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Barbour AB, Blouw B, Taylor LP, Graber JJ, McGranahan T, Blau M, Halasz LM, Lo SS, Tseng YD, Venur V, Yang JT. Prognostic value of cerebrospinal fluid tumor cell count in leptomeningeal disease from solid tumors. J Neurooncol 2024; 167:509-514. [PMID: 38441840 DOI: 10.1007/s11060-024-04615-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 02/19/2024] [Indexed: 05/16/2024]
Abstract
PURPOSE Treatment decisions for leptomeningeal disease (LMD) rely on patient risk stratification, since clinicians lack objective prognostic tools. The introduction of rare cell capture technology for identification of cerebrospinal fluid tumor cells (CSF-TCs), such as CNSide assay, improved the sensitivity of LMD diagnosis, but prognostic value is unknown. This study assesses the prognostic value of CSF-TC density in patients with LMD from solid tumors. METHODS We conducted a retrospective cohort study of patients with newly diagnosed or previously treated LMD from a single institution who had CNSide assay testing for CSF-TCs from 2020 to 2023. Univariable and multivariable survival analyses were conducted with Cox proportional-hazards modeling. Maximally-selected rank statistics were used to determine an optimal cutpoint for CSF-TC density and survival. RESULTS Of 31 patients, 29 had CSF-TCs detected on CNSide. Median (interquartile range [IQR]) CSF-TC density was 67.8 (4.7-639) TCs/mL. CSF cytology was positive in 16 of 29 patients with positive CNSide (CNSide diagnostic sensitivity = 93.5%, negative predictive value = 85.7%). Median (IQR) survival from time of CSF-TC detection was 176 (89-481) days. On univariable and multivariable analysis, CSF-TC density was significantly associated with survival. An optimal cutpoint for dichotomizing survival by CSF-TC density was 19.34 TCs/mL. The time-dependent sensitivity and specificity for survival using this stratification were 76% and 67% at 6 months and 65% and 67% at 1 year, respectively. CONCLUSIONS CSF-TC density may carry prognostic value in patients with LMD from solid tumors. Integrating CSF-TC density into LMD patient risk-stratification may help guide treatment decisions.
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Affiliation(s)
- Andrew B Barbour
- Department of Radiation Oncology, University of Washington- Fred Hutchinson Cancer Center, Seattle, WA, USA
| | | | - Lynne P Taylor
- Department of Neurology, University of Washington- Alvord Brain Tumor Center, Seattle, WA, USA
| | - Jerome J Graber
- Department of Neurology, University of Washington- Alvord Brain Tumor Center, Seattle, WA, USA
| | - Tresa McGranahan
- Division of Hematology-Oncology, Scripps Cancer Center, La Jolla, CA, USA
| | - Molly Blau
- Department of Radiation Oncology, University of Washington- Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Lia M Halasz
- Department of Radiation Oncology, University of Washington- Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington- Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Yolanda D Tseng
- Department of Radiation Oncology, University of Washington- Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Vyshak Venur
- Department of Neurology, University of Washington- Alvord Brain Tumor Center, Seattle, WA, USA
- Division of Medical Oncology, University of Washington- Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Jonathan T Yang
- Department of Radiation Oncology, University of Washington- Fred Hutchinson Cancer Center, Seattle, WA, USA.
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Gillespie EF, Vaynrub M, Yang JT. Reply to A.W. Chan et al. J Clin Oncol 2024; 42:1328-1329. [PMID: 38320232 PMCID: PMC11095854 DOI: 10.1200/jco.23.02566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 12/01/2023] [Indexed: 02/08/2024] Open
Affiliation(s)
- Erin F. Gillespie
- Corresponding author: Erin F. Gillespie, MD, MPH, University of Washington, Department of Radiation Oncology, 1959 NE Pacific St, Seattle, WA; Twitter: @ErinGillespieMD; e-mail:
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Barbour AB, Kotecha R, Lazarev S, Palmer JD, Robinson T, Yerramilli D, Yang JT. Radiation Therapy in the Management of Leptomeningeal Disease From Solid Tumors. Adv Radiat Oncol 2024; 9:101377. [PMID: 38405313 PMCID: PMC10885590 DOI: 10.1016/j.adro.2023.101377] [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: 03/24/2023] [Accepted: 09/03/2023] [Indexed: 02/27/2024] Open
Abstract
Purpose Leptomeningeal disease (LMD) is clinically detected in 5% to 10% of patients with solid tumors and is a source of substantial morbidity and mortality. Prognosis for this entity remains poor and treatments are palliative. Radiation therapy (RT) is an essential tool in the management of LMD, and a recent randomized trial demonstrated a survival benefit for proton craniospinal irradiation (CSI) in select patients. In the setting of this recent advance, we conducted a review of the role of RT in LMD from solid tumors to evaluate the evidence basis for RT recommendations. Methods and Materials In November 2022, we conducted a comprehensive literature search in PubMed, as well as a review of ongoing clinical trials listed on ClinicalTrials.gov, to inform a discussion on the role of RT in solid tumor LMD. Because of the paucity of high-quality published evidence, discussion was informed more by expert consensus and opinion, including a review of societal guidelines, than evidence from clinical trials. Results Only 1 prospective randomized trial has evaluated RT for LMD, demonstrating improved central nervous system progression-free survival for patients with breast and lung cancer treated with proton CSI compared with involved-field RT. Modern photon CSI techniques have improved upon historical rates of acute hematologic toxicity, but the overall benefit of this modality has not been prospectively evaluated. Multiple retrospective studies have explored the use of involved-field RT or the combination of RT with chemotherapy, but clear evidence of survival benefit is lacking. Conclusions Optimal management of LMD with RT remains reliant upon expert opinion, with proton CSI indicated in patients with good performance status and extra-central nervous system disease that is either well-controlled or for which effective treatment options are available. Photon-based CSI traditionally has been associated with increased marrow and gastrointestinal toxicities, though intensity modulated RT/volumetric-modulated arc therapy based photon CSI may have reduced the toxicity profile. Further work is needed to understand the role of radioisotopes as well as combined modality treatment with intrathecal or central nervous system penetrating systemic therapies.
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Affiliation(s)
- Andrew B. Barbour
- Department of Radiation Oncology, University of Washington – Fred Hutchinson Cancer Center, Seattle, Washington
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - Stanislav Lazarev
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Joshua D. Palmer
- Department of Radiation Oncology, The James Cancer Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Timothy Robinson
- Department of Therapeutic Radiology, Yale University, New Haven, Connecticut
| | - Divya Yerramilli
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonathan T. Yang
- Department of Radiation Oncology, University of Washington – Fred Hutchinson Cancer Center, Seattle, Washington
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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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Ebadi M, Morse M, Gooley T, Ermoian R, Halasz LM, Lo SS, Yang JT, Blau MH, Percival ME, Cassaday RD, Graber J, Taylor LP, Venur V, Tseng YD. Craniospinal irradiation for CNS leukemia: rates of response and durability of CNS control. J Neurooncol 2024; 166:351-357. [PMID: 38244173 DOI: 10.1007/s11060-023-04501-5] [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: 10/01/2023] [Accepted: 11/03/2023] [Indexed: 01/22/2024]
Abstract
PURPOSE Management of CNS involvement in leukemia may include craniospinal irradiation (CSI), though data on CSI efficacy are limited. METHODS We retrospectively reviewed leukemia patients who underwent CSI at our institution between 2009 and 2021 for CNS involvement. CNS local recurrence (CNS-LR), any recurrence, progression-free survival (PFS), CNS PFS, and overall survival (OS) were estimated. RESULTS Of thirty-nine eligible patients treated with CSI, most were male (59%) and treated as young adults (median 31 years). The median dose was 18 Gy to the brain and 12 Gy to the spine. Twenty-five (64%) patients received CSI immediately prior to allogeneic hematopoietic cell transplant, of which 21 (84%) underwent total body irradiation conditioning (median 12 Gy). Among 15 patients with CSF-positive disease immediately prior to CSI, all 14 assessed patients had pathologic clearance of blasts (CNS-response rate 100%) at a median of 23 days from CSI start. With a median follow-up of 48 months among survivors, 2-year PFS and OS were 32% (95% CI 18-48%) and 43% (95% CI 27-58%), respectively. Only 5 CNS relapses were noted (2-year CNS-LR 14% (95% CI 5-28%)), which occurred either concurrently or after a systemic relapse. Only systemic relapse after CSI was associated with higher risk of CNS-LR on univariate analysis. No grade 3 or higher acute toxicity was seen during CSI. CONCLUSION CSI is a well-tolerated and effective treatment option for patients with CNS leukemia. Control of systemic disease after CSI may be important for CNS local control. CNS recurrence may reflect reseeding from the systemic space.
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Affiliation(s)
- Maryam Ebadi
- Department of Radiation Oncology, University of Washington, 1959 NE Pacific Street, 98195, Seattle, WA, USA
| | - Margaret Morse
- University of Washington School of Medicine, Seattle, WA, USA
| | - Ted Gooley
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Ralph Ermoian
- Department of Radiation Oncology, University of Washington, 1959 NE Pacific Street, 98195, Seattle, WA, USA
| | - Lia M Halasz
- Department of Radiation Oncology, University of Washington, 1959 NE Pacific Street, 98195, Seattle, WA, USA
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington, 1959 NE Pacific Street, 98195, Seattle, WA, USA
| | - Jonathan T Yang
- Department of Radiation Oncology, University of Washington, 1959 NE Pacific Street, 98195, Seattle, WA, USA
| | - Molly H Blau
- Department of Radiation Oncology, University of Washington, 1959 NE Pacific Street, 98195, Seattle, WA, USA
| | - Mary-Elizabeth Percival
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Division of Hematology and Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Ryan D Cassaday
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Division of Hematology and Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Jerome Graber
- Department of Neurology, Division of Medical Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Lynne P Taylor
- Department of Neurology, Division of Medical Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Vyshak Venur
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Division of Hematology and Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Yolanda D Tseng
- Department of Radiation Oncology, University of Washington, 1959 NE Pacific Street, 98195, Seattle, WA, USA.
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA.
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Gillespie EF, Yang JC, Mathis NJ, Marine CB, White C, Zhang Z, Barker CA, Kotecha R, McIntosh A, Vaynrub M, Bartelstein MK, Mitchell A, Guttmann DM, Yerramilli D, Higginson DS, Yamada YJ, Kohutek ZA, Powell SN, Tsai J, Yang JT. Prophylactic Radiation Therapy Versus Standard of Care for Patients With High-Risk Asymptomatic Bone Metastases: A Multicenter, Randomized Phase II Clinical Trial. J Clin Oncol 2024; 42:38-46. [PMID: 37748124 PMCID: PMC10730067 DOI: 10.1200/jco.23.00753] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [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: 04/04/2023] [Revised: 05/16/2023] [Accepted: 07/19/2023] [Indexed: 09/27/2023] Open
Abstract
PURPOSE External-beam radiation therapy (RT) is standard of care (SOC) for pain relief of symptomatic bone metastases. We aimed to evaluate the efficacy of radiation to asymptomatic bone metastases in preventing skeletal-related events (SRE). METHODS In a multicenter randomized controlled trial, adult patients with widely metastatic solid tumor malignancies were stratified by histology and planned SOC (systemic therapy or observation) and randomly assigned in a 1:1 ratio to receive RT to asymptomatic high-risk bone metastases or SOC alone. The primary outcome of the trial was SRE. Secondary outcomes included hospitalizations for SRE and overall survival (OS). RESULTS A total of 78 patients with 122 high-risk bone metastases were enrolled between May 8, 2018, and August 9, 2021, at three institutions across an affiliated cancer network in the United States. Seventy-three patients were evaluable for the primary end point. The most common primary cancer types were lung (27%), breast (24%), and prostate (22%). At 1 year, SRE occurred in one of 62 bone metastases (1.6%) in the RT arm and 14 of 49 bone metastases (29%) in the SOC arm (P < .001). There were significantly fewer patients hospitalized for SRE in the RT arm compared with the SOC arm (0 v 4, P = .045). At a median follow-up of 2.5 years, OS was significantly longer in the RT arm (hazard ratio [HR], 0.49; 95% CI, 0.27 to 0.89; P = .018), which persisted on multivariable Cox regression analysis (HR, 0.46; 95% CI, 0.23 to 0.85; P = .01). CONCLUSION Radiation delivered prophylactically to asymptomatic, high-risk bone metastases reduced SRE and hospitalizations. We also observed an improvement in OS with prophylactic radiation, although a confirmatory phase III trial is warranted.
