation, delineation of target volumes and organs at risk, treatment planning, plan evaluation, quality assurance, and motion management strategies. By sharing the approaches of the New York Proton Center and providing recommendations across simulation, treatment planning, and treatment delivery, it is anticipated that the valuable experience will be provided to a broader proton therapy community, serving as a useful reference for future clinical practice and research endeavors in the field of stereotactic body proton therapy for lung tumors.
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Affiliation(s)
| | - J. Isabelle Choi
- New York Proton Center, New York, NY, USA
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York NY, USA
| | | | - Jun Zhou
- Emory University, Department of Radiation Oncology, Atlanta, GA, USA|
| | - Gang Yu
- New York Proton Center, New York, NY, USA
| | - Annemarie F. Shepherd
- New York Proton Center, New York, NY, USA
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York NY, USA
| | - Nitin Ohri
- New York Proton Center, New York, NY, USA
- Montefiore Medical Center, Department of Radiation Oncology, Bronx, NY, USA
| | - Stanislav Lazarev
- New York Proton Center, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, Department of Radiation Oncology, New York, NY, USA
| | - Liyong Lin
- Emory University, Department of Radiation Oncology, Atlanta, GA, USA|
| | - Haibo Lin
- New York Proton Center, New York, NY, USA
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York NY, USA
- Montefiore Medical Center, Department of Radiation Oncology, Bronx, NY, USA
| | - Charles B. Simone
- New York Proton Center, New York, NY, USA
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York NY, USA
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16
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McMillan MT, Shepherd AF, Kang M, Lin L, Shaverdian N, Wu AJ, Gelblum DY, Ohri N, Lazarev S, Xu L, Chhabra AM, Hasan S, Choi JI, Gomez DR, Rimner A, Lin H, Simone CB. Safety and efficacy of stereotactic body proton therapy for high-risk lung tumors. J Radiosurg SBRT 2023; 9:63-74. [PMID: 38029007 PMCID: PMC10681142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 07/11/2023] [Indexed: 12/01/2023]
Abstract
Purpose Stereotactic body proton therapy (SBPT) is an emerging treatment strategy for lung tumors that aims to combine the excellent local control benefits of ultra-hypofractionation with the physical advantages of protons, which reduce the integral dose to organs at risk (OARs) compared to photons. To date, however, very little data delivering SBPT in 5 or fewer fractions to lung tumors have been reported. Given that photon stereotactic body radiation therapy can struggle to deliver ablative doses to high-risk tumors (i.e., central/ultra-central location, prior in-field radiation, tumor size >5 cm, or the presence of severe pulmonary comorbidities) while adhering to OAR dose constraints, we hypothesized that SBPT would be an effective alternative for patients with high-risk tumors. Methods and Materials Twenty-seven high-risk patients with 29 lung tumors treated with SBPT at the New York Proton Center between December 2019 and November 2022 were retrospectively identified. Patients were divided into three major subgroups: early-stage non-small cell lung cancer (NSCLC), locally recurrent NSCLC, and metastatic cancer from lung cancer or other histologies. Patient characteristics were reported using descriptive statistics, actuarial methods were used to quantify disease control rates, and toxicities were scored using CTCAE v 5.0. Results The most common high-risk indications for SBPT were central/ultra-central tumor location (69.0%), severe COPD (48.1%), reirradiation (44.4%), significant pulmonary fibrosis (22.2%), and large tumor size > 5 cm (18.5%). In total, 96.6% of tumors were fully covered by the prescription dose without compromising target coverage. Three-year actuarial rates of local control for early-stage NSCLC, locally recurrent NSCLC, and metastatic patients were 89%, 100%, and 43%, respectively. Three-year actuarial rates of regional control were 89%, 67%, and 86%. Three-year actuarial rates of distant metastasis-free survival were 79%, 100%, and 0%. Two patients (7.4%), both of whom had clinically significant baseline interstitial lung disease and pre-treatment continuous oxygen demand, experienced grade ≥2 pulmonary toxicity (1 grade 3, 1 grade 5). There were no acute or late grade ≥2 toxicities related to esophagitis, cardiac injury, airway injury, pulmonary fibrosis, bronchopulmonary hemorrhage or brachial plexopathy. Conclusions In the largest study of proton SBRT reported to date, SBPT has a favorable toxicity profile while being an effective approach for treating most high-risk tumors without requiring dose de-escalation or compromising tumor coverage and warrants further investigation.
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Affiliation(s)
- Matthew T. McMillan
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, NY, USA
| | - Annemarie F. Shepherd
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, NY, USA
- New York Proton Center, New York, NY, USA
| | | | - Liyong Lin
- Emory University, Department of Radiation Oncology, Atlanta, GA, USA
| | - Narek Shaverdian
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, NY, USA
| | - Abraham J. Wu
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, NY, USA
| | - Daphna Y. Gelblum
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, NY, USA
| | - Nitin Ohri
- New York Proton Center, New York, NY, USA
- Montefiore Medical Center, Department of Radiation Oncology, Bronx, New York, USA
| | - Stanislav Lazarev
- New York Proton Center, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, Department of Radiation Oncology, New York, New York, USA
| | - Lee Xu
- New York Proton Center, New York, NY, USA
| | - Arpit M. Chhabra
- New York Proton Center, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, Department of Radiation Oncology, New York, New York, USA
| | - Shaakir Hasan
- New York Proton Center, New York, NY, USA
- Montefiore Medical Center, Department of Radiation Oncology, Bronx, New York, USA
| | - J. Isabelle Choi
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, NY, USA
- New York Proton Center, New York, NY, USA
| | - Daniel R. Gomez
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, NY, USA
| | - Andreas Rimner
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, NY, USA
| | - Haibo Lin
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, NY, USA
- New York Proton Center, New York, NY, USA
- Montefiore Medical Center, Department of Radiation Oncology, Bronx, New York, USA
| | - Charles B. Simone
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, NY, USA
- New York Proton Center, New York, NY, USA
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17
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Haseltine JM, Apte A, Jackson A, Yorke E, Yu AF, Plodkowski A, Wu A, Peleg A, Al-Sadawi M, Iocolano M, Gelblum D, Shaverdian N, Simone CB, Rimner A, Gomez DR, Shepherd AF, Thor M. Association of cardiac calcium burden with overall survival after radiotherapy for non-small cell lung cancer. Phys Imaging Radiat Oncol 2023; 25:100410. [PMID: 36687507 PMCID: PMC9852638 DOI: 10.1016/j.phro.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 12/05/2022] [Accepted: 01/03/2023] [Indexed: 01/07/2023] Open
Abstract
Background and purpose Coronary calcifications are associated with coronary artery disease in patients undergoing radiotherapy (RT) for non-small cell lung cancer (NSCLC). We quantified calcifications in the coronary arteries and aorta and investigated their relationship with overall survival (OS) in patients treated with definitive RT (Def-RT) or post-operative RT (PORT). Materials and methods We analyzed 263 NSCLC patients treated from 2004 to 2017. Calcium burden was ascertained with a Hounsfield unit (HU) cutoff of > 130 in addition to a deep learning (DL) plaque estimator. The HU cutoff volumes were defined for coronary arteries (PlaqueCoro) and coronary arteries and aorta combined (PlaqueCoro+Ao), while the DL estimator ranged from 0 (no plaque) to 3 (high plaque). Patient and treatment characteristics were explored for association with OS. Results The median PlaqueCoro and PlaqueCoro+Ao was 0.75 cm3 and 0.87 cm3 in the Def-RT group and 0.03 cm3 and 0.52 cm3 in the PORT group. The median DL estimator was 2 in both cohorts. In Def-RT, large PlaqueCoro (HR:1.11 (95%CI:1.04-1.19); p = 0.008), and PlaqueCoro+Ao (HR:1.06 (95%CI:1.02-1.11); p = 0.03), and poor Karnofsky Performance Status (HR: 0.97 (95%CI: 0.94-0.99); p = 0.03) were associated with worse OS. No relationship was identified between the plaque volumes and OS in PORT, or between the DL plaque estimator and OS in either Def-RT or PORT. Conclusions Coronary artery calcification assessed from RT planning CT scans was significantly associated with OS in patients who underwent Def-RT for NSCLC. This HU thresholding method can be straightforwardly implemented such that the role of calcifications can be further explored.