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Affiliation(s)
- Erin F. Gillespie
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Joanna C. Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Radiation Oncology, Washington University in St Louis, St Louis, MO
| | - Noah J. Mathis
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Catherine B. Marine
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Charlie White
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Christopher A. Barker
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL
| | - Alyson McIntosh
- Department of Radiation Oncology, Lehigh Valley Cancer Institute, Allentown, PAa
| | - Max Vaynrub
- Department of Surgery, Orthopaedic Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Meredith K. Bartelstein
- Department of Surgery, Orthopaedic Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Aaron Mitchell
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David M. Guttmann
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Divya Yerramilli
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Daniel S. Higginson
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Yoshida J. Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Zachary A. Kohutek
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Radiation Oncology, Vanderbilt University, Nashville, TN
| | - Simon N. Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jillian Tsai
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Radiation Oncology, Princess Margaret Hospital Cancer Centre, Toronto, Ontario, CA
| | - Jonathan T. Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Radiation Oncology, University of Washington, Seattle, WA
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Malani R, Bhatia A, Warner AB, Yang JT. Leptomeningeal Carcinomatosis from Solid Tumor Malignancies: Treatment Strategies and Biomarkers. Semin Neurol 2023; 43:859-866. [PMID: 37989214 DOI: 10.1055/s-0043-1776996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
Leptomeningeal metastases/diseases (LMDs) are a late-stage complication of solid tumor or hematologic malignancies. LMD is spread of cancer cells to the layers of the leptomeninges (pia and arachnoid maters) and subarachnoid space seen in 3 to 5% of cancer patients. It is a disseminated disease which carries with it significant neurologic morbidity and mortality. Our understanding of disease pathophysiology is currently lacking; however, advances are being made. As our knowledge of disease pathogenesis has improved, treatment strategies have evolved. Mainstays of treatment such as radiotherapy have changed from involved-field radiotherapy strategies to proton craniospinal irradiation which has demonstrated promising results in recent clinical trials. Systemic treatment strategies have also improved from more traditional chemotherapeutics with limited central nervous system (CNS) penetration to more targeted therapies with better CNS tumor response. Many challenges remain from earlier clinical detection of disease through improvement of active treatment options, but we are getting closer to meaningful treatment.
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Affiliation(s)
- Rachna Malani
- Department of Neurosurgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Ankush Bhatia
- Department of Neurology, Carbone Cancer Center, University of Wisconsin, Madison, Wisconsin
| | - Allison Betof Warner
- Division of Oncology, Department of Medicine, Stanford Cancer Institute, Stanford University, Stanford, California
| | - Jonathan T Yang
- Department of Radiation Oncology, Fred Hutchinson Cancer Center, University of Washington, Seattle, Washington
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8
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Barbour AB, Zaki P, McGranahan TM, Venur V, Vellayappan B, Palmer J, Halasz LM, Yang JT, Blau M, Tseng YD, Chao ST, Suh JH, Foote M, Redmond KJ, Combs SE, Chang EL, Sahgal A, Lo SS. Emergent radiotherapy for brain and leptomeningeal metastases: a narrative review. Ann Palliat Med 2023; 12:1405-1419. [PMID: 37431225 DOI: 10.21037/apm-22-1276] [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] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 06/09/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND AND OBJECTIVE As novel systemic therapies allow patients to live longer with cancer, the risk of developing central nervous system (CNS) metastases increases and providers will more frequently encounter emergent presentation of brain metastases (BM) and leptomeningeal metastases (LM). Management of these metastases requires appropriate work-up and well-coordinated multidisciplinary care. We set out to perform a review of emergent radiotherapy (RT) for CNS metastases, specifically focusing on BM and LM. METHODS We review the appropriate pathways for workup and initial management of BM and LM, while reviewing the literature supporting emergent treatment of these entities with surgery, systemic anti-cancer therapy, and RT. To inform this narrative review, literature searches in PubMed and Google Scholar were conducted, with preference given to articles employing modern RT techniques, when applicable. Due to the paucity of high-quality evidence for management of BM and LM in the emergent setting, discussion was supplemented by the authors' expert commentary. KEY CONTENT AND FINDINGS This work highlights the importance of surgical evaluation, particularly for patients presenting with significant mass effect, hemorrhagic metastases, or increased intracranial pressure. We review the rare situations where emergent initiation of systemic anti-cancer therapy is indicated. When defining the role of RT, we review factors guiding selection of appropriate modality, treatment volume, and dose-fractionation. Generally, 2D- or 3D-conformal treatment techniques prescribed as 30 Gy in 10 fractions or 20 Gy in 5 fractions, should be employed in the emergent setting. CONCLUSIONS Patients with BM and LM present from a diverse array of clinical situations, requiring well-coordinated multidisciplinary management, and there is a paucity of high-quality evidence guiding such management decisions. This narrative review aims to more thoroughly prepare providers for the challenging situation of emergent management of BM and LM.
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Affiliation(s)
- Andrew B Barbour
- Department of Radiation Oncology, University of Washington/Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Peter Zaki
- Department of Radiation Oncology, University of Washington/Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Tresa M McGranahan
- Department of Neurology, University of Washington/Alvord Brain Tumor Center, Seattle, WA, USA
| | - Vyshak Venur
- Division of Medical Oncology, University of Washington/Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Balamurugan Vellayappan
- Deparment of Radiation Oncology, National University Cancer Institute of Singapore, Singapore, Singapore
| | - Joshua Palmer
- Deparment of Radiation Oncology, The Ohio State University/Arthur G. James Cancer Hospital, Columbus, OH, USA
| | - Lia M Halasz
- Department of Radiation Oncology, University of Washington/Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Jonathan T Yang
- Department of Radiation Oncology, University of Washington/Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Molly Blau
- Department of Radiation Oncology, University of Washington/Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Yolanda D Tseng
- Department of Radiation Oncology, University of Washington/Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Samuel T Chao
- Deparment of Radiation Oncology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - John H Suh
- Deparment of Radiation Oncology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Matthew Foote
- Department of Radiation Oncology, Princess Alexandra Hospital, University of Queensland/ICON Cancer Centre, Brisbane, QLD, Australia
| | - Kristin J Redmond
- Deparmemt of Radiation and Molecular Oncology, John Hopkins University, Baltimore, MD, USA
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany; Institute for Radiation Medicine (IRM), Helmholtz Zentrum München, Neuherberg, Germany
| | - Eric L Chang
- Department of Radiation Oncology, Keck School of Medicine and Norris Cancer Center at University of Southern California, Los Angeles, CA, USA
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Science Centre, University of Toronto, Toronto, ON, Canada
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington/Fred Hutchinson Cancer Center, Seattle, WA, USA
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9
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Tian Y, Ding B, Ma ZR, Yang JT, Ding GT, Liu HN. Study on physicochemical properties, fatty acids, texture, antioxidant and antibacterial activities of ghee from different regions. J Dairy Sci 2023; 106:7419-7431. [PMID: 37641279 DOI: 10.3168/jds.2023-23300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 05/26/2023] [Indexed: 08/31/2023]
Abstract
Due to the lack of basic information on Chinese ghee and the increasing demand of consumers for natural oils, this study aims to explore and distinguish the quality characteristics of ghee in different regions of China. Ghee samples from 16 regions of Qinghai Province, Gansu Province, Xinjiang Uyghur Autonomous Region, and Tibet Autonomous Region were selected and their physicochemical properties, fatty acids, texture, antioxidant and antibacterial activities were determined. The results showed that: (1) The physicochemical properties of ghee were different from different regions, but the freshness and fat content are generally high. The results of iodine value and saponification value suggest that the fatty acid composition is good; (2) The unsaturated fatty acid/saturated fatty acid content of ghee in Tibet and Xinjiang ranges from 63.05% to 79.13%, which is better than that in other regions; (3) Gansu Diebu ghee has the highest hardness (40.69 N); (4) Ghee from different regions has good antioxidant activity, DPPH free radical scavenging activity is 30.45% to 58.06%, ABTS free radical scavenging activity is 41.14% to 65.53%, and has varying degrees of inhibition on gram-positive bacteria. In addition, yak ghee, cattle-yak ghee and cow ghee have better fatty acid composition and antibacterial ability than scalper ghee. The results of this study distinguish the differences in the quality characteristics of yak ghee in different geographical regions. Therefore, it can provide a theoretical basis for the origin tracing and quality-oriented improvement of yak ghee.
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Affiliation(s)
- Y Tian
- China-Malaysia National Joint Laboratory, Biomedical Research Center, Northwest Minzu University, Gansu Lanzhou 730030, China; College of Life Science and Engineering, Northwest Minzu University, Gansu Lanzhou 730030, China
| | - B Ding
- College of Life Science and Engineering, Northwest Minzu University, Gansu Lanzhou 730030, China
| | - Z R Ma
- China-Malaysia National Joint Laboratory, Biomedical Research Center, Northwest Minzu University, Gansu Lanzhou 730030, China
| | - J T Yang
- College of Life Science and Engineering, Northwest Minzu University, Gansu Lanzhou 730030, China
| | - G T Ding
- China-Malaysia National Joint Laboratory, Biomedical Research Center, Northwest Minzu University, Gansu Lanzhou 730030, China
| | - H N Liu
- China-Malaysia National Joint Laboratory, Biomedical Research Center, Northwest Minzu University, Gansu Lanzhou 730030, China; College of Life Science and Engineering, Northwest Minzu University, Gansu Lanzhou 730030, China.
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10
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Zaki P, Barbour A, Zaki MM, Tseng YD, Amin AG, Venur V, McGranahan T, Vellayappan B, Palmer JD, Chao ST, Yang JT, Foote M, Redmond KJ, Chang EL, Sahgal A, Lo SS, Schaub SK. Emergent radiotherapy for spinal cord compression/impingement-a narrative review. Ann Palliat Med 2023; 12:1447-1462. [PMID: 37817502 DOI: 10.21037/apm-23-342] [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] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 08/28/2023] [Indexed: 10/12/2023]
Abstract
BACKGROUND AND OBJECTIVE Malignant epidural spinal cord compression (MESCC), often presenting with back pain and motor/sensory deficits, is associated with poor survival, particularly when there is loss of ambulation. The purpose of this review is to evaluate the literature and discuss appropriate workup and management of MESCC, specifically in the emergent setting. METHODS A PubMed search was conducted on "spinal cord compression" and "radiation therapy." Articles were analyzed for the purpose of this narrative review. KEY CONTENT AND FINDINGS If MESCC is suspected, neurologic examination and complete spine imaging are recommended. Emergent treatment is indicated if there is radiographic evidence of high-grade compression and/or clinically significant motor deficits. Treatment involves a combination of medical management, surgical decompression, radiation therapy (RT), and rehabilitation. For motor deficits, emergent initiation of high dose steroids is recommended. Circumferential surgical decompression ± stabilization followed by RT provides superior clinical outcomes than RT alone. For patients whom surgery is not reasonable, RT alone may provide significant treatment response which depends on radioresponsiveness of the pathology. Systemic therapy, if indicated, is typically reserved till after primary treatment of MESCC, but patients with chemoresponsive tumors may receive primary chemotherapy. The selected RT schedule should be personalized to each patient and commonly is 30 Gy in 10 fractions (fx), 20 Gy in 5 fx, or 8 Gy in 1 fx. MESCC recurrence may be treated with additional RT, if within the spinal cord tolerance, or surgery. Stereotactic body radiation therapy (SBRT) has been used for high grade MESCC in patients with relatively intact neurologic function at a few centers with a very robust infrastructure to support rapid initiation of treatment within a short period of time, but is generally not feasible for most clinical practices. SBRT may be advantageous for low grade MESCC, recurrence, or in the post-operative setting. Detection of MESCC prior to development of high-grade compression or deterioration of neurologic function may allow patients to benefit more from advanced therapies and improve prognosis. CONCLUSIONS MESCC is a devastating condition; optimal treatment should be personalized to each patient and approached collaboratively by a multidisciplinary team.
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Affiliation(s)
- Peter Zaki
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Andrew Barbour
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Mark M Zaki
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Yolanda D Tseng
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Anubhav G Amin
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Vyshak Venur
- Division of Medical Oncology, Fred Hutchinson Cancer Center/University of Washington, Seattle, WA, USA
| | - Tresa McGranahan
- Department of Neurology, Alvord Brain Tumor Center/University of Washington, Seattle, WA, USA
| | - Balamurugan Vellayappan
- Department of Radiation Oncology, National University Cancer Institute of Singapore, Singapore, Singapore
| | - Joshua D Palmer
- Department of Radiation Oncology, Arthur G. James Cancer Hospital/The Ohio State University, Columbus, OH, USA
| | - Samuel T Chao
- Department of Radiation Oncology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Jonathan T Yang
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Matthew Foote
- Department of Radiation Oncology, Princess Alexandra Hospital, University of Queensland, and ICON Cancer Centre, Brisbane, Queensland, Australia
| | - Kristin J Redmond
- Department of Radiation and Molecular Oncology, John Hopkins University, Baltimore, MD, USA
| | - Eric L Chang
- Department of Radiation Oncology, Keck School of Medicine and Norris Cancer Center at University of Southern California, CA, USA
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Science Centre, University of Toronto, Toronto, Ontario, Canada
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Stephanie K Schaub
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
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11
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Nguyen MH, Swensen SN, Colbert CM, Amin AG, Sponseller PA, Melancon D, Schaub SK, Tseng YD, Blau MH, Halasz LM, Yang JT, Rengan R, Bloch C, Mossa-Basha M, Hofstetter CP, Lo SS. Dosimetric Impact of Radiolucent Carbon Fiber Hardware for Post-Operative Spine Stereotactic Body Radiation Therapy. Int J Radiat Oncol Biol Phys 2023; 117:e140-e141. [PMID: 37784713 DOI: 10.1016/j.ijrobp.2023.06.950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) The spine is the most common site of osseous metastases. In the non-operative setting, there is growing support for stereotactic body radiation therapy (SBRT) over conventional radiation therapy for improved pain relief and local control. Hybrid therapy consisting of separation surgery and post-operative SBRT is considered in patients with biomechanical instability and epidural cord compression. Surgery traditionally requires titanium (Ti) implants, which introduce artifacts on post-operative imaging in addition to increased uncertainty and beam attenuation. Use of radiolucent carbon fiber reinforced polyetheretherketone (CFR-PEEK) hardware has been shown to provide safe and comparable surgical outcomes as compared to Ti. Our primary objective is to assess the dosimetric impact of Ti versus carbon fiber implants in spine SBRT. MATERIALS/METHODS Single institution retrospective series of post-operative spine SBRT from 2019-2020. Re-irradiation cases were excluded. The electronic medical record and treatment planning systems (TPS) were queried. Dosimetric analyses compared original Ti plans with reoptimized plans, replacing Ti hardware electronic density with carbon fiber. Maintaining clinical goals, dose calculations were performed in a treatment planning system using a collapsed cone algorithm. All treatments used step and shoot intensity modulated radiation therapy to avoid beam angles with significant metal along the beam path. Metallic artifacts were contoured and assigned the appropriate tissue density. A D'Agostino-Pearson test was used to assess data for normality. We used paired Student's t-tests to compare three dosimetric outcomes in the setting of Ti and carbon fiber implants. Planning target volume (PTV) coverage was represented by the volume receiving at least the prescribed dose (%), the maximum point dose (dmax, cGy) to the spinal cord planning risk volume (PRV, 2 mm margin), and the overall hot spot intensity (plan dmax). RESULTS A series of 14 consecutive SBRT cases were evaluated (dose 27-30 Gy in 3-5 fractions). All dosimetric outcomes were normally distributed (p>0.05). We found a statistically significant difference in PTV coverage between the original SBRT treatment plans with Ti hardware (mean 85.1 ± 7.9%) and reoptimized carbon fiber hardware (87.3 ± 6.6%; p = 0.002). There was no significant difference in mean spinal cord PRV dmax between Ti and carbon fiber plans (1846 ± 483 cGy vs. 1842 ± 495 cGy; p>0.05). We observed a nonsignificant increase in mean overall dmax from 3932 ± 416 cGy in the Ti cohort to 4111 ± 906 cGy in the carbon fiber cohort (p>0.05). CONCLUSION Carbon fiber implants provide a significant increase in SBRT target coverage, without impacting the overall plan and spinal cord PRV dmax in this retrospective series. In addition to improved post-operative imaging and reduced uncertainty, carbon fiber hardware may offer dosimetric advantages as compared to traditional Ti spinal implants, and warrants further investigation in a larger cohort.
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Affiliation(s)
- M H Nguyen
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - S N Swensen
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - C M Colbert
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - A G Amin
- Department of Neurological Surgery, University of Washington, Seattle, WA
| | - P A Sponseller
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - D Melancon
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - S K Schaub
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Y D Tseng
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - M H Blau
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - L M Halasz
- Department of Radiation Oncology, University of Washington/ Fred Hutchinson Cancer Center, Seattle, WA
| | - J T Yang
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - R Rengan
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - C Bloch
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - M Mossa-Basha
- Department of Radiology, University of Washington, Seattle, WA
| | - C P Hofstetter
- Department of Neurological Surgery, University of Washington, Seattle, WA
| | - S S Lo
- Department of Radiation Oncology, University of Washington, Seattle, WA
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12
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Ebadi M, Morse M, Gooley T, Ermoian RP, Halasz LM, Lo SS, Yang JT, Percival ME, Cassaday R, Graber J, Taylor L, Venur V, Tseng YD. Craniospinal Irradiation for CNS Leukemia: Rates of Response and Durability of CNS Control. Int J Radiat Oncol Biol Phys 2023; 117:e464-e465. [PMID: 37785483 DOI: 10.1016/j.ijrobp.2023.06.1665] [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) Craniospinal irradiation (CSI) is used in the management of leukemia patients with central-nervous-system (CNS) involvement, though the data on response and local control are limited. Given the radioresponsiveness of leukemia, we hypothesized that response to CSI would be high, but CNS control would be influenced by control of systemic disease. MATERIALS/METHODS This retrospective, single-institution analysis included consecutive pediatric and adult patients between 2009-2021 with leukemia that underwent CSI for CNS involvement, defined as presence of blasts (i.e., >0%) on CSF flow cytometry. Endpoints included CNS response rate (RR), CNS local recurrence (LR), progression-free survival (PFS), and overall survival (OS), which were estimated from start of CSI. The probability of CNS LR was summarized using a cumulative incidence estimate, where death without LR was considered a competing risk. The probabilities of OS and PFS were obtained using Kaplan-Meier estimates. RESULTS Among the 39 eligible patients (43% AML, 49% ALL, 8% blast-phase CML), most were male (59%). All had CSF confirmation of disease. Median age at CSI was 31 years (range 7-67). CSI (protons 54%, photons 46%) was utilized early within the CNS disease course (median 0 CNS relapses prior to CSI). Twenty-five patients (64%) received CSI immediately prior to a stem-cell transplant (SCT), of which 21 (84%) had TBI conditioning to a median dose of 12 Gy (range 2-13.2). Patients treated with CSI alone received a higher CSI dose (median 18 Gy; range 10.8-24) than those treated with SCT consolidation (median 12 Gy; range 10.8-24). Fifteen patients had CSF-positive disease immediately prior to CSI; all 14 of those assessed for response (RR 100%) had confirmed clearance of blasts at a median of 23 days (range 7-197) from CSI start. With a median follow-up of 48 months (range 0.4-123) for survivors, 2-year PFS and OS estimates were 32% and 43%, respectively. Only 5 CNS relapses were noted (2-year CNS LR of 14%). All CNS relapses either occurred after (n = 4) or concurrently (n = 1) with a systemic relapse. In Cox regression univariate models, age, sex, time to CNS disease, positive CSF immediately prior to CSI, and SCT did not show demonstrable evidence of association with CNS LR. However, systemic relapse after CSI (HR 5.9, 95% CI 2.5-13.8, P<0.0001) and systemic disease at the time of CSI (HR 3.9, 95% CI 1.6-9.5, P = 0.003) were associated with higher risk of CNS LR. No grade-3+ acute toxicity was seen during CSI. CONCLUSION CSI is a well-tolerated and effective treatment option for patients with CNS leukemia. Though CNS local recurrence was modest, there was a high risk of systemic relapse and/or death. Control of systemic disease, both before and after CSI, may be important for CNS local control, and raises consideration that CNS recurrence may reflect reseeding from the systemic space.
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Affiliation(s)
- M Ebadi
- Department of Radiation Oncology, University of Washington/ Fred Hutchinson Cancer Center, Seattle, WA
| | - M Morse
- University of Washington, Seattle, WA
| | - T Gooley
- Fred Hutchinson Cancer Center, Seattle, WA
| | - R P Ermoian
- Department of Radiation Oncology, University of Washington/ Fred Hutchinson Cancer Center, Seattle, WA
| | - L M Halasz
- Department of Radiation Oncology, University of Washington/ Fred Hutchinson Cancer Center, Seattle, WA
| | - S S Lo
- Department of Radiation Oncology, University of Washington/ Fred Hutchinson Cancer Center, Seattle, WA
| | - J T Yang
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - M E Percival
- Department of Medical Oncology, Fred Hutchinson Cancer Center, Seattle, WA
| | - R Cassaday
- Department of Medical Oncology, Fred Hutchinson Cancer Center, Seattle, WA
| | - J Graber
- Department of Neuro-Oncology, University of Washington, Seattle, WA
| | - L Taylor
- Department of Neuro-Oncology, University of Washington, Seattle, WA
| | - V Venur
- Department of Medical Oncology, Fred Hutchinson Cancer Center, Seattle, WA
| | - Y D Tseng
- Department of Radiation Oncology, University of Washington/ Fred Hutchinson Cancer Center, Seattle, WA
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13
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Santos P, Chakraborty N, Salz T, Curry M, Vicioso NL, Mathis NJ, Caron M, Ostroff J, Guttman D, Salner AL, Panoff JE, McIntosh AF, Pfister DG, Yang JT, Snyderman AL, Gillespie EF. Implementation Outcomes of Strategies to Promote Short-Course Radiation for Nonspine Bone Metastases in an Academic-Community Partnership: Survey Results from the ALIGNMENT Trial. Int J Radiat Oncol Biol Phys 2023; 117:S124-S125. [PMID: 37784321 DOI: 10.1016/j.ijrobp.2023.06.466] [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) Local treatment of nonspine bone metastases has become increasingly complex, resulting in physician practice variability nationwide. The purpose of this study was to assess physician perceptions of 3 implementation strategies to promote adoption of short course radiotherapy (RT) for nonspine bone metastases. MATERIALS/METHODS ALIGNMENT ("Alliance Group for Bone Metastasis") was a multi-institutional stepped wedge cluster randomized implementation trial testing strategies to increase use of ≤5 fractions for nonspine bone metastases conducted across 3 clinical sites in an academic-community partnership. Strategies included a) multidisciplinary consensus guidelines, b) e-Consults, an email-based consultation platform, and c) personalized audit and feedback (A&F) reports with peer comparison. Using the Proctor et al. framework and validated questions from Weiner et al., physician surveys were used to assess each strategy's usefulness, acceptability (i.e., "I welcome [strategy]"), appropriateness (i.e., "[strategy] seems like a good match"), and feasibility (i.e., "[strategy] seems implementable" or "easy to use"). Survey responses were anonymized, so Fisher's Exact test was used to compare proportions with significance set at p<0.05. RESULTS Overall, 29 of 38 and 30 of 38 physicians participated in the pre- and post-implementation surveys, respectively, with 80% completing both. Pre-implementation, guidelines was most often ranked 1st in terms of usefulness (61%), followed by eConsults (38%) and A&F (3%). Post-implementation, guidelines and eConsults had the most and least favorable acceptability, appropriateness, and feasibility scores, respectively (Table), with 77% of physicians being likely to recommend the guidelines to other oncologists. In contrast, while 43% of physicians reported having at least 1 difficult clinical question regarding bone metastases during the study, only 33% of physicians preferred eConsults, while 50% preferred reaching out to a friend/colleague. Lastly, although A&F had the lowest perceived usefulness pre-implementation, A&F had the greatest increase in acceptability (72%→90%; p = 0.10), appropriateness (66%→90%; p = 0.03) feasibility ("implementable": 59%→93%, p = 0.002; "easy to use": 45%→93%, p<0.001). CONCLUSION In this multicenter trial, all strategies were acceptable, appropriate, and feasible, with guidelines and A&F showing the most favorable outcomes post-implementation. While guidelines were assessed as the most useful, A&F had significant increases in appropriateness and feasibility.