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Affiliation(s)
- Justin M. Haseltine
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Aditya Apte
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Andrew Jackson
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Anthony F. Yu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Andrew Plodkowski
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Abraham Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Ariel Peleg
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Mohammed Al-Sadawi
- Department of Medicine, Stony Brook University Hospital, Stony Brook, NY 11794, USA
| | - Michelle Iocolano
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Daphna Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Narek Shaverdian
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Charles B. Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Daniel R. Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Annemarie F. Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
- Corresponding authors.
| | - Maria Thor
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
- Corresponding authors.
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18
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McMillan MT, Kang M, Shepherd AF, Liu W, Lin L, Lin H, Simone CB. Stereotactic body proton therapy for non-small cell lung cancer: Clinical indications and recommendations. J Radiosurg SBRT 2023; 9:17-32. [PMID: 38029014 PMCID: PMC10681144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/11/2023] [Indexed: 12/01/2023]
Abstract
Stereotactic body radiation therapy (SBRT) has emerged as a standard treatment approach for early-stage lung cancer and intrathoracic oligometastatic or oligoprogressive disease. While local control is often excellent with this modality when delivered with photon therapy, toxicities for select patients can be significant. Proton therapy offers a unique opportunity to widen the therapeutic window when treating patients with thoracic malignancies requiring or benefitting from ultra-high doses per fraction. Thoracic proton SBRT may be particularly beneficial in cases requiring dose escalation, for tumors >5 cm, for central or ultra-central tumors, for reirradiation, in patients with interstitial lung diseases, and when combining radiation with immunotherapy. These clinical indications are detailed, along with supporting literature and clinical recommendations. Other considerations, future directions and potential benefits of proton SBRT, including sparing lymphocytes, when delivered as intensity-modulated proton therapy or as FLASH, and for the treatment of locally advanced non-small cell lung cancer or in patients with homologous recombination repair deficiencies, are also discussed.
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Affiliation(s)
- Matthew T. McMillan
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, NY, USA
| | | | - Annemarie F. Shepherd
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, NY, USA
- New York Proton Center, New York, NY, USA
| | - Wei Liu
- Mayo Clinic, Department of Radiation Oncology, Phoenix, AZ, USA
| | - Liyong Lin
- Emory University, Department of Radiation Oncology, Atlanta, GA, USA
| | - Haibo Lin
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, NY, USA
- New York Proton Center, New York, NY, USA
| | - Charles B. Simone
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, NY, USA
- New York Proton Center, New York, NY, USA
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19
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Rimner A, Adusumilli PS, Offin MD, Solomon SB, Ziv E, Hayes SA, Ginsberg MS, Sauter JL, Gelblum DY, Shepherd AF, Guttmann DM, Eichholz JE, Zhang Z, Ritter E, Wong P, Iqbal AN, Daly RM, Namakydoust A, Li H, McCune M, Gelb EH, Taunk NK, von Reibnitz D, Tyagi N, Yorke ED, Rusch VW, Zauderer MG. A Phase 1 Safety Study of Avelumab Plus Stereotactic Body Radiation Therapy in Malignant Pleural Mesothelioma. JTO Clin Res Rep 2022; 4:100440. [PMID: 36590015 PMCID: PMC9801123 DOI: 10.1016/j.jtocrr.2022.100440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/11/2022] [Accepted: 11/17/2022] [Indexed: 12/02/2022] Open
Abstract
Introduction Single-agent monoclonal antibody therapy against programmed death-ligand 1 (PD-L1) has modest effects in malignant pleural mesothelioma. Radiation therapy can enhance the antitumor effects of immunotherapy. Nevertheless, the safety of combining anti-PD-L1 therapy with stereotactic body radiation therapy (SBRT) is unknown. We present the results of a phase 1 trial to evaluate the safety of the anti-PD-L1 antibody avelumab plus SBRT in patients with malignant pleural mesothelioma. Methods This was a single-arm, investigator-initiated trial in patients who progressed on prior chemotherapy. Avelumab was delivered every other week, and SBRT was delivered to one lesion in three to five fractions (minimum of 30 Gy) followed by continuation of avelumab up to 24 months or until disease progression. The primary end point of the study was safety on the basis of grade 3+ nonhematologic adverse events (AEs) within 3 months of SBRT. Results Thirteen assessable patients received a median of seven cycles (range: 2-26 cycles) of avelumab. There were 27 grade 1, 17 grade 2, four grade 3, and no grade 4 or 5 avelumab-related AEs. The most common were infusion-related allergic reactions (n = 6), anorexia or weight loss (n = 6), fatigue (n = 6), thyroid disorders (n = 5), diarrhea (n = 3), and myalgia or arthralgias (n = 3). There were 10 grade 1, four grade 2, one grade 3, and no grade 4 or 5 SBRT-related AEs. The most common were diarrhea (n = 3), chest pain/myalgia (n = 2), fatigue (n = 2), cough (n = 2), dyspnea (n = 2), and nausea/vomiting (n = 2). Conclusions Combination avelumab plus SBRT seems tolerable on the basis of the prespecified toxicity end points of the first stage of this Simon two-stage design phase 1 study.
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Affiliation(s)
- Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, New York,Corresponding author. Address for correspondence: Andreas Rimner, MD, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 530 East 74th Street, New York, NY 10021.