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Affiliation(s)
- P Santos
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; Harvard T.H. Chan School of Public Health, Boston, MA
| | - N Chakraborty
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - T Salz
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - M Curry
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - N Ledesma Vicioso
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - N J Mathis
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - M Caron
- Strategic Partnerships, Memorial Sloan Kettering Cancer Center, New York, NY
| | - J Ostroff
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY
| | - D Guttman
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - A L Salner
- Hartford HealthCare Cancer Institute, Hartford, CT
| | - J E Panoff
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL
| | - A F McIntosh
- Allentown Radiation Oncology Associates, Allentown, PA, United States
| | - D G Pfister
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - J T Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Radiation Oncology, University of Washington, Seattle, WA
| | - A Lipitz Snyderman
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - E F Gillespie
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Radiation Oncology, University of Washington, Seattle, WA
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14
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Mathis NJ, Maya H, Santoro A, Bartelstein M, Vaynrub M, Yang JT, Gillespie EF, Desai AV, Yerramilli D. A Worksheet to Facilitate Discussions of Values for Patients With Metastatic Cancer: A Pilot Study. J Pain Symptom Manage 2023; 66:242-247.e1. [PMID: 37302532 DOI: 10.1016/j.jpainsymman.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/17/2023] [Accepted: 06/04/2023] [Indexed: 06/13/2023]
Abstract
CONTEXT Individual goals and values should drive medical decision making for patients with serious illness. Unfortunately, clinicians' existing strategies to encourage reflection and communication regarding patients' personal values are generally time-consuming and limited in scope. OBJECTIVES Herein, we develop a novel intervention to facilitate at-home reflection and discussion about goals and values. We then conduct a pilot study of our intervention in a small population of patients with metastatic cancer. METHODS We first engaged former cancer patients and their families to adapt an existing serious illness communication guide to a worksheet format. We then distributed this adapted "Values Worksheet" to 28 patients with metastatic cancer. We surveyed participants about their perceptions of the Worksheet to assess its feasibility. RESULTS Of 30 patients approached, 28 agreed to participate. Seventeen participants completed the Values Worksheet, and of those 11 (65%) responded to the follow-up survey. Seven of eleven reported that the Values Worksheet was a good use of time, and nine of eleven would be likely to recommend it to other patients with cancer. Eight of ten reported mild distress, two of ten reported moderate to severe distress. CONCLUSION The Values Worksheet was a feasible way to facilitate at-home discussions of goals and values for select patients with metastatic cancer. Further research should focus on identifying which patients are most likely to benefit from the Values Worksheet, and should employ the Worksheet as one tool to facilitate reflection on the questions that arise around serious illness, as an adjunct to serious illness conversations with a physician.
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Affiliation(s)
- Noah J Mathis
- Department of Radiation Oncology (N.J.M., A.S., D.Y.), Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Hadley Maya
- Department of Surgery (H.M., M.B., M.V.), Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Amanda Santoro
- Department of Radiation Oncology (N.J.M., A.S., D.Y.), Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Meredith Bartelstein
- Department of Surgery (H.M., M.B., M.V.), Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Max Vaynrub
- Department of Surgery (H.M., M.B., M.V.), Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jonathan T Yang
- Department of Radiation Oncology (J.T.Y., E.F.G.), University of Washington Medical Center, Seattle, Washington, USA
| | - Erin F Gillespie
- Department of Radiation Oncology (J.T.Y., E.F.G.), University of Washington Medical Center, Seattle, Washington, USA
| | - Anjali V Desai
- Department of Medicine (A.V.D.), Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Divya Yerramilli
- Department of Radiation Oncology (N.J.M., A.S., D.Y.), Memorial Sloan Kettering Cancer Center, New York, New York, USA.
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15
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Freret ME, Wijetunga NA, Shamseddine AA, Higginson DS, Schmitt AM, Yamada Y, Lis E, Boire A, Yang JT, Xu AJ. Early Detection of Leptomeningeal Metastases Among Patients Undergoing Spinal Stereotactic Radiosurgery. Adv Radiat Oncol 2023; 8:101154. [PMID: 36845624 PMCID: PMC9943781 DOI: 10.1016/j.adro.2022.101154] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 12/15/2022] [Indexed: 12/27/2022] Open
Abstract
Purpose The management of patients with advanced solid malignancies increasingly uses stereotactic body radiation therapy (SBRT). Advanced cancer patients are at risk for developing leptomeningeal metastasis (LM), a fatal complication of metastatic cancer. Cerebrospinal fluid (CSF) is routinely collected during computed tomography (CT) myelography for spinal SBRT planning, offering an opportunity for early LM detection by CSF cytology in the absence of radiographic LM or LM symptoms (subclinical LM). This study tested the hypothesis that early detection of tumor cells in CSF in patients undergoing spine SBRT portends a similarly poor prognosis compared with clinically overt LM. Methods and Materials We retrospectively analyzed clinical records for 495 patients with metastatic solid tumors who underwent CT myelography for spinal SBRT planning at a single institution from 2014 to 2019. Results Among patients planned for SBRT, 51 (10.3%) developed LM. Eight patients (1.6%) had subclinical LM. Median survival with LM was similar between patients with subclinical versus clinically evident LM (3.6 vs 3.0 months, P = .30). Patients harboring both parenchymal brain metastases and LM (29/51) demonstrated shorter survival than those with LM alone (2.4 vs 7.1 months, P = .02). Conclusions LM remains a fatal complication of metastatic cancer. Subclinical LM detected by CSF cytology in spine SBRT patients has a similarly poor prognosis compared with standardly detected LM and warrants consideration of central nervous system-directed therapies. As aggressive local therapies are increasingly used for metastatic patients, more sensitive CSF evaluation may further identify patients with subclinical LM and should be evaluated prospectively.
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Affiliation(s)
- Morgan E. Freret
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - N. Ari Wijetunga
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Achraf A. Shamseddine
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel S. Higginson
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Adam M. Schmitt
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yoshiya Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Eric Lis
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Adrienne Boire
- Department of Neurology, Human Oncology and Pathogenesis Program, Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonathan T. Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Amy J. Xu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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16
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Wijetunga NA, Goglia AG, Weinhold N, Berger MF, Cislo M, Higginson DS, Chabot K, Osman AM, Schaff L, Pentsova E, Miller AM, Powell SN, Boire A, Yang JT. Dynamic Mutational Landscape of Cerebrospinal Fluid Circulating Tumor DNA and Predictors of Survival after Proton Craniospinal Irradiation for Leptomeningeal Metastases. Clin Cancer Res 2023; 29:775-783. [PMID: 36449664 PMCID: PMC9957915 DOI: 10.1158/1078-0432.ccr-22-2434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/05/2022] [Accepted: 11/21/2022] [Indexed: 12/02/2022]
Abstract
PURPOSE Proton craniospinal irradiation (pCSI) is a promising treatment for patients with solid tumor leptomeningeal metastasis (LM). We hypothesize that genetic characteristics before and changes resulting after pCSI will reflect clinical response to pCSI. We analyzed the cerebrospinal fluid (CSF) circulating tumor DNA (ctDNA) from patients receiving pCSI for LM and explored genetic variations associated with response. EXPERIMENTAL DESIGN We subjected CSF from 14 patients with LM before and after pCSI to cell-free DNA sequencing using a targeted-sequencing panel. In parallel, plasma ctDNA and primary tumors were subjected to targeted sequencing. Variant allele frequency (VAF) and cancer cell fraction (CCF) were calculated; clonality of observed mutations was determined. Kaplan-Meier analysis was used to associate genomic changes with survival. RESULTS The median overall survival (OS) for the cohort was 9 months [interquartile range (IQR), 5-21 months]. We showed clonal evolution between tumor and ctDNA of the CSF and plasma with unique mutations identified by compartment. Higher CSF ctDNA mean VAF before pCSI (VAFpre) had worse OS (6 months for VAFpre ≥ 0.32 vs. 9 months for VAFpre < 0.32; P = 0.05). Similarly, increased VAF after pCSI portended worse survival (6 vs. 18 months; P = 0.008). Higher mean CCF of subclonal mutations appearing after pCSI was associated with worse OS (8 vs. 17 months; P = 0.05). CONCLUSIONS In patients with solid tumor LM undergoing pCSI, we found unique genomic profiles associated with pCSI through CSF ctDNA analyses. Patients with reduced genomic diversity within the leptomeningeal compartment demonstrated improved OS after pCSI suggesting that CSF ctDNA analysis may have use in predicting pCSI response.
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Affiliation(s)
- N. Ari Wijetunga
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center
| | | | - Nils Weinhold
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center
| | | | - Michael Cislo
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center
| | | | - Kiana Chabot
- Human Oncology and Pathogenesis Program, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center
| | - Ahmed M. Osman
- Human Oncology and Pathogenesis Program, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center
| | - Lauren Schaff
- Department of Neurology, Memorial Sloan Kettering Cancer Center
| | - Elena Pentsova
- Department of Neurology, Memorial Sloan Kettering Cancer Center
| | | | - Simon N. Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center
| | - Adrienne Boire
- Human Oncology and Pathogenesis Program, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center
- Department of Neurology, Memorial Sloan Kettering Cancer Center
| | - Jonathan T. Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center
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17
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McKenney AS, Weg E, Bale TA, Wild AT, Um H, Fox MJ, Lin A, Yang JT, Yao P, Birger ML, Tixier F, Sellitti M, Moss NS, Young RJ, Veeraraghavan H. Radiomic Analysis to Predict Histopathologically Confirmed Pseudoprogression in Glioblastoma Patients. Adv Radiat Oncol 2023; 8:100916. [PMID: 36711062 PMCID: PMC9873493 DOI: 10.1016/j.adro.2022.100916] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 01/18/2022] [Indexed: 02/01/2023] Open
Abstract
Purpose Pseudoprogression mimicking recurrent glioblastoma remains a diagnostic challenge that may adversely confound or delay appropriate treatment or clinical trial enrollment. We sought to build a radiomic classifier to predict pseudoprogression in patients with primary isocitrate dehydrogenase wild type glioblastoma. Methods and Materials We retrospectively examined a training cohort of 74 patients with isocitrate dehydrogenase wild type glioblastomas with brain magnetic resonance imaging including dynamic contrast enhanced T1 perfusion before resection of an enhancing lesion indeterminate for recurrent tumor or pseudoprogression. A recursive feature elimination random forest classifier was built using nested cross-validation without and with O6-methylguanine-DNA methyltransferase status to predict pseudoprogression. Results A classifier constructed with cross-validation on the training cohort achieved an area under the receiver operating curve of 81% for predicting pseudoprogression. This was further improved to 89% with the addition of O6-methylguanine-DNA methyltransferase status into the classifier. Conclusions Our results suggest that radiomic analysis of contrast T1-weighted images and magnetic resonance imaging perfusion images can assist the prompt diagnosis of pseudoprogression. Validation on external and independent data sets is necessary to verify these advanced analyses, which can be performed on routinely acquired clinical images and may help inform clinical treatment decisions.
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Affiliation(s)
- Anna Sophia McKenney
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Radiology, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - Emily Weg
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Tejus A. Bale
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
- Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Aaron T. Wild
- Department Southeast Radiation Oncology, Levine Cancer Institute, Charlotte, North Carolina
| | - Hyemin Um
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael J. Fox
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew Lin
- Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonathan T. Yang
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Peter Yao
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Maxwell L. Birger
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Florent Tixier
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Matthew Sellitti
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nelson S. Moss
- Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Robert J. Young
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Radiology, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
- Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York
- Corresponding author: Robert J. Young, MD
| | - Harini Veeraraghavan
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
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18
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Yang JT, Wijetunga NA, Pentsova E, Wolden S, Young RJ, Correa D, Zhang Z, Zheng J, Steckler A, Bucwinska W, Bernstein A, Betof Warner A, Yu H, Kris MG, Seidman AD, Wilcox JA, Malani R, Lin A, DeAngelis LM, Lee NY, Powell SN, Boire A. Randomized Phase II Trial of Proton Craniospinal Irradiation Versus Photon Involved-Field Radiotherapy for Patients With Solid Tumor Leptomeningeal Metastasis. J Clin Oncol 2022; 40:3858-3867. [PMID: 35802849 PMCID: PMC9671756 DOI: 10.1200/jco.22.01148] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 05/26/2022] [Accepted: 06/14/2022] [Indexed: 01/12/2023] Open
Abstract
PURPOSE Photon involved-field radiotherapy (IFRT) is the standard-of-care radiotherapy for patients with leptomeningeal metastasis (LM) from solid tumors. We tested whether proton craniospinal irradiation (pCSI) encompassing the entire CNS would result in superior CNS progression-free survival (PFS) compared with IFRT. PATIENTS AND METHODS We conducted a randomized, phase II trial of pCSI versus IFRT in patients with non-small-cell lung cancer and breast cancers with LM. We enrolled patients with other solid tumors to an exploratory pCSI group. For the randomized groups, patients were assigned (2:1), stratified by histology and systemic disease status, to pCSI or IFRT. The primary end point was CNS PFS. Secondary end points included overall survival (OS) and treatment-related adverse events (TAEs). RESULTS Between April 16, 2020, and October 11, 2021, 42 and 21 patients were randomly assigned to pCSI and IFRT, respectively. At planned interim analysis, a significant benefit in CNS PFS was observed with pCSI (median 7.5 months; 95% CI, 6.6 months to not reached) compared with IFRT (2.3 months; 95% CI, 1.2 to 5.8 months; P < .001). We also observed OS benefit with pCSI (9.9 months; 95% CI, 7.5 months to not reached) versus IFRT (6.0 months; 95% CI, 3.9 months to not reached; P = .029). There was no difference in the rate of grade 3 and 4 TAEs (P = .19). In the exploratory pCSI group, 35 patients enrolled, the median CNS PFS was 5.8 months (95% CI, 4.4 to 9.1 months) and OS was 6.6 months (95% CI, 5.4 to 11 months). CONCLUSION Compared with photon IFRT, we found pCSI improved CNS PFS and OS for patients with non-small-cell lung cancer and breast cancer with LM with no increase in serious TAEs.
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Affiliation(s)
- Jonathan T. Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - N. Ari Wijetunga
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Elena Pentsova
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Suzanne Wolden
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Robert J. Young
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Denise Correa
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Junting Zheng
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alexa Steckler
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Weronika Bucwinska
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ashley Bernstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Allison Betof Warner
- Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, Melanoma and Immunotherapeutics Service, New York, NY
| | - Helena Yu
- Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, Thoracic Oncology Service, New York, NY
| | - Mark G. Kris
- Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, Thoracic Oncology Service, New York, NY
| | - Andrew D. Seidman
- Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, Breast Medicine Service, New York, NY
| | - Jessica A. Wilcox
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Rachna Malani
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andrew Lin
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Lisa M. DeAngelis
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nancy Y. Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Simon N. Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Adrienne Boire
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, Brain Tumor Center, New York, NY
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19
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Imber BS, Young RJ, Beal K, Reiner AS, Giantini-Larsen AM, Krebs S, Yang JT, Aramburu-Nunez D, Cohen GN, Brennan C, Tabar V, Moss NS. Correction to: Salvage resection plus cesium-131 brachytherapy durably controls post-SRS recurrent brain metastases. J Neurooncol 2022; 159:619. [PMID: 35997921 DOI: 10.1007/s11060-022-04121-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Brandon S Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Robert J Young
- Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Radiology, Neuroradiology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kathryn Beal
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anne S Reiner
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
| | | | - Simone Krebs
- Department of Radiology, Molecular Imaging and Therapy Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jonathan T Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David Aramburu-Nunez
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Gil'ad N Cohen
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Cameron Brennan
- Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Viviane Tabar
- Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nelson S Moss
- Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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20
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Yang JT, Liu ZK, Zhan SY. [Progress in epidemiological research of 2019-nCoV infection and COVID-19 vaccination in pregnancy]. Zhonghua Liu Xing Bing Xue Za Zhi 2022; 43:1215-1221. [PMID: 35981982 DOI: 10.3760/cma.j.cn112338-20220323-00217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Coronavirus disease 2019 (COVID-19) is an acute respiratory infectious disease caused by 2019-nCoV. Due to the physiological change in pregnancy, pregnant women are susceptible to COVID-19 and are at increased risk for adverse pregnancy outcomes, especially in the context of spread of novel variants. At present, less evidences have been obtained from randomized controlled trials on the effectiveness and safety of COVID-19 vaccine use in pregnant women, and the recommendations of COVID-19 vaccination for pregnant women vary with countries, posing challenge to the prevention and control of COVID-19 in pregnant women. This paper summarizes the progress in major research of 2019-nCoV infection in pregnancy conducted both at home and abroad, describes the harm of COVID-19 in pregnancy to pregnant women, fetuses and infants and introduces the effectiveness and safety of COVID-19 vaccination in pregnancy revealed by real world studies in order to provide reference for the related research and development of COVID-19 prevention and control strategies in pregnant women.
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Affiliation(s)
- J T Yang
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing 100191, China Key Laboratory for Research and Evaluation of Pharmacovigilance, National Medical Products Administration, Peking University,Beijing 100191, China
| | - Z K Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing 100191, China Key Laboratory for Research and Evaluation of Pharmacovigilance, National Medical Products Administration, Peking University,Beijing 100191, China
| | - S Y Zhan
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing 100191, China Key Laboratory for Research and Evaluation of Pharmacovigilance, National Medical Products Administration, Peking University,Beijing 100191, China Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing 100191, China Center for Intelligent Public Health, Institute for Artificial Intelligence, Peking University, Beijing 100871, China
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21
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Imber BS, Beal K, Reiner AS, Giantini-Larsen A, Yang JT, Aramburu-Nunez D, Cohen G, Brennan C, Tabar V, Young RJ, Moss NS. LOCL-15 PERMANENT CARRIER-EMBEDDED CESIUM-131 BRACHYTHERAPY FOR THE SALVAGE TREATMENT OF PREVIOUSLY IRRADIATED, RECURRENT BRAIN METASTASES. Neurooncol Adv 2022. [PMCID: PMC9354192 DOI: 10.1093/noajnl/vdac078.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Salvage of recurrent of previously-irradiated brain metastases (rBrM) is a significant clinical challenge. High local failure rates are seen following salvage resection without adjuvant re-irradiation, while reirradiation is associated with high radionecrosis rates. Salvage surgery plus intraoperative Cs131 brachytherapy may offer dosimetric and biologic advantages including improved local control versus observation, with reduced integral brain dose versus re-irradiation.
METHODS
A prospective registry of consecutively treated patients with rBrM after prior stereotactic radiosurgery (SRS) was analyzed. Following maximal-safe resection and intraoperative viable-disease confirmation, cavities were implanted with commercially-available, collagen-matrix embedded Cs131 seeds (GammaTile, GT Medical Technologies). Prescribed dose was 60Gy at 5mm from the cavity.
RESULTS
Twenty patients underwent 24 operations with Cs131 implantation in 25 cavities. Previous SRS occurred a median of 358d preoperatively (range=56-1334). Median maximum preoperative diameter was 3.0cm (range=1.1-6.3) and enhancing volume was 9.5cm3 (range=0.6-69.7). Gross- or near-total resection was achieved in 60% of lesions. A median of 16 Cs131 seeds (range=6-30), with a median activity of 3.5U/seed were implanted. Maximal preoperative diameter and enhancing volume were weakly associated with the number of implanted seeds (correlation coefficients=0.50, 0.41, respectively). There was one postoperative wound dehiscence in a multiply resected and irradiated patient with hydrocephalus. With median follow-up of 12.5 months, 2 tumors recurred (one in-field, one marginal) resulting in a 1-year progression incidence of 9.8% (95%CI=0.0-23.2). Radiographic seed migration was identified in 7/25 cavities (28%) on surveillance scans ranging from 1.9-11.7 months post-implantation, without clinical sequelae.
CONCLUSIONS
With >1 year of follow-up, intraoperative brachytherapy with commercially-available Cs131 implants was associated with a high rate of local control and a favorable toxicity profile. Modest correlation between preoperative tumor geometry and implanted tiles in the context of high associated cost suggests a need to optimize planning criteria. A randomized trial of salvage resection with or without Cs131 is ongoing (NCT04690348) to assess the incremental benefit of brachytherapy.
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Affiliation(s)
| | - Kathryn Beal
- Memorial Sloan Kettering Cancer Center , New York , USA
| | - Anne S Reiner
- Memorial Sloan Kettering Cancer Center , New York , USA
| | | | | | | | - Gilad Cohen
- Memorial Sloan Kettering Cancer Center , New York , USA
| | | | - Viviane Tabar
- Memorial Sloan Kettering Cancer Center , New York , USA
| | | | - Nelson S Moss
- Memorial Sloan Kettering Cancer Center , New York , USA
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22
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Imber BS, Young RJ, Beal K, Reiner AS, Giantini-Larsen AM, Yang JT, Aramburu-Nunez D, Cohen GN, Brennan C, Tabar V, Moss NS. Salvage resection plus cesium-131 brachytherapy durably controls post-SRS recurrent brain metastases. J Neurooncol 2022; 159:609-618. [PMID: 35896906 PMCID: PMC9328626 DOI: 10.1007/s11060-022-04101-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 07/16/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Salvage of recurrent previously irradiated brain metastases (rBrM) is a significant challenge. Resection without adjuvant re-irradiation is associated with a high local failure rate, while reirradiation only partially reduces failure but is associated with greater radiation necrosis risk. Salvage resection plus Cs131 brachytherapy may offer dosimetric and biologic advantages including improved local control versus observation, with reduced normal brain dose versus re-irradiation, however data are limited. METHODS A prospective registry of consecutive patients with post-stereotactic radiosurgery (SRS) rBrM undergoing resection plus implantation of collagen-matrix embedded Cs131 seeds (GammaTile, GT Medical Technologies) prescribed to 60 Gy at 5 mm from the cavity was analyzed. RESULTS Twenty patients underwent 24 operations with Cs131 implantation in 25 tumor cavities. Median maximum preoperative diameter was 3.0 cm (range 1.1-6.3). Gross- or near-total resection was achieved in 80% of lesions. A median of 16 Cs131 seeds (range 6-30), with a median air-kerma strength of 3.5 U/seed were implanted. There was one postoperative wound dehiscence. With median follow-up of 1.6 years for survivors, two tumors recurred (one in-field, one marginal) resulting in 8.4% 1-year progression incidence (95%CI = 0.0-19.9). Radiographic seed settling was identified in 7/25 cavities (28%) 1.9-11.7 months post-implantation, with 1 case of distant migration (4%), without clinical sequelae. There were 8 cases of radiation necrosis, of which 4 were symptomatic. CONCLUSIONS With > 1.5 years of follow-up, intraoperative brachytherapy with commercially available Cs131 implants was associated with favorable local control and toxicity profiles. Weak correlation between preoperative tumor geometry and implanted tiles highlights a need to optimize planning criteria.
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Affiliation(s)
- Brandon S Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Robert J Young
- Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Radiology, Neuroradiology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kathryn Beal
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anne S Reiner
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
| | | | - Jonathan T Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David Aramburu-Nunez
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Gil'ad N Cohen
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Cameron Brennan
- Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Viviane Tabar
- Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nelson S Moss
- Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA. .,Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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23
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Joshirao M, Sait SF, Bouvier N, Hill K, Khakoo Y, Kramer K, Gilheeney S, Wolden S, Nolan C, Schaff L, Rosenblum M, Bale TA, Yang JT, Lin A, Dunkel IJ, Karajannis M. HGG-35. Radiation Induced High Grade Gliomas: A Single Center Experience. Neuro Oncol 2022. [PMCID: PMC9164933 DOI: 10.1093/neuonc/noac079.250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION: Patients receiving cranial radiotherapy (RT) are at risk for a subsequent radiation-induced glioma (RIG). RIGs are rare, generally develop with a latency of 2 years to several decades, display high-grade histology and an aggressive clinical course with poor prognosis. METHODS: We retrospectively analyzed patients with a diagnosis of RIG seen at our institution from 2001-2021, analyzing clinical, histological, molecular, and genetic characteristics. RESULTS: Twenty-one patients (n=15 male) with a history of ALL (n=6), medulloblastoma (n=5), germ cell tumors (n=4), or other (n=6) diagnosed at a median age of 8.3 years (range 1.6 to 36.4) were identified. Median age at RIG diagnosis was 18 years (range 7.8 to 66.9). Prior RT was focal+craniospinal (n=7), whole brain (n=5), total body (n=3), focal (n=1), or unknown (n=5). Median radiation dose received was 2,340 cGy (range 1,200 to 5,400). The median time from RT to RIG diagnosis was 7.7 years (range 1.6 to 23.8). All RIGs were histologically high grade (WHO Grade III or IV). Immunohistochemistry did not reveal IDH(R132H) (n=9) or H3K27M (n=8) in any tumor. Some tumors demonstrated loss of expression of ATRX (1/9) and/or H3K27me3 (3/6), and/or strong diffuse expression of p53 (0/3). Targeted panel sequencing (n=10) revealed recurrent somatic alterations including CDKN2A/B, PDGFRa/KIT/KDR, TEK, MTAP, ATM and NF1. Germline alterations were detected in 4/12 patients (pathogenetic variants in ATM, CHEK2, HOXB13 and NF1). With median follow-up of 4.5 years, two-year PFS and OS for the cohort (n=20) were 10% and 44% respectively. Two patients (with anaplastic oligodendroglioma and anaplastic astrocytoma) are alive without progression 5.4 and 13.6 years after diagnosis following surgery, RT and chemotherapy. CONCLUSION: Although RIGs are associated with a poor prognosis, they are not always fatal. Our findings suggest aggressive therapy should be considered for these patients.