| | - Prasad S. Adusumilli
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, New York
| | - Michael D. Offin
- Thoracic Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, New York
| | - Stephen B. Solomon
- Department of Radiology, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, New York
| | - Etay Ziv
- Department of Radiology, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, New York
| | - Sara A. Hayes
- Department of Radiology, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, New York
| | - Michelle S. Ginsberg
- Department of Radiology, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, New York
| | - Jennifer L. Sauter
- Department of Pathology, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, New York
| | - Daphna Y. Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, New York
| | - Annemarie F. Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, New York
| | - David M. Guttmann
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, New York
| | - Jordan E. Eichholz
- Thoracic Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, New York
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, New York
| | - Erika Ritter
- Department of Immune Monitoring Core Facility, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, New York
| | - Phillip Wong
- Department of Immune Monitoring Core Facility, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, New York
| | - Afsheen N. Iqbal
- Thoracic Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, New York
| | - Robert M. Daly
- Thoracic Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, New York
| | - Azadeh Namakydoust
- Thoracic Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, New York
| | - Henry Li
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, New York
| | - Megan McCune
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, New York
| | - Emily H. Gelb
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, New York
| | - Neil K. Taunk
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, New York
| | - Donata von Reibnitz
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, New York
| | - Neelam Tyagi
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, New York
| | - Ellen D. Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, New York
| | - Valerie W. Rusch
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, New York
| | - Marjorie G. Zauderer
- Thoracic Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, New York, New York
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20
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Hubbeling H, Choudhury N, Flynn J, Zhang Z, Falcon C, Rusch VW, Park BJ, Ziv E, Shaverdian N, Gelblum DY, Shepherd AF, Simone CB, Wu AJ, Gomez DR, Drilon A, Rimner A. Outcomes With Local Therapy and Tyrosine Kinase Inhibition in Patients With ALK/ ROS1/ RET-Rearranged Lung Cancers. JCO Precis Oncol 2022; 6:e2200024. [PMID: 36201714 PMCID: PMC9848570 DOI: 10.1200/po.22.00024] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 05/08/2022] [Accepted: 08/08/2022] [Indexed: 11/06/2022] Open
Abstract
PURPOSE Local therapy prolongs progression-free survival in patients with oligometastatic non-small-cell lung cancers treated with chemotherapy. We previously reported that local therapy also prolongs survival and time to next therapy in patients on tyrosine kinase inhibitors (TKIs) for EGFR-mutant lung adenocarcinomas. Here, we investigate the role of local therapy in patients progressing on TKIs for ALK/ROS1/RET-rearranged lung adenocarcinomas. MATERIALS AND METHODS Patients with advanced ALK/ROS/RET-rearranged lung adenocarcinomas who underwent radiation, surgery, or percutaneous thermal ablation from 2012 to 2020 for progression on an ALK/ROS1/RET TKI were included. Progression patterns were identified. Times from local therapy to progression, next therapy, and death were measured. RESULTS Sixty-one patients with ALK (n = 37), ROS1 (n = 12), and RET (n = 12) fusions were identified. Patients received radiotherapy (92%), surgery (13%), and percutaneous thermal ablation (8%). Local therapy was administered for solitary/oligoprogressive (94%) or polyprogressive (6%) disease. For most patients (85%), local therapy addressed all progressing sites. The median times from any local therapy to subsequent progression and next systemic therapy were 6.8 months (95% CI, 5.1 to 8.1) and 10 months (95% CI, 8.4 to 15.3), respectively. Third or greater local therapy was associated with shorter time to progression and next therapy than first/second local therapies (hazard ratio, 4.97; P < .001 and hazard ratio, 2.48; P < .001). The median overall survival from first local therapy was 34 months (95% CI, 26 to not reached). CONCLUSION Local therapy for progression on ALK, ROS1, or RET TKIs is associated with clinically meaningful time on continued TKI therapy beyond progression, especially earlier in the course of disease.
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Affiliation(s)
- Harper Hubbeling
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Noura Choudhury
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jessica Flynn
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Zhigang Zhang
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Christina Falcon
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Valerie W. Rusch
- Department of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Bernard J. Park
- Department of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Etay Ziv
- Department of Interventional Radiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Narek Shaverdian
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Daphna Y. Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Annemarie F. Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Charles B. Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Abraham J. Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Daniel R. Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alexander Drilon
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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21
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Shepherd AF, Rimner A. Radiation strategy and techniques for metastatic pleural disease from thymic malignancies: extended abstract. Mediastinum 2022; 6:27. [PMID: 36164364 PMCID: PMC9385872 DOI: 10.21037/med-21-61] [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] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 06/01/2022] [Indexed: 06/16/2023]
Affiliation(s)
- Annemarie F Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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22
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Roden AC, Ahmad U, Cardillo G, Girard N, Jain D, Marom EM, Marx A, Moreira AL, Nicholson AG, Rajan A, Shepherd AF, Simone CB, Strange CD, Szolkowska M, Truong MT, Rimner A. Thymic Carcinomas-A Concise Multidisciplinary Update on Recent Developments From the Thymic Carcinoma Working Group of the International Thymic Malignancy Interest Group. J Thorac Oncol 2022; 17:637-650. [PMID: 35227908 PMCID: PMC11080660 DOI: 10.1016/j.jtho.2022.01.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 01/07/2022] [Accepted: 01/29/2022] [Indexed: 10/19/2022]
Abstract
Thymic carcinomas are rare malignancies that in general arise in the prevascular (anterior) mediastinum. These tumors are usually invasive, often present at advanced stages, and typically behave aggressively. Studies are hampered by the paucity of these tumors, the large variety of carcinoma subtypes, and the lack of unique morphologic and immunophenotypic features. Despite these challenges, advances in diagnostic imaging, surgical approaches, systemic therapies, and radiation therapy techniques have been made. The WHO classification of thymic epithelial tumors has been updated in 2021, and the eighth tumor nodal metastasis staging by the American Joint Committee on Cancer/Union for International Cancer Control included thymic carcinomas in 2017. Molecular alterations that provide more insight into the pathogenesis of these tumors and that potentially permit use of novel targeted therapies are increasingly being identified. New approaches to radiation therapy, chemotherapy, and immunotherapy are under evaluation. International societies, including the International Thymic Malignancy Interest Group, European Society of Thoracic Surgeons, and Japanese, Chinese, and Korean thymic associations, have been critical in organizing and conducting multi-institutional clinical studies. Herein, we review contemporary multidisciplinary perspectives in diagnosis and management of thymic carcinoma.
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Affiliation(s)
- Anja C Roden
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota.
| | - Usman Ahmad
- Department of Cardiothoracic Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Giuseppe Cardillo
- Department of Thoracic Surgery, Carlo Forlanini Hospital, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - Nicolas Girard
- Institut Curie, Institut du thorax Curie Montsouris, Paris, France; Université de Versailles Saint-Quentin-en-Yvelines (UVSQ), Paris Saclay Campus, Versailles, France
| | - Deepali Jain
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Edith M Marom
- Radiology Department, The Chaim Sheba Medical Center Affiliated With Tel Aviv University, Tel Aviv, Israel
| | - Alexander Marx
- Institute of Pathology, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Andre L Moreira
- Department of Pathology, New York University Langone Health, New York, New York
| | - Andrew G Nicholson
- Department of Histopathology, Royal Brompton and Harefield Hospitals, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Arun Rajan
- Thoracic and Gastrointestinal Malignancies Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Annemarie F Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center and New York Proton Center, New York, New York
| | - Chad D Strange
- Division of Diagnostic Imaging, MD Anderson Cancer Center, Houston, Texas
| | - Malgorzata Szolkowska
- Department of Pathology, National Tuberculosis and Lung Diseases Research Institute, Warsaw, Poland
| | - Mylene T Truong
- Division of Diagnostic Imaging, MD Anderson Cancer Center, Houston, Texas
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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23
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Thor M, Shepherd AF, Preeshagul I, Offin M, Gelblum DY, Wu AJ, Apte A, Simone CB, Hellmann MD, Rimner A, Chaft JE, Gomez DR, Deasy JO, Shaverdian N. Pre-treatment immune status predicts disease control in NSCLCs treated with chemoradiation and durvalumab. Radiother Oncol 2022; 167:158-164. [PMID: 34942280 PMCID: PMC9518843 DOI: 10.1016/j.radonc.2021.12.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/08/2021] [Accepted: 12/11/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND The impact of peripheral blood immune measures and radiation-induced lymphopenia on outcomes in non-small cell lung cancer (NSCLC) patients treated with concurrent chemoradiation (cCRT) and immune check point inhibition (ICI) has yet to be fully defined. METHODS Stage III NSCLC patients treated with cCRT and ≥1 dose of durvalumab across a cancer center were examined. Peripheral blood counts were assessed pre-cCRT, during cCRT and at the start of ICI. These measures and risk-scores from two published models estimating radiation dose to immune-bearing organs were tested for association with disease control. RESULTS We assessed 113 patients treated with cCRT and a median of 8.5 months of durvalumab. Median PFS was 29 months (95% CI 18-35 months). A lower pre-cCRT ALC (HR: 0.51 (95% CI: 0.32-0.82), p = 0.02) and a higher pre-cCRT ANC (HR: 1.14 (1.06-1.23), p = 0.005) were associated with poor PFS. Neither ALC nadir, ALC at ICI start, ANC at ICI start or the normalized change in ALC from pre-cCRT to nadir were significantly associated with PFS (p = 0.07-0.49). Also, risk scores from the two radiation-dose models were not associated with PFS (p = 0.14, p = 0.21) but were so with the ALC Nadir (p = 0.001, p = 0.002). A higher pre-cCRT NLR was the strongest predictor for PFS (HR: 1.09 (1.05-1.14), p = 0.0001). The 12-month PFS in patients with the bottom vs. top NLR tertile was 84% vs 46% (p = 0.000004). CONCLUSIONS Baseline differences in peripheral immune cell populations are associated with disease outcomes in NSCLC patients treated with cCRT and ICI.