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Affiliation(s)
- Mrinal Joshirao
- Memorial Sloan Kettering Cancer Center, New York , New York , USA
- SUNY Downstate Health Sciences University, Brooklyn , New York , USA
| | | | - Nancy Bouvier
- Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - Katherine Hill
- Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - Yasmin Khakoo
- Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - Kim Kramer
- Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | | | - Suzanne Wolden
- Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - Craig Nolan
- Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - Lauren Schaff
- Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - Marc Rosenblum
- Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - Tejus A Bale
- Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - Jonathan T Yang
- Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - Andrew Lin
- Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - Ira J Dunkel
- Memorial Sloan Kettering Cancer Center, New York , New York , USA
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24
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Ma J, del Balzo L, Khaleel SS, Flynn J, Zhang Z, Voss MH, Freeman B, Hakimi AA, Lee CH, Eichholz J, Kelly DW, Yang JT, Mueller B, Carlo MI, Motzer RJ, Imber BS, Beal K, Moss NS, Kotecha R, Pike LRG. Molecular profile and clinical outcomes of renal cell carcinoma brain metastases treated with stereotactic radiosurgery. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.4526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
4526 Background: Molecular profiles of renal cell carcinoma (RCC) tumors are associated with systemic treatment (ST) responses and clinical outcomes. However, the molecular profiles of RCC brain metastases (BM) and their correlation with ST response and clinical outcomes are not well characterized. Effective management of BM with locoregional therapies including stereotactic radiosurgery (SRS) is critical as ST advances have improved overall survival (OS). Therefore, we sought to identify the clinical and genomic features of RCC BM in a large cohort of patients treated with SRS. Methods: We performed an institutional retrospective analysis of RCC BM patients treated with SRS and evaluated corresponding genomic next generation sequencing (NGS) data via a targeted sequencing panel (MSK-IMPACT). A comparison cohort of all institutional patients with available NGS data was utilized to investigate genes enriched in our BM cohort using Fisher exact testing. Kaplan Meier analyses were performed for OS and intracranial progression-free survival (iPFS). Clinical factors and genes mutated in ≥ 10% of samples were assessed per patient using Cox proportional hazards models, and per individual BMs using clustered competing risks regression with a competing risk of death. Results: From 2010-2021, 91 RCC BM patients underwent SRS for 212 BMs, including 86% clear cell and 14% non-clear cell RCC. NGS data was available for 76 patients (84%), including 18 resected BMs, 26 extra-cranial metastatic lesions (EM), and 32 primary kidney tumors (Table 1). Median follow-up was 3.2 years with median OS of 21 months (m) and median iPFS of 7.8m. Karnofsky performance status ≥80 and extracranial disease control were significantly associated with improved OS on multivariable analyses (MVA; p=0.049 and 0.01, respectively). No clinical variables were significantly associated with iPFS on MVA. At the BM level, SETD2 alterations approached significance for improved iPFS (HR=0.35; 95%CI 0.11, 1.05; p=0.06). Enrichment in SMARCA4 alterations was seen in the BM cohort as compared to primary kidney and EM samples from patients without BM (17% vs 1% vs 2%, p<0.05). Conclusions: To our knowledge, this is the largest study investigating mutational profiles of RCC BM. SMARCA4 alterations were enriched in BM samples and a trend towards improved iPFS was seen in SETD2 variant BMs, warranting further investigation.[Table: see text]
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Affiliation(s)
- Jennifer Ma
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Sari Safaa Khaleel
- Memorial Sloan-Kettering Cancer Center-Fellowship (GME Office), New York, NY
| | - Jessica Flynn
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Zhigang Zhang
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Martin H Voss
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - A. Ari Hakimi
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Chung-Han Lee
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | - Boris Mueller
- Memorial Sloan-Kettering Cancer Center, Tarrytown, NY
| | | | | | | | - Kathryn Beal
- Memorial Sloan Kettering Cancer Center, New York, NY
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25
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Yang JT, Wijetunga NA, Pentsova E, Wolden SL, Young RJ, Correa D, Zhang Z, Zheng J, Betof Warner A, Yu HA, Kris MG, Seidman AD, Malani R, Lin A, DeAngelis LM, Lee NY, Powell SN, Boire AA. Phase II randomized study comparing proton craniospinal irradiation with photon involved-field radiotherapy for patients with solid tumor leptomeningeal metastasis. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.2000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
2000 Background: Leptomeningeal metastasis (LM) is associated with limited survival and treatments. Photon involved-field radiotherapy (IFRT) is the standard of care radiotherapy (RT) but benefits are limited. We hypothesized that proton craniospinal irradiation (pCSI) encompassing the central nervous system (CNS) compartment would result in superior CNS disease control compared to IFRT. Methods: We conducted a randomized phase 2 study comparing pCSI vs. IFRT in patients with non-small cell lung cancer (NSCLC) or breast cancer LM. Eligibility criteria included radiographic and/or cytologic LM and Karnofsky performance status (KPS) ≥ 60. Patients were stratified by histology (breast vs. NSCLC) and systemic disease (active vs. stable) and were randomized in a 2:1 ratio of pCSI:IFRT. Patients with all other solid tumor histologies were enrolled to an exploratory pCSI arm. RT was 3Gy x 10 fractions for all patients. The primary endpoint is CNS progression-free survival (CNS PFS), defined as time from randomization to CNS progression (POD); secondary endpoints include overall survival (OS) and treatment-related adverse events (TAEs). A target of 81 patients to compare pCSI and IFRT was designed with a one-sided alpha of 0.025 and a power of 0.8 based on stratified log-rank test. Analysis is based on intent-to-treat. Results: From 4/2020-10/2021, 42 and 21 patients were randomized to pCSI and IFRT, respectively. Baseline factors were not different: median age was 56 vs. 61 years (p = 0.5); both cohorts included 57% NSCLC and 52% with active systemic disease. At median follow up of 7.1 months, 25 patients had CNS POD (pCSI = 9 [21%], IFRT = 16 [76%]) and 28 died (pCSI = 15 [36%], IFRT = 13 [62%]). At planned interim analysis, significant benefit in CNS PFS was observed with pCSI (median = 7.5 months, 95% CI: 6.6-NA) vs. IFRT (median = 2.0, 95% CI: 1.0-5.1, p < 0.001). As a result, the Data and Safety Monitoring Committee recommended early discontinuation of the trial. In addition, OS benefit with pCSI (median = 8.2 months, 95% CI: 7.4-NA) vs. IFRT (median = 4.9 months, 95% CI: 3.1-NA, p = 0.04) was observed. In a multivariable analysis including age, KPS and stratification factors, CNS PFS and OS benefit for pCSI remained significant. Grade 3 non-heme TAEs occurred in 3 patients with pCSI and 5 with IFRT. For the exploratory pCSI cohort, 35 patients enrolled, the median age was 61, 20 (57%) had active systemic disease and ovarian (7 [20%]) was the most common histology. At median follow up of 9.6 months, 7 (20%) had CNS POD and 20 (57%) died. Median CNS PFS was 5.4 months (95% CI: 4.8-9.1), OS was 6.6 months (95% CI: 5.4-12.1) and 4 patients had Grade 3 TAEs. Conclusions: In this trial, the first randomized study of RT for LM, we demonstrated improved CNS PFS of pCSI compared to IFRT, meeting the primary endpoint. pCSI also had a significant OS benefit. Grade 3 toxicities were comparable. Clinical trial information: NCT04343573.
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Affiliation(s)
| | | | | | | | | | - Denise Correa
- Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Zhigang Zhang
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Junting Zheng
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Mark G. Kris
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Rachna Malani
- Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Andrew Lin
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Nancy Y. Lee
- Memorial Sloan Kettering Cancer Center, New York, NY
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26
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Skakodub A, Tringale KR, Walch HS, Vasudevan H, Eichholz J, Kelly DW, Moss NS, Yu KKH, Li BT, Mueller B, Yang JT, Beal K, Imber BS, Gomez DR, Schultz N, Pike LRG. Genomic analysis and clinical correlations of non-small cell lung cancer (NSCLC) brain metastasis (BM). J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.2008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
2008 Background: Approximately 30% of patients with NSCLC present with BM, and up to 50% of patients ultimately develop BM. While modern NSCLC-directed agents yield excellent systemic response, most patients require focal treatment. Prior reports of BM genomics have been limited by low numbers, missing clinical data, and lack of matched specimens. Here, we report the largest cohort to date of molecularly profiled NSCLC BM samples with clinical correlates. Methods: Clinical data and outcomes for 244 patients with NSCLC and resected BM were identified, and BM samples were assessed with one of four versions (341, 410, 468, 505) of MSK-IMPACT, a custom FDA-approved next generation sequencing-based tumor sequencing assay. 51 (20.9%) patients had matched primary site tissue, and 44 (18%) patients had matched tissue from another metastatic site or CSF. Genomic alterations were filtered for driver variants using OncoKB. Results: Median age was 66 years (range 31-91), and median follow-up was 2.3 years (IQR 1.3-4.3). Adenocarcinoma was the most common histology (183, 78%). Half presented with a single BM, and 121 (51%) patients were treatment naive. Most (197, 83%) received adjuvant stereotactic radiosurgery (SRS) to the resection site and 28% received SRS to additional BM. After resection, 130 (55.1%) had CNS progression, often regional (54, 42%). SRS to new BMs (32%) was the most common salvage treatment. Median overall survival from BM diagnosis was 2.5 years (95%CI 2.1-3.2). Median CNS-progression-free survival was 1.2 years (95%CI 0.9-1.4). The most frequently altered genes in BM samples were TP53 (72%), CDKN2A (34%), KRAS (31%), KEAP1 (26%), and EGFR (21%). CDKN2A was more frequently altered in BM samples when compared to NSCLC primary samples (34% vs 14%, p = 0.003, q = 0.034). With regard to overrepresented gene sets, cell cycle pathway alterations were enriched in BM (56% vs 31%, p = 0.002, q = 0.022). BM samples had a significantly higher fraction of genome altered relative to the primary samples (p < 0.0001, q < 0.0001). After grouping patients based on type of CNS progression, we found that EGFR alterations were enriched in patients with leptomeningeal failures when compared to both patients without progression (42% vs 18%, p = 0.03, q = 0.93) and to patients with either local or regional progression (42% vs 19%, p = 0.03, q = 0.9). Conclusions: In the largest-ever assembled cohort of genomically-profiled NSCLC BM, we found significant enrichment for CDKN2A and cell cycle pathway alterations in BM compared to extracranial disease, as well as a higher fraction of genome altered, in BMs compared to matched primary tumor controls. We also observed EGFR alteration enrichment in patients who develop LMD, suggesting specific biologic underpinnings driving patterns of CNS failure. Further investigation into the role of systemic therapy and time course will elucidate potential mechanisms for CNS failure in patients with NSCLC.
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Affiliation(s)
- Anna Skakodub
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | | | | | | | | | - Bob T. Li
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Boris Mueller
- Memorial Sloan-Kettering Cancer Center, Tarrytown, NY
| | | | - Kathryn Beal
- Memorial Sloan Kettering Cancer Center, New York, NY
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27
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Ledesma Vicioso N, Lin D, Gomez DR, Yang JT, Lee NY, Rimner A, Yamada Y, Zelefsky MJ, Kalman NS, Rutter CE, Kotecha RR, Mehta MP, Panoff JE, Chuong MD, Salner AL, Ostroff JS, Diamond LC, Mathis NJ, Cahlon O, Pfister DG, Zhang Z, Chino F, Tsai J, Gillespie EF. Implementation Strategies to Increase Clinical Trial Enrollment in a Community-Academic Partnership and Impact on Hispanic Representation: An Interrupted Time Series Analysis. JCO Oncol Pract 2022; 18:e780-e785. [PMID: 35544650 PMCID: PMC10166438 DOI: 10.1200/op.22.00037] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Community-academic partnerships have the potential to improve access to clinical trials for under-represented minority patients who more often receive cancer treatment in community settings. In 2017, the Memorial Sloan Kettering (MSK) Cancer Center began opening investigator-initiated clinical trials in radiation oncology in targeted community-based partner sites with a high potential to improve diverse population accrual. This study evaluates the effectiveness of a set of implementation strategies for increasing overall community-based enrollment and the resulting proportional enrollment of Hispanic patients on trials on the basis of availability in community-based partner sites. METHODS An interrupted time series analysis evaluating implementation strategies was conducted from April 2018 to September 2021. Descriptive analysis ofHispanic enrollment on investigator-initiated randomized therapeutic radiation trials open at community-based sites was compared with those open only at themain academic center. RESULTS Overall, 84 patients were enrolled in clinical trials in the MSK Alliance, of which 48 (56%) identified as Hispanic. The quarterly patient enrollment pre- vs postimplementation increased from 1.39 (95% CI, -3.67 to 6.46) to 9.42 (95% CI, 2.05 to 16.78; P5 .017). In the investigator-initiated randomized therapeutic radiation trials open in the MSK Alliance, Hispanic representation was 11.5% and 35.9% in twometastatic trials and 14.2% in a proton versus photon trial. Inmatched trials open only at the main academic center, Hispanic representation was 5.6%, 6.0%, and 4.0%, respectively. CONCLUSION A combination of practice-level and physician-level strategies implemented at community-based partner sites was associated with increased clinical trial enrollment, which translated to improved Hispanic representation. This supports the role Q:2 of strategic community-academic partnerships in addressing disparities in clinical trial enrollment.
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Affiliation(s)
| | - Diana Lin
- 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
| | - Jonathan T Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nancy Y Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Yoshiya Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Michael J Zelefsky
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Noah S Kalman
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL
| | | | - Rupesh R Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL
| | - Joseph E Panoff
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL
| | - Michael D Chuong
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL
| | | | - Jamie S Ostroff
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Lisa C Diamond
- Immigrant Health and Cancer Disparities Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Noah J Mathis
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David G Pfister
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jillian Tsai
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Erin F Gillespie
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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28
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Swinburne NC, Yadav V, Kim J, Choi YR, Gutman DC, Yang JT, Moss N, Stone J, Tisnado J, Hatzoglou V, Haque SS, Karimi S, Lyo J, Juluru K, Pichotta K, Gao J, Shah SP, Holodny AI, Young RJ. Semisupervised Training of a Brain MRI Tumor Detection Model Using Mined Annotations. Radiology 2022; 303:80-89. [PMID: 35040676 PMCID: PMC8962822 DOI: 10.1148/radiol.210817] [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] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 10/12/2021] [Accepted: 11/03/2021] [Indexed: 11/11/2022]
Abstract
Background Artificial intelligence (AI) applications for cancer imaging conceptually begin with automated tumor detection, which can provide the foundation for downstream AI tasks. However, supervised training requires many image annotations, and performing dedicated post hoc image labeling is burdensome and costly. Purpose To investigate whether clinically generated image annotations can be data mined from the picture archiving and communication system (PACS), automatically curated, and used for semisupervised training of a brain MRI tumor detection model. Materials and Methods In this retrospective study, the cancer center PACS was mined for brain MRI scans acquired between January 2012 and December 2017 and included all annotated axial T1 postcontrast images. Line annotations were converted to boxes, excluding boxes shorter than 1 cm or longer than 7 cm. The resulting boxes were used for supervised training of object detection models using RetinaNet and Mask region-based convolutional neural network (R-CNN) architectures. The best-performing model trained from the mined data set was used to detect unannotated tumors on training images themselves (self-labeling), automatically correcting many of the missing labels. After self-labeling, new models were trained using this expanded data set. Models were scored for precision, recall, and F1 using a held-out test data set comprising 754 manually labeled images from 100 patients (403 intra-axial and 56 extra-axial enhancing tumors). Model F1 scores were compared using bootstrap resampling. Results The PACS query extracted 31 150 line annotations, yielding 11 880 boxes that met inclusion criteria. This mined data set was used to train models, yielding F1 scores of 0.886 for RetinaNet and 0.908 for Mask R-CNN. Self-labeling added 18 562 training boxes, improving model F1 scores to 0.935 (P < .001) and 0.954 (P < .001), respectively. Conclusion The application of semisupervised learning to mined image annotations significantly improved tumor detection performance, achieving an excellent F1 score of 0.954. This development pipeline can be extended for other imaging modalities, repurposing unused data silos to potentially enable automated tumor detection across radiologic modalities. © RSNA, 2022 Online supplemental material is available for this article.
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Affiliation(s)
| | | | - Julie Kim
- From the Departments of Radiology (N.C.S., V.Y., Y.R.C., D.C.G.,
J.T., V.H., S.S.H., S.K., J.L., K.J., A.I.H., R.J.Y.), Radiation Oncology
(J.T.Y.), Neurosurgery (N.M.), Neurology (J.S.), and Epidemiology and
Biostatistics, Division of Computational Oncology, (K.P., J.G., S.P.S.),
Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065; Weill
Cornell Medical College, New York, NY (J.K.)
| | - Ye R. Choi
- From the Departments of Radiology (N.C.S., V.Y., Y.R.C., D.C.G.,
J.T., V.H., S.S.H., S.K., J.L., K.J., A.I.H., R.J.Y.), Radiation Oncology
(J.T.Y.), Neurosurgery (N.M.), Neurology (J.S.), and Epidemiology and
Biostatistics, Division of Computational Oncology, (K.P., J.G., S.P.S.),
Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065; Weill
Cornell Medical College, New York, NY (J.K.)
| | - David C. Gutman
- From the Departments of Radiology (N.C.S., V.Y., Y.R.C., D.C.G.,
J.T., V.H., S.S.H., S.K., J.L., K.J., A.I.H., R.J.Y.), Radiation Oncology
(J.T.Y.), Neurosurgery (N.M.), Neurology (J.S.), and Epidemiology and
Biostatistics, Division of Computational Oncology, (K.P., J.G., S.P.S.),
Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065; Weill
Cornell Medical College, New York, NY (J.K.)
| | - Jonathan T. Yang
- From the Departments of Radiology (N.C.S., V.Y., Y.R.C., D.C.G.,
J.T., V.H., S.S.H., S.K., J.L., K.J., A.I.H., R.J.Y.), Radiation Oncology
(J.T.Y.), Neurosurgery (N.M.), Neurology (J.S.), and Epidemiology and
Biostatistics, Division of Computational Oncology, (K.P., J.G., S.P.S.),
Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065; Weill
Cornell Medical College, New York, NY (J.K.)
| | - Nelson Moss
- From the Departments of Radiology (N.C.S., V.Y., Y.R.C., D.C.G.,
J.T., V.H., S.S.H., S.K., J.L., K.J., A.I.H., R.J.Y.), Radiation Oncology
(J.T.Y.), Neurosurgery (N.M.), Neurology (J.S.), and Epidemiology and
Biostatistics, Division of Computational Oncology, (K.P., J.G., S.P.S.),
Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065; Weill
Cornell Medical College, New York, NY (J.K.)
| | - Jacqueline Stone
- From the Departments of Radiology (N.C.S., V.Y., Y.R.C., D.C.G.,
J.T., V.H., S.S.H., S.K., J.L., K.J., A.I.H., R.J.Y.), Radiation Oncology
(J.T.Y.), Neurosurgery (N.M.), Neurology (J.S.), and Epidemiology and
Biostatistics, Division of Computational Oncology, (K.P., J.G., S.P.S.),
Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065; Weill
Cornell Medical College, New York, NY (J.K.)
| | - Jamie Tisnado
- From the Departments of Radiology (N.C.S., V.Y., Y.R.C., D.C.G.,
J.T., V.H., S.S.H., S.K., J.L., K.J., A.I.H., R.J.Y.), Radiation Oncology
(J.T.Y.), Neurosurgery (N.M.), Neurology (J.S.), and Epidemiology and
Biostatistics, Division of Computational Oncology, (K.P., J.G., S.P.S.),
Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065; Weill
Cornell Medical College, New York, NY (J.K.)
| | - Vaios Hatzoglou
- From the Departments of Radiology (N.C.S., V.Y., Y.R.C., D.C.G.,
J.T., V.H., S.S.H., S.K., J.L., K.J., A.I.H., R.J.Y.), Radiation Oncology
(J.T.Y.), Neurosurgery (N.M.), Neurology (J.S.), and Epidemiology and
Biostatistics, Division of Computational Oncology, (K.P., J.G., S.P.S.),
Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065; Weill
Cornell Medical College, New York, NY (J.K.)
| | - Sofia S. Haque
- From the Departments of Radiology (N.C.S., V.Y., Y.R.C., D.C.G.,
J.T., V.H., S.S.H., S.K., J.L., K.J., A.I.H., R.J.Y.), Radiation Oncology
(J.T.Y.), Neurosurgery (N.M.), Neurology (J.S.), and Epidemiology and
Biostatistics, Division of Computational Oncology, (K.P., J.G., S.P.S.),
Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065; Weill
Cornell Medical College, New York, NY (J.K.)
| | - Sasan Karimi
- From the Departments of Radiology (N.C.S., V.Y., Y.R.C., D.C.G.,
J.T., V.H., S.S.H., S.K., J.L., K.J., A.I.H., R.J.Y.), Radiation Oncology
(J.T.Y.), Neurosurgery (N.M.), Neurology (J.S.), and Epidemiology and
Biostatistics, Division of Computational Oncology, (K.P., J.G., S.P.S.),
Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065; Weill
Cornell Medical College, New York, NY (J.K.)
| | - John Lyo
- From the Departments of Radiology (N.C.S., V.Y., Y.R.C., D.C.G.,
J.T., V.H., S.S.H., S.K., J.L., K.J., A.I.H., R.J.Y.), Radiation Oncology
(J.T.Y.), Neurosurgery (N.M.), Neurology (J.S.), and Epidemiology and
Biostatistics, Division of Computational Oncology, (K.P., J.G., S.P.S.),
Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065; Weill
Cornell Medical College, New York, NY (J.K.)
| | - Krishna Juluru
- From the Departments of Radiology (N.C.S., V.Y., Y.R.C., D.C.G.,
J.T., V.H., S.S.H., S.K., J.L., K.J., A.I.H., R.J.Y.), Radiation Oncology
(J.T.Y.), Neurosurgery (N.M.), Neurology (J.S.), and Epidemiology and
Biostatistics, Division of Computational Oncology, (K.P., J.G., S.P.S.),
Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065; Weill
Cornell Medical College, New York, NY (J.K.)
| | - Karl Pichotta
- From the Departments of Radiology (N.C.S., V.Y., Y.R.C., D.C.G.,
J.T., V.H., S.S.H., S.K., J.L., K.J., A.I.H., R.J.Y.), Radiation Oncology
(J.T.Y.), Neurosurgery (N.M.), Neurology (J.S.), and Epidemiology and
Biostatistics, Division of Computational Oncology, (K.P., J.G., S.P.S.),
Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065; Weill
Cornell Medical College, New York, NY (J.K.)
| | - Jianjiong Gao
- From the Departments of Radiology (N.C.S., V.Y., Y.R.C., D.C.G.,
J.T., V.H., S.S.H., S.K., J.L., K.J., A.I.H., R.J.Y.), Radiation Oncology
(J.T.Y.), Neurosurgery (N.M.), Neurology (J.S.), and Epidemiology and
Biostatistics, Division of Computational Oncology, (K.P., J.G., S.P.S.),
Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065; Weill
Cornell Medical College, New York, NY (J.K.)
| | - Sohrab P. Shah
- From the Departments of Radiology (N.C.S., V.Y., Y.R.C., D.C.G.,
J.T., V.H., S.S.H., S.K., J.L., K.J., A.I.H., R.J.Y.), Radiation Oncology
(J.T.Y.), Neurosurgery (N.M.), Neurology (J.S.), and Epidemiology and
Biostatistics, Division of Computational Oncology, (K.P., J.G., S.P.S.),
Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065; Weill
Cornell Medical College, New York, NY (J.K.)
| | - Andrei I. Holodny
- From the Departments of Radiology (N.C.S., V.Y., Y.R.C., D.C.G.,
J.T., V.H., S.S.H., S.K., J.L., K.J., A.I.H., R.J.Y.), Radiation Oncology
(J.T.Y.), Neurosurgery (N.M.), Neurology (J.S.), and Epidemiology and
Biostatistics, Division of Computational Oncology, (K.P., J.G., S.P.S.),
Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065; Weill
Cornell Medical College, New York, NY (J.K.)
| | - Robert J. Young
- From the Departments of Radiology (N.C.S., V.Y., Y.R.C., D.C.G.,
J.T., V.H., S.S.H., S.K., J.L., K.J., A.I.H., R.J.Y.), Radiation Oncology
(J.T.Y.), Neurosurgery (N.M.), Neurology (J.S.), and Epidemiology and
Biostatistics, Division of Computational Oncology, (K.P., J.G., S.P.S.),
Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065; Weill
Cornell Medical College, New York, NY (J.K.)
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Diplas BH, Santos PMG, Shahrokni A, Warner A, Iyengar P, Yang JT, Gomez DR, Palma DA, Tsai CJ. The Role of Ablative Radiotherapy in Older Adults With Limited Metastatic Disease. Semin Radiat Oncol 2022; 32:135-141. [PMID: 35307115 PMCID: PMC10898514 DOI: 10.1016/j.semradonc.2021.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
For patients with oligometastatic cancer, radiotherapy presents a promising avenue for achieving meaningful symptom relief and durable disease control. Data from recently published and ongoing randomized studies are helping to define the appropriate contexts for effective intervention with stereotactic ablative body radiotherapy (SABR) in the oligometastatic setting. Importantly, older adults represent a significant portion of patients with oligometastatic disease, yet often comprise a minority of patients in clinical trials. Moreover, older adults of the same chronologic age may have variable degrees of fitness and frailty. In this review, we highlight the specific challenges and considerations for the use of radiotherapy for older adults with oligometastatic disease-noting the importance of geriatric assessments in clinical decision-making about the appropriateness of SABR and other metastasis-directed therapies in this population. We then review data from existing trials, including a subset analysis of adverse events and survival estimates among older adults enrolled in the landmark SABR-COMET trial. Finally, we discuss future directions for research, including the need for focused clinical trials in older adult cohorts. Ultimately, a multidisciplinary approach is critical when carefully balancing the potential risks and benefits of this emerging treatment paradigm in the older adult population.