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Affiliation(s)
- Maria Thor
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center,1275 York Ave, New York, New York, United States
| | - Annemarie F. Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center,1275 York Ave, New York, New York, United States
| | - Isabel Preeshagul
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, New York, United States
| | - Michael Offin
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, New York, United States
| | - Daphna Y. Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center,1275 York Ave, New York, New York, United States
| | - Abraham J. Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center,1275 York Ave, New York, New York, United States
| | - Aditya Apte
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center,1275 York Ave, New York, New York, United States
| | - Charles B. Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center,1275 York Ave, New York, New York, United States
| | - Matthew D. Hellmann
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, New York, United States
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center,1275 York Ave, New York, New York, United States
| | - Jamie E. Chaft
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, New York, United States
| | - Daniel R. Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center,1275 York Ave, New York, New York, United States
| | - Joseph O. Deasy
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center,1275 York Ave, New York, New York, United States
| | - Narek Shaverdian
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center,1275 York Ave, New York, New York, United States
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24
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Shepherd AF, Yu AF, Iocolano M, Leeman JE, Wild AT, Imber BS, Chaft JE, Offin M, Huang J, Isbell JM, Wu AJ, Gelblum DY, Shaverdian N, Simone CB, Gomez D, Yorke E, Jackson A, Rimner A. Increasing Heart Dose Reduces Overall Survival in Patients Undergoing Postoperative Radiation Therapy for NSCLC. JTO Clin Res Rep 2021; 2:100209. [PMID: 34590050 PMCID: PMC8474215 DOI: 10.1016/j.jtocrr.2021.100209] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/30/2021] [Accepted: 07/04/2021] [Indexed: 12/25/2022] Open
Abstract
Introduction Given the concern for cardiopulmonary toxicity in patients with NSCLC undergoing postoperative radiation therapy (PORT), the purpose of this study was to evaluate the association between heart dose and overall survival (OS) in patients undergoing PORT with modern techniques. Methods This is a retrospective study of consecutive patients with NSCLC treated with PORT between May 2004 and January 2017. Clinical records were reviewed and radiation dose distributions were analyzed for association with OS. Results A total of 284 patients were analyzed. At the time of surgery, most patients had pathologic American Joint Committee on Cancer seventh edition stage III disease (91.2 %) and received either preoperative or adjuvant chemotherapy (92.3 %). Most patients underwent a lobectomy (81.3 %) and had R0 (80.6 %) or R1 (19.4 %) resection. PORT was delivered with a median radiation dose of 54 Gy, and 70.4 % of patients were treated with intensity-modulated radiation therapy. Dosimetric variables across a large range of doses to the heart were highly significant (p < 0.05) for OS. The volume of the heart receiving 8 Gy (HV8) was the most significant dosimetric variable (p < 0.001), and the median HV8 was 35.5 %. The median OS was 33.2 versus 53.6 months (p < 0.005) for patients with HV8 above or below 35.5 %, respectively. On multivariable analysis accounting for other potential prognostic confounders, HV8 remained highly significant (p < 0.001). Conclusions The data reveal a strong correlation between increasing heart dose and OS in patients with NSCLC undergoing PORT. Taken together with the recently presented LungART trial, lowering heart dose in PORT patients may help to decrease the risk of morbidity and mortality and improve the therapeutic ratio of PORT.
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Affiliation(s)
- Annemarie F Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Anthony F Yu
- Department of Medicine, Cardiology, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Michelle Iocolano
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jonathan E Leeman
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Aaron T Wild
- Southeast Radiation Oncology Group, Levine Cancer Institute, Charlotte, North Carolina
| | - Brandon S Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Jamie E Chaft
- Department of Medical Oncology, Thoracic Oncology Service, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Michael Offin
- Department of Medical Oncology, Thoracic Oncology Service, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - James Huang
- Department of Surgery, Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - James M Isbell
- Department of Surgery, Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Daphna Y Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Narek Shaverdian
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Daniel Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Andrew Jackson
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York City, New York
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25
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Mah D, Yorke E, Zemanaj E, Han Z, Liu H, George J, Lambiase J, Czmielewski C, Lovelock DM, Rimner A, Shepherd AF. A Planning Comparison of IMRT vs. Pencil Beam Scanning for Deep Inspiration Breath Hold Lung Cancers. Med Dosim 2021; 47:26-31. [PMID: 34426041 DOI: 10.1016/j.meddos.2021.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 04/26/2021] [Revised: 07/09/2021] [Accepted: 07/20/2021] [Indexed: 12/25/2022]
Abstract
Deep inspiration breath hold (DIBH) has dosimetric advantages for lung cancer patients treated with external beam therapy, but is difficult for many patients to perform. Proton therapy permits sparing of the downstream organs at risk (OAR). We compared conventionally fractionated proton (p) and photon(x) plans on both free breathing (FB) and DIBH planning CTs to determine the effect of DIBH with proton therapy. We evaluated 24 plans from 6 lung cancer patients treated with photon DIBH on a prospective protocol. All patients were re-planned using pencil beam scanning (PBS) proton therapy. New plans were generated for FB datasets with both modalities. All plans were renormalized to 60 Gy. We evaluated dosimetric parameters for heart, lung and esophagus. We also compared FBp to DIBHx parameters to quantify how FBp plans compare to DIBHx plans. Significant differences were found for lung metrics V20 and mean lung dose between FB and DIBH plans regardless of treatment modality. Furthermore, lung metrics for FBp were comparable or superior to DIBHx, suggesting that FB protons may be a viable alternative for those patients that cannot perform DIBH with IMRT. The heart dose metrics were significantly different for the 5 out of 6 patients where the PTV overlapped the heart as DIBH moved heart out of the high dose volume. Heart dose metrics were further reduced by proton therapy. DIBH offers similar relative advantages for lung sparing for PBS as it does for IMRT but the magnitude of the DIBH related gains in OAR sparing were smaller for PBS than IMRT. FBp plans offer similar or better lung and heart sparing compared to DIBHx plans. For IMRT patients who have difficulty performing DIBH, FB protons may offer an alternative.
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Affiliation(s)
- Dennis Mah
- Department of Medical Physics, ProCure Proton Therapy Center, Somerset NJ 08873, USA.
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Entela Zemanaj
- Department of Medical Physics, ProCure Proton Therapy Center, Somerset NJ 08873, USA
| | - Zhiqiang Han
- Department of Medical Physics, ProCure Proton Therapy Center, Somerset NJ 08873, USA
| | - Haoyang Liu
- Department of Medical Physics, ProCure Proton Therapy Center, Somerset NJ 08873, USA
| | - Jobin George
- Department of Medical Physics, ProCure Proton Therapy Center, Somerset NJ 08873, USA
| | - Jason Lambiase
- Department of Medical Physics, ProCure Proton Therapy Center, Somerset NJ 08873, USA
| | - Christian Czmielewski
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - D Michael Lovelock
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Annemarie F Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
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26
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Shaverdian N, Offin M, Shepherd AF, Simone CB, Gelblum DY, Wu AJ, Hellmann MD, Rimner A, Paik PK, Chaft JE, Gomez DR. The Impact of Durvalumab on Local-Regional Control in Stage III NSCLCs Treated With Chemoradiation and on KEAP1-NFE2L2-Mutant Tumors. J Thorac Oncol 2021; 16:1392-1402. [PMID: 33992811 DOI: 10.1016/j.jtho.2021.04.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/25/2021] [Accepted: 04/30/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION KEAP1-NFE2L2-mutant NSCLCs are chemoradiation resistant and at high risk for local-regional failure (LRF) after concurrent chemoradiation (cCRT). To elucidate the impact of durvalumab on local-regional control, we evaluated LRF in patients with NSCLC treated with cCRT with and without durvalumab. METHODS Patients with stage III NSCLC treated with cCRT or cCRT and durvalumab who underwent tumor genomic profiling were evaluated. The incidence of LRF and outcomes of patients with and without KEAP1-NFE2L2-mutant tumors were evaluated. RESULTS We analyzed 120 consecutive patients (cCRT alone, n = 54; cCRT and durvalumab, n = 66). Patients treated with cCRT alone had significantly more LRF events compared with those treated with cCRT and durvalumab, with 12-month LRF incidence of 39% (95% confidence interval [CI]: 24%-54%) and 18% (95% CI: 8%-28%), respectively (p = 0.002). Among patients treated with cCRT alone and cCRT and durvalumab, 20 patients (37%) and 18 patients (27%), respectively, had KEAP1-NFE2L2-mutant tumors. In patients treated with cCRT alone, those with KEAP1-NFE2L2-mutant tumors had worse local-regional control (p = 0.015), and on multivariate analysis, KEAP1-NFE2L2 mutation predicted for LRF (hazard ratio = 3.9, 95% CI: 1.6-9.8, p = 0.003). Nevertheless, patients with and without KEAP1-NFE2L2-mutant tumors had similar LRF outcomes (p = 0.541) when treated with cCRT and durvalumab, and mutational status did not predict for LRF (p = 0.545). Among those with KEAP1-NFE2L2-mutant tumors, cCRT and durvalumab significantly reduced the incidence of LRF compared with cCRT alone: 12-month LRF incidence of 62% (95% CI: 40%-84%) versus 25% (95% CI: 4%-46%), respectively (p = 0.021). CONCLUSIONS Durvalumab after cCRT significantly improves local-regional control and reduces LRF in chemoradiation-resistant KEAP1-NFE2L2-mutant NSCLC tumors.
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Affiliation(s)
- Narek Shaverdian
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Michael Offin
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Annemarie F Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daphna Y Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Matthew D Hellmann
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Paul K Paik
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jamie E Chaft
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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Yorke ED, Thor M, Gelblum DY, Gomez DR, Rimner A, Shaverdian N, Shepherd AF, Simone CB, Wu A, McKnight D, Jackson A. Treatment planning and outcomes effects of reducing the preferred mean esophagus dose for conventionally fractionated non-small cell lung cancer radiotherapy. J Appl Clin Med Phys 2021; 22:42-48. [PMID: 33492763 PMCID: PMC7882106 DOI: 10.1002/acm2.13150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 11/20/2020] [Accepted: 12/08/2020] [Indexed: 12/13/2022] Open
Abstract
Based on an analysis of published literature, our department recently lowered the preferred mean esophagus dose (MED) constraint for conventionally fractionated (2 Gy/fraction in approximately 30 fractions) treatment of locally advanced non-small cell lung cancer (LA-NSCLC) with the goal of reducing the incidence of symptomatic acute esophagitis (AE). The goal of the change was to encourage treatment planners to achieve a MED close to 21 Gy while still permitting MED to go up to the previous guideline of 34 Gy in difficult cases. We compared all our suitable LA-NSCLC patients treated with plans from one year before through one year after the constraint change. The primary endpoint for this study was achievability of the new constraint by the planners; the secondary endpoint was reduction in symptomatic AE. Planners were able to achieve the new constraint in statistically significantly more cases during the year following its explicit implementation than in the year before (P = 0.0025). Furthermore, 38% of patients treated after the new constraint developed symptomatic AE during their treatment as opposed to 48% of the patients treated before. This is a clinically desirable endpoint although the observed difference was not statistically significant. A subsequent power calculation suggests that this is due to the relatively small number of patients in the study.
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Affiliation(s)
- Ellen D Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Maria Thor
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Daphna Y Gelblum
- Department of Radiation Oncology Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Daniel R Gomez
- Department of Radiation Oncology Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Andreas Rimner
- Department of Radiation Oncology Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Narek Shaverdian
- Department of Radiation Oncology Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Annemarie F Shepherd
- Department of Radiation Oncology Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Charles B Simone
- Department of Radiation Oncology Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Abraham Wu
- Department of Radiation Oncology Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Dominique McKnight
- Department of Radiation Oncology Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Andrew Jackson
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
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Shepherd AF, Preeshagul IR, Shaverdian N, Wu AJ, Gelblum DY, Gomez DR, Rimner A, Simone CB. Optimizing adjuvant therapy in EGFR-mutated non-small cell lung cancer. Ann Transl Med 2021; 8:1613. [PMID: 33437812 PMCID: PMC7791205 DOI: 10.21037/atm-20-3982] [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] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Annemarie F Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Radiation Oncology, New York Proton Center, New York, NY, USA
| | - Isabel R Preeshagul
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Narek Shaverdian
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daphna Y Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Radiation Oncology, New York Proton Center, New York, NY, USA
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29
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Shepherd AF, Iocolano M, Leeman J, Imber BS, Wild AT, Offin M, Chaft JE, Huang J, Rimner A, Wu AJ, Gelblum DY, Shaverdian N, Simone CB, Gomez DR, Yorke ED, Jackson A. Clinical and Dosimetric Predictors of Radiation Pneumonitis in Patients With Non-Small Cell Lung Cancer Undergoing Postoperative Radiation Therapy. Pract Radiat Oncol 2020; 11:e52-e62. [PMID: 33068790 DOI: 10.1016/j.prro.2020.09.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 08/03/2020] [Accepted: 09/28/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE Radiation pneumonitis (RP) is a common and potentially life-threatening toxicity from lung cancer radiation therapy. Data sets reporting RP rates after postoperative radiation therapy (PORT) have historically been small and with predominantly outdated field designs and radiation techniques. We examined a large cohort of patients in this context to assess the incidence and causes of RP in the modern era. METHODS AND MATERIALS We reviewed 285 patients with non-small cell lung cancer treated with PORT at our institution from May 2004 to January 2017. Complete dosimetric data and clinical records were reviewed and analyzed with grade 2 or higher RP as the endpoint (RP2+) (Common Terminology Criteria for Adverse Events v4.0). Patients were a median of 67 years old (range, 28-87), and most had pathologic stage III non-small cell lung cancer (91%) and received trimodality therapy (90%). Systematic dosimetric analyses using Dx increments of 5% and Vx increments of 2 Gy were performed to robustly evaluate dosimetric variables. Lung V5 was also evaluated. RESULTS The incidence of RP2+ after PORT was 12.6%. Dosimetric factors most associated with RP2+ were total lungV4 (hazard ratio [HR] 1.04, P < .001) and heart V16 (HR 1.03, P = .001). On univariate analysis, the clinical factors of age (HR 1.05, P = .006) and carboplatin chemotherapy (HR 2.32, P = .012) were correlated with RP2+. On step-up multivariate analysis, only bivariate models remained significant, including lungV5 (HR 1.037, P < .001) and age (HR 1.052, P = .011). CONCLUSIONS The incidence of RP after PORT is consistent with the literature. Factors correlated with RP include lung and heart doses, age, and carboplatin chemotherapy. These data also suggest that elderly patients may be more susceptible to lower doses of radiation to the lung. Based on these data, dose constraints to limit the risk of RP2+ to <5% in the setting of PORT include lungV5 ≤65% in patients <65 years old and lungV5 ≤36% in patients 65 years or older.
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Affiliation(s)
- Annemarie F Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Michelle Iocolano
- Department of Radiation Oncology, The Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jonathan Leeman
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts
| | - Brandon S Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Aaron T Wild
- Southeast Radiation Oncology Group, Charlotte, North Carolina
| | - Michael Offin
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jamie E Chaft
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - James Huang
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daphna Y Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Narek Shaverdian
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ellen D Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew Jackson
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
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30
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Shaverdian N, Beattie J, Thor M, Offin M, Shepherd AF, Gelblum DY, Wu AJ, Simone CB, Hellmann MD, Chaft JE, Rimner A, Gomez DR. Safety of thoracic radiotherapy in patients with prior immune-related adverse events from immune checkpoint inhibitors. Ann Oncol 2020; 31:1719-1724. [PMID: 33010460 DOI: 10.1016/j.annonc.2020.09.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [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: 07/05/2020] [Revised: 09/18/2020] [Accepted: 09/21/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) and thoracic radiotherapy are increasingly used to treat advanced cancers. Despite data indicating exaggerated radiation toxicities in patients with autoimmune disease, the safety of thoracic radiotherapy in patients with prior ICI-associated immune-related adverse events (irAEs) is undefined. PATIENTS AND METHODS Patients treated from 2014 to 2020 with ICIs were queried for receipt of corticosteroids and radiotherapy. Patients who received thoracic radiation after symptomatic irAEs were assessed for ≥grade 2 radiation pneumonitis (RP). Characteristics predictive of RP were assessed using logistic regression and response relationships were modeled. RESULTS Among 496 assessed patients, 41 with irAE history subsequently treated with thoracic radiotherapy were analyzed. Most irAEs were grade 2 (n = 21) and 3 (n = 19). Median time from irAE onset to radiotherapy was 8.1 months. Most patients received stereotactic body radiation therapy (n = 20) or hypofractionated radiotherapy (n = 18). In total, 25 patients (61%) developed ≥grade 2 RP at a median of 4 months from radiotherapy and 11 months from onset of irAEs. Three months from RP onset, 16 of 24 (67%) assessable patients had persistent symptoms. Among patients with prior ICI pneumonitis (n = 6), five patients (83%) developed ≥grade 2 RP (grade 2, n = 3; grade ≥3, n = 2). The mean lung radiation dose (MLD) predicted for RP (odds ratio: 1.60, P = 0.00002). The relationship between MLD and RP was strong (area under the receiver-operating characteristic curve: 0.85) and showed an exaggerated dose-response. Among patients with an MLD >5 Gy (n = 26), 21 patients (81%) developed ≥grade 2 RP. CONCLUSION This is the first study assessing the toxicity of radiotherapy among patients with prior irAEs from ICIs. Patients with prior irAEs were found to be at very high risk for clinically significant and persistent RP from thoracic radiotherapy. Careful consideration should be given to the possibility of an increased risk of RP, and close monitoring is recommended in these patients.
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Affiliation(s)
- N Shaverdian
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA.
| | - J Beattie
- Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, USA
| | - M Thor
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, USA
| | - M Offin
- Thoracic Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, USA
| | - A F Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - D Y Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - A J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - C B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - M D Hellmann
- Thoracic Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, USA
| | - J E Chaft
- Thoracic Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, USA
| | - A Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - D R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
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Shaverdian N, Shepherd AF, Rimner A, Wu AJ, Simone CB, Gelblum DY, Gomez DR. Need for Caution in the Diagnosis of Radiation Pneumonitis During the COVID-19 Pandemic. Adv Radiat Oncol 2020; 5:617-620. [PMID: 32377597 PMCID: PMC7199721 DOI: 10.1016/j.adro.2020.04.015] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 04/14/2020] [Accepted: 04/15/2020] [Indexed: 01/08/2023] Open
Abstract
PURPOSE Patients with cancer are at high risk for mortality from coronavirus disease 2019 (COVID-19). Radiation pneumonitis (RP) is a common toxicity of thoracic radiation therapy with clinical and imaging features that overlap with those of COVID-19; however, RP is treated with high-dose corticosteroids, which may exacerbate COVID-19-associated lung injury. We reviewed patients who presented with symptoms of RP during the intensification of a regional COVID-19 epidemic to report on their clinical course and COVID-19 testing results. METHODS AND MATERIALS The clinical course and chest computed tomography (CT) imaging findings of consecutive patients who presented with symptoms of RP in March 2020 were reviewed. The first regional COVID-19 case was diagnosed on March 1, 2020. All patients underwent COVID-19 qualitative RNA testing. RESULTS Four patients with clinical suspicion for RP were assessed. Three out of 4 patients tested positive for COVID-19. All patients presented with symptoms of cough and dyspnea. Two patients had a fever, of whom only 1 tested positive for COVID-19. Two patients started on an empirical high-dose corticosteroid taper for presumed RP, but both had clinical deterioration and ultimately tested positive for COVID-19 and required hospitalization. Chest CT findings in patients suspected of RP but ultimately diagnosed with COVID-19 showed ground-glass opacities mostly pronounced outside the radiation field. CONCLUSIONS As this pandemic continues, patients with symptoms of RP require diagnostic attention. We recommend that patients suspected of RP be tested for COVID-19 before starting empirical corticosteroids and for careful attention to be paid to chest CT imaging to prevent potential exacerbation of COVID-19 in these high-risk patients.
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Affiliation(s)
| | | | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Abraham J. Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Charles B. Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Daniel R. Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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32
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Samson P, Ning MS, Shaverdian N, Shepherd AF, Gomez DR, McGinnis GJ, Nitsch PL, Chmura S, O’Reilly MS, Lee P, Chang JY, Robinson C, Lin SH. Clinical and Radiographic Presentations of COVID-19 Among Patients Receiving Radiation Therapy for Thoracic Malignancies. Adv Radiat Oncol 2020; 5:700-704. [PMID: 32395673 PMCID: PMC7212983 DOI: 10.1016/j.adro.2020.04.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 04/23/2020] [Accepted: 04/27/2020] [Indexed: 12/23/2022] Open
Affiliation(s)
- Pamela Samson
- Department of Radiation Oncology, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Matthew S. Ning
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Narek Shaverdian
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Annemarie F. Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel R. Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Paige L. Nitsch
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Steven Chmura
- Department of Radiation Oncology, University of Chicago, Chicago, Illinois
| | | | - Percy Lee
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Joe Y. Chang
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Clifford Robinson
- Department of Radiation Oncology, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Steven H. Lin
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
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33
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Wu AJ, Rimner A, Shepherd AF, Gelblum DY, Shaverdian N, Yorke E, Simone CB, Gomez DR. Thoracic Radiation Therapy During Coronavirus Disease 2019: Provisional Guidelines from a Comprehensive Cancer Center within a Pandemic Epicenter. Adv Radiat Oncol 2020; 5:603-607. [PMID: 32318643 PMCID: PMC7169880 DOI: 10.1016/j.adro.2020.04.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 04/08/2020] [Accepted: 04/08/2020] [Indexed: 02/07/2023] Open
Abstract
Coronavirus disease 2019 is an unprecedented pandemic with significant and evolving impact on the practice of radiation oncology. Radiation oncology departments must anticipate and account for coronavirus disease 2019 exposure risk for both patients and staff. The potential for severe radiation therapy resource constraints, particularly due to staff illness, must also be considered. Here we present provisional guidelines for thoracic radiation therapy adopted at our facility, a high-volume cancer center located in a United States pandemic epicenter. Generally, these guidelines reflect the principle that where evidence-supported hypofractionated schedules with comparable efficacy and toxicity exist, the shortest such schedules should be employed. In addition, we discuss potential adaptations in the prioritization and timing of radiation therapy for thoracic malignancies under these circumstances.
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Affiliation(s)
- Abraham J. Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Annemarie F. Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daphna Y. Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Narek Shaverdian
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Charles B. Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel R. Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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34
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Shaverdian N, Thor M, Shepherd AF, Offin MD, Jackson A, Wu AJ, Gelblum DY, Yorke ED, Simone CB, Chaft JE, Hellmann MD, Gomez DR, Rimner A, Deasy JO. Radiation pneumonitis in lung cancer patients treated with chemoradiation plus durvalumab. Cancer Med 2020; 9:4622-4631. [PMID: 32372571 PMCID: PMC7333832 DOI: 10.1002/cam4.3113] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/12/2020] [Accepted: 04/22/2020] [Indexed: 12/13/2022] Open
Abstract
Introduction Durvalumab after concurrent chemoradiation (cCRT) is now standard of care for unresected stage III non–small cell lung cancer (NSCLC). However, there is limited data on radiation pneumonitis (RP) with this regimen. Therefore, we assessed RP and evaluated previously validated toxicity models in predicting for RP in patients treated with cCRT and durvalumab. Methods Patients treated with cCRT and ≥ 1 dose of durvalumab were evaluated to identify cases of ≥ grade 2 RP. The validity of previously published RP models was assessed in this cohort as well a reference cohort treated with cCRT alone. The timing and incidence of RP was compared between cohorts. Results In total, 11 (18%) of the 62 patients who received cCRT and durvalumab developed ≥ grade 2 RP a median of 3.4 months after cCRT. The onset of RP among patients treated with cCRT and durvalumab was significantly longer vs the reference cohort (3.4 vs 2.1 months; P = .01). Numerically more patients treated with cCRT and durvalumab developed RP than patients in the reference cohort (18% vs 9%, P = .09). Among patients treated with cCRT and durvalumab, 82% (n = 9) were responsive to treatment with high‐dose glucocorticoids. Previously published RP models widely underestimated the rate of RP in patients treated with cCRT and durvalumab [AUC ~ 0.50; p(Hosmer‐Lemeshow): 0.98‐1.00]. Conclusions Our data suggest a delayed onset of RP in patients treated with cCRT and durvalumab vs cCRT alone, and for RP to develop in a greater number of patients treated with cCRT and durvalumab. Previously published RP models significantly underestimate the rate of symptomatic RP among patients treated with cCRT and durvalumab.
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Affiliation(s)
- Narek Shaverdian
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Maria Thor
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Annemarie F Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Michael D Offin
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Andrew Jackson
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Daphna Y Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ellen D Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jamie E Chaft
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Matthew D Hellmann
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Daniel R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Joseph O Deasy
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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35
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Offin M, Shaverdian N, Rimner A, Lobaugh S, Shepherd AF, Simone CB, Gelblum DY, Wu AJ, Lee N, Kris MG, Rudin CM, Zhang Z, Hellmann MD, Chaft JE, Gomez DR. Clinical outcomes, local-regional control and the role for metastasis-directed therapies in stage III non-small cell lung cancers treated with chemoradiation and durvalumab. Radiother Oncol 2020; 149:205-211. [PMID: 32361014 DOI: 10.1016/j.radonc.2020.04.047] [Citation(s) in RCA: 35] [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: 02/21/2020] [Revised: 04/23/2020] [Accepted: 04/26/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND PURPOSE Concurrent chemoradiation (cCRT) and durvalumab is standard therapy for patients with unresectable stage III non-small-cell lung cancers (NSCLC). Data is limited on outcomes with this regimen outside of clinical trials. Local-regional control rates remain undefined. MATERIALS AND METHODS We reviewed patients with stage III unresectable NSCLCs treated between November 2017 and February 2019 with cCRT and ≥1 dose of durvalumab. We examined 12-month progression-free-survival (PFS), overall-survival (OS), toxicities, and the incidence and pattern of local-regional and metastatic failures. RESULTS Sixty-two patients (median follow-up 12 months) with median age of 66 years of which 73% had stage IIIB (n = 33) or IIIC (n = 12) disease started durvalumab a median of 1.5 months from the end of cCRT and were treated with a median of 8 months of durvalumab. Common reasons for stopping durvalumab included disease progression (32%, 20/62) and toxicity (24%, 15/62). The estimated 12-month PFS and OS were 65% (95% CI: 51-79%) and 85% (95% CI: 75-95%), respectively. The cumulative 12-month incidence of local-regional and distant failures were 18% (95% CI: 5.9-30%) and 30% (95% CI: 16.3-44.5%), respectively. Among patients with distant metastatic disease (n = 17), 47% had oligometastatic disease. High tumor mutation burden (≥8.8 mt/Mb) or PD-L1 (≥1% or PD-L1 ≥ 50%) did not predict improved PFS. CONCLUSIONS Outcomes with cCRT and durvalumab in practice align with the PACIFIC trial. A substantial minority of patients are candidates for metastasis-directed therapies at progression. Local regional outcomes appear improved to historical data of cCRT alone.
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Affiliation(s)
- Michael Offin
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, New York, United States.
| | - Narek Shaverdian
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, United States.
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, United States.
| | - Stephanie Lobaugh
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, United States.
| | - Annemarie F Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, United States.
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, United States.
| | - Daphna Y Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, United States.
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, United States.
| | - Nancy Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, United States.
| | - Mark G Kris
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, New York, United States.
| | - Charles M Rudin
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, New York, United States.
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, United States.
| | - Matthew D Hellmann
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, New York, United States.
| | - Jamie E Chaft
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, New York, United States.
| | - Daniel R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, United States.
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Yerramilli D, Xu AJ, Gillespie EF, Shepherd AF, Beal K, Gomez D, Yamada J, Tsai CJ, Yang TJ. Palliative Radiation Therapy for Oncologic Emergencies in the Setting of COVID-19: Approaches to Balancing Risks and Benefits. Adv Radiat Oncol 2020; 5:589-594. [PMID: 32363243 PMCID: PMC7194647 DOI: 10.1016/j.adro.2020.04.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 03/31/2020] [Accepted: 04/01/2020] [Indexed: 12/15/2022] Open
Abstract
Palliation of metastatic disease compromises a significant portion of radiation treatments in the United States. These patients present a unique challenge in resource-limited settings, as expeditious treatment is often required to prevent serious morbidity. In order to reduce the risk of infection with severe acute respiratory syndrome coronavirus-2 and maximize the benefit to patients, we present evidence-based recommendations for radiation in patients with oncologic emergencies. Radiation oncologists with expertise in the treatment of metastatic disease at a high-volume comprehensive cancer center reviewed the available evidence and recommended best practices for the treatment of common oncologic emergencies, with attention to balancing the risk of infection with severe acute respiratory syndrome coronavirus-2 and the potential morbidity of delaying treatment. Many prospective trials and national guidelines support the use of abbreviated courses of radiotherapy for patients with oncologic emergencies. As such, in the setting of the current coronavirus disease 2019 pandemic, the use of hypofractionated radiation therapy for patients requiring palliation for oncologic emergencies achieves desirable functional outcomes without compromising care.
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Affiliation(s)
- Divya Yerramilli
- PROMISE (Precision Radiation for Oligometastatic and Metastatic Disease) Program, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Amy J Xu
- PROMISE (Precision Radiation for Oligometastatic and Metastatic Disease) Program, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Erin F Gillespie
- PROMISE (Precision Radiation for Oligometastatic and Metastatic Disease) Program, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Annemarie F Shepherd
- PROMISE (Precision Radiation for Oligometastatic and Metastatic Disease) Program, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kathryn Beal
- PROMISE (Precision Radiation for Oligometastatic and Metastatic Disease) Program, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel Gomez
- PROMISE (Precision Radiation for Oligometastatic and Metastatic Disease) Program, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Josh Yamada
- PROMISE (Precision Radiation for Oligometastatic and Metastatic Disease) Program, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - C Jillian Tsai
- PROMISE (Precision Radiation for Oligometastatic and Metastatic Disease) Program, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - T Jonathan Yang
- PROMISE (Precision Radiation for Oligometastatic and Metastatic Disease) Program, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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Haseltine JM, Rimner A, Shepherd AF, Wu AJ, Gelblum DY, Shaverdian N, Gomez DR, Simone CB. Delivering safe and effective stereotactic body radiation therapy for patients with centrally located early stage non-small cell lung cancer. Chin Clin Oncol 2020; 9:39. [PMID: 32008333 DOI: 10.21037/cco.2019.12.17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 12/13/2019] [Indexed: 11/06/2022]
Affiliation(s)
- Justin M Haseltine
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Annemarie F Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA; New York Proton Center, New York, NY, USA
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daphna Y Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Narek Shaverdian
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA; New York Proton Center, New York, NY, USA
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Iocolano M, Wild AT, Hannum M, Zhang Z, Simone CB, Gelblum D, Wu AJ, Rimner A, Shepherd AF. Hypofractionated vs. conventional radiation therapy for stage III non-small cell lung cancer treated without chemotherapy. Acta Oncol 2020; 59:164-170. [PMID: 31608751 DOI: 10.1080/0284186x.2019.1675907] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background: Patients with unresectable locally advanced NSCLC who refuse or are not candidates for chemotherapy often receive radiation therapy (RT) alone. Hypofractionated RT (HFRT) regimens are becoming increasingly common. An analysis of the National Cancer Database (NCDB) was performed to evaluate the practice patterns and outcomes of HFRT vs. conventionally fractionated RT (CFRT) in patients with stage III NSCLC undergoing definitive RT alone.Material and methods: The NCDB was queried for all patients with stage III NSCLC diagnosed between 2004 and 2014 who received RT alone. CFRT was defined as patients treated to a total dose of 60-80 Gy in 1.8-2 Gy daily fractions. HFRT was defined as patients treated to a total dose of 50-80 Gy in 2.25-4 Gy fractions. Logistic regression, univariable and multivariable analyses (MVAs) for overall survival (OS) and propensity score matched analyses (PSMAs) were performed.Results: A total of 6490 patients were evaluated: 5378 received CFRT and 1112 received HFRT. Median CFRT dose was 66 Gy in 2 Gy fractions vs. 58.5 Gy in 2.5 Gy fractions for HFRT. HFRT was associated with older age, lower biological effective dose (BED10), academic facility type, higher T-stage and lower N-stage. On initial analysis, HFRT was associated with inferior OS (median 9.9 vs. 11.1 months, p<.001), but after adjusting for the imbalance in covariates such as age, BED10, T-stage and N-stage using PSMA, the difference in survival was no longer significant (p=.1).Conclusions: In the appropriate clinical context, HFRT can be an option for patients with locally advanced NSCLC who are not candidates for chemotherapy or surgical resection. HFRT needs to be further studied in prospective trials to evaluate toxicity and tumor control.
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Affiliation(s)
| | - Aaron T. Wild
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Margaret Hannum
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Charles B. Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daphna Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Abraham J. Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Annemarie F. Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Abstract
Between 1977 and 1988 144 patients with tumours of testicular origin were referred to the Queen Elizabeth Military Hospital at Woolwich. 140 of these were malignant and all but two were treated and followed. Three of the malignant lesions appeared to be extragonadal. During the 12 year period staging has become increasingly accurate and treatment protocols have improved. These changes are reflected in this series. Ten deaths from tumour occurred (6.9%) but only one of these in the last three years of the study period despite an increasing case load at the time. The clinical presentation, treatment, and results of treatment are presented and the advances of treatment and improvement of prognosis discussed.
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Affiliation(s)
- B A Price
- Department of Oncology, Queen Elizabeth Military Hospital, Woolwich, London
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40
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Silverman SH, Ambrose NS, Youngs DJ, Shepherd AF, Roberts AP, Keighley MR. The effect of peritoneal lavage with tetracycline solution on postoperative infection. A prospective, randomized, clinical trial. Dis Colon Rectum 1986; 29:165-9. [PMID: 3510839 DOI: 10.1007/bf02555014] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
A prospective randomized trial was performed to determine the value of tetracycline lavage in addition to systemic antibiotic prophylaxis in 159 patients undergoing elective and emergency intestinal operations. Tetracycline lavage was associated with a significant overall reduction in postoperative infection rates in 25 of 74 patients (34 percent) receiving saline lavage compared with 15 of 85 patients (18 percent) having tetracycline lavage (P less than 0.05). Tetracycline lavage was associated with a significant reduction in the counts of aerobic and anaerobic bacteria in the peritoneal fluid at the end of the operation (P less than 0.05 and P less than 0.01, respectively) and with a significant reduction of aerobes 24 hours postoperatively (P less than 0.02). Tetracycline lavage would appear to confer clinical benefit in preventing postoperative infection.
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Shepherd AF, Allan RN, Dykes PW, Keighley MR, Alexander-Williams J. The surgical treatment of gastroduodenal Crohn's disease. Ann R Coll Surg Engl 1985; 67:382-4. [PMID: 4073768 PMCID: PMC2498087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Crohn's disease can affect any part of the gastrointestinal tract. Gastroduodenal involvement is uncommon and was not recognised until 1949 (1). Since then approximately 200 cases have been described in several series in the world literature. This paper describes the clinical presentation and surgical management of ten patients treated in the Birmingham General Hospital between 1970 and 1984.
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