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Affiliation(s)
- Bill H Diplas
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Patricia Mae G Santos
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Armin Shahrokni
- Department of Medicine, Geriatrics Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andrew Warner
- Department of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Puneeth Iyengar
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, TX
| | - Jonathan T Yang
- 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
| | - David A Palma
- Department of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - C Jillian Tsai
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY.
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30
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Mathis NJ, Wijetunga NA, Imber BS, Pike LRG, Yang JT. Recent Advances and Applications of Radiation Therapy for Brain Metastases. Curr Oncol Rep 2022; 24:335-342. [PMID: 35133614 DOI: 10.1007/s11912-022-01209-z] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW Radiation therapy (RT) is a mainstay of treatment for brain metastases from solid tumors. Treatment of these patients is complex and should focus on minimizing symptoms, preserving functional status, and prolonging survival. RECENT FINDINGS Whole-brain radiotherapy (WBRT) can lead to toxicity, and while it does reduce recurrence in the CNS, this has not been shown to provide a survival benefit. Recent advances focus on reducing the toxicity of WBRT or using more targeted radiation therapy. New paradigms including the use of proton RT for leptomeningeal metastases (LM) and stereotactic radiosurgery (SRS) before craniotomy hold promise in improving treatment efficacy and reducing toxicity. Omission or replacement of WBRT is often safe and the use of SRS is expanding to include patients with more lesions and preoperative RT. Proton RT holds promise for LM. Progress is being made in improving patient-centered outcomes and reducing toxicity for patients with brain metastases.
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Affiliation(s)
- Noah J Mathis
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - N Ari Wijetunga
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - Brandon S Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - Luke R G Pike
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - Jonathan T Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA.
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31
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Shin JY, Mathis NJ, Wijetunga NA, Yerramilli D, Higginson DS, Schmitt AM, Gomez DR, Yamada YJ, Yang JT. Clinical outcomes of dose-escalated hypofractionated external beam radiotherapy (5 Gy x 5 fractions) for spine metastasis. Adv Radiat Oncol 2022; 7:100906. [PMID: 35287317 PMCID: PMC8917266 DOI: 10.1016/j.adro.2022.100906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 01/10/2022] [Indexed: 12/31/2022] Open
Abstract
Purpose Methods and Materials Results Conclusions
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32
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Zarepisheh M, Hong L, Zhou Y, Huang Q, Yang J, Jhanwar G, Pham HD, Dursun P, Zhang P, Hunt MA, Mageras GS, Yang JT, Yamada Y, Deasy JO. Automated and Clinically Optimal Treatment Planning for Cancer Radiotherapy. INFORMS J Appl Anal 2022; 52:69-89. [PMID: 35847768 PMCID: PMC9284667 DOI: 10.1287/inte.2021.1095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Each year, approximately 18 million new cancer cases are diagnosed worldwide, and about half must be treated with radiotherapy. A successful treatment requires treatment planning with the customization of penetrating radiation beams to sterilize cancerous cells without harming nearby normal organs and tissues. This process currently involves extensive manual tuning of parameters by an expert planner, making it a time-consuming and labor-intensive process, with quality and immediacy of critical care dependent on the planner's expertise. To improve the speed, quality, and availability of this highly specialized care, Memorial Sloan Kettering Cancer Center developed and applied advanced optimization tools to this problem (e.g., using hierarchical constrained optimization, convex approximations, and Lagrangian methods). This resulted in both a greatly improved radiotherapy treatment planning process and the generation of reliable and consistent high-quality plans that reflect clinical priorities. These improved techniques have been the foundation of high-quality treatments and have positively impacted over 4,000 patients to date, including numerous patients in severe pain and in urgent need of treatment who might have otherwise required longer hospital stays or undergone unnecessary surgery to control the progression of their disease. We expect that the wide distribution of the system we developed will ultimately impact patient care more broadly, including in resource-constrained countries.
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Affiliation(s)
- Masoud Zarepisheh
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York
| | - Linda Hong
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York
| | - Ying Zhou
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York
| | - Qijie Huang
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York
| | - Jie Yang
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York
| | - Gourav Jhanwar
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York
| | - Hai D Pham
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York
| | - Pinar Dursun
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York
| | - Pengpeng Zhang
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York
| | - Margie A Hunt
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York
| | - Gig S Mageras
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York
| | - Jonathan T Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York
| | - Yoshiya Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York
| | - Joseph O Deasy
- Departments of Medical Physics, Memorial Sloan Kettering Cancer Center, New York
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33
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Zaorsky NG, Wang X, Garrett SM, Lehrer EJ, Lin C, DeGraff DJ, Spratt DE, Trifiletti DM, Kishan AU, Showalter TN, Park HS, Yang JT, Chinchilli VM, Wang M. Pan-cancer analysis of prognostic metastatic phenotypes. Int J Cancer 2022; 150:132-141. [PMID: 34287840 PMCID: PMC8595638 DOI: 10.1002/ijc.33744] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/21/2021] [Accepted: 06/29/2021] [Indexed: 01/03/2023]
Abstract
Although cancer is highly heterogeneous, all metastatic cancer is considered American Joint Committee on Cancer (AJCC) Stage IV disease. The purpose of this project was to redefine staging of metastatic cancer. Internal validation of nationally representative patient data from the National Cancer Database (n = 461 357; 2010-2013), and external validation using the Surveillance, Epidemiology and End Results database (n = 106 595; 2014-2015) were assessed using the concordance index for evaluation of survival prediction. A Cox proportional hazards model was used for overall survival by considering identified phenotypes (latent classes) and other confounding variables. Latent class analysis was performed for phenotype identification, where Bayesian information criterion (BIC) and sample-size-adjusted BIC were used to select the optimal number of distinct clusters. Kappa coefficients assessed external cluster validation. Latent class analysis identified five metastatic phenotypes with differences in overall survival (P < .0001): (Stage IVA) nearly exclusive bone-only metastases (n = 59 049, 12.8%; median survival 12.7 months; common in lung, breast and prostate cancers); (IVB) predominant lung metastases (n = 62 491, 13.5%; 11.4 months; common in breast, stomach, kidney, ovary, uterus, thyroid, cervix and soft tissue cancers); (IVC) predominant liver/lung metastases (n = 130 014, 28.2%; 7.0 months; common in colorectum, pancreatic, lung, esophagus and stomach cancers); (IVD) bone/liver/lung metastases predominant over brain (n = 61 004, 13.2%; 5.9 months; common in lung and breast cancers); and (IVE) brain/lung metastases predominant over bone/liver (n = 148 799, 32.3%; 5.7 months; lung cancer and melanoma). Long-term survivors were identified, particularly in Stages IVA-B. A pan-cancer nomogram model to predict survival (STARS: site, tumor, age, race, sex) was created, validated and provides 13% better prognostication than AJCC: 1-month concordance index of 0.67 (95% confidence interval [CI]: 0.66-0.67) vs 0.61 (95% CI: 0.60-0.61). STARS is simple, uses easily accessible variables, better prognosticates survival outcomes and provides a platform to develop novel metastasis-directed clinical trials.
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Affiliation(s)
- Nicholas G. Zaorsky
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA,Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA,Corresponding author: Nicholas G. Zaorsky, MD MS, Department of Radiation Oncology, Penn State Cancer Institute and Department of Public Health Sciences, Penn State College of Medicine, ; , Twitter: @NicholasZaorsky
| | - Xi Wang
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Sara M. Garrett
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA,Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Eric J. Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Christine Lin
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, USA,Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - David J. DeGraff
- Division of Experimental Pathology, Department of Pathology and Laboratory Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Daniel E. Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | | | - Amar U. Kishan
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA
| | | | - Henry S. Park
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT
| | - Jonathan T. Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Vernon M. Chinchilli
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Ming Wang
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
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Mathis NJ, Doyle CJ, Rosen DB, Wijetunga NA, Vaynrub M, Bartelstein M, Guttmann DM, Brennan VS, Yamada YJ, Gillespie EF, Yerramilli D, Yang JT. Personalized Treatment Selection Leads to Low Rates of Local Salvage Therapy for Bone Metastases. Int J Radiat Oncol Biol Phys 2022; 112:99-105. [PMID: 34715255 PMCID: PMC9396633 DOI: 10.1016/j.ijrobp.2021.06.025] [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: 05/07/2021] [Revised: 06/07/2021] [Accepted: 06/10/2021] [Indexed: 01/03/2023]
Abstract
PURPOSE Local therapy for patients with nonspine bone metastases is evolving, with data supporting the use of single-fraction treatments, and more recently, showing possible benefit from stereotactic body radiation therapy (SBRT). However, the rate of local salvage therapy (LST) after each technique has not been characterized in real-world clinic settings where patients are selected at physician discretion. We examined rates of LST in patients with nonspine bone metastases. METHODS AND MATERIALS We reviewed records of RT for nonspine bone metastases at our institution from January 1, 2016, to December 31, 2018. We defined LST as the first occurrence of RT or surgery for oncologic progression to a bone metastasis after initial RT. Cumulative incidence functions for retreatment were generated. We conducted multivariate analysis to identify variables associated with LST. RESULTS A total of 1754 patients were analyzed, with median follow-up of 16.2 months (range, 0-36.8 months). Of all episodes of RT, 51.5% were multifraction external beam radiation therapy (EBRT), 7.0% were single-fraction EBRT, and 41.4% were SBRT. Altogether, 88 patients (5.0%) required LST, with an incidence at 6 months of 2.5%. Incidence of LST at 6 months was 2.1% for SBRT, 5.3% for single-fraction conventional regimens, and 2.4% for multifraction conventional regimens (P = .26). Patients of younger age, who had a higher Karnofsky performance status, and/or who had lesions in the pelvis had a higher risk of retreatment. CONCLUSIONS In this large institutional cohort, the rate of LST was low, with no difference between RT techniques. The findings indicated that SBRT for patients at high risk for treatment failure may reduce the rate of retreatment overall. When treatment modality was selected based on patient characteristics, rates of LST were lower than when treatment was randomly selected.
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Affiliation(s)
- Noah J. Mathis
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Connor J. Doyle
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Daniel B. Rosen
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Neil A. Wijetunga
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Max Vaynrub
- Department of Orthopaedic Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Meredith Bartelstein
- Department of Orthopaedic Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David M Guttmann
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Victoria S Brennan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Yoshiya J Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Erin F Gillespie
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Divya Yerramilli
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jonathan T Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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35
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Xu AJ, Yerramilli D, Cahlon O, Powell SN, Yang JT, Gomez DR. Novel Inpatient Radiation Oncology Consult Service Model Reduces Hospital Length of Stay. JCO Oncol Pract 2021; 17:e1930-e1934. [PMID: 33788624 PMCID: PMC9810125 DOI: 10.1200/op.20.00923] [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: 01/07/2023] Open
Abstract
Palliative care and radiation therapy have played an expanding role in the management of patients with advanced cancers. Recent advances in our understanding of oligometastatic disease have led to increasing demand for familiarity with ablative techniques. Recognizing the demands of hospitalized patients for rapid access to care, we created an inpatient radiation oncology consult service (IROC) with consolidated expertise in palliative radiation and ablative techniques. In this quality improvement cohort study, we analyzed inpatient radiation oncology consults placed before and after IROC implementation and found that IROC led to increased delivery of specialty care and decreased hospital length of stay (median 8 days v 7 days, P = .005). This difference was most pronounced for patients for whom radiation therapy was indicated (14.5 v 11 days, P = .007). Our institutional experience demonstrates the value of recognizing metastatic disease as a distinct discipline and providing rapid access to palliative treatments for patients with advanced malignancies.
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Affiliation(s)
- Amy J. Xu
- Precision Radiation for Oligometastatic and Metastatic Disease (PROMISE) Program, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY,Amy J. Xu, MD, PhD, Memorial Sloan Kettering Cancer Center, 1275 York Ave New York, NY 10065; e-mail:
| | - Divya Yerramilli
- Precision Radiation for Oligometastatic and Metastatic Disease (PROMISE) Program, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Simon N. Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jonathan T. Yang
- Precision Radiation for Oligometastatic and Metastatic Disease (PROMISE) Program, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Daniel R. Gomez
- Precision Radiation for Oligometastatic and Metastatic Disease (PROMISE) Program, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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36
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Rosen DB, Haseltine JM, Bartelstein M, Flynn JR, Zhang Z, Kohutek ZA, Yamada Y, Schmitt A, Higginson DS, Vaynrub M, Yang JT, Gillespie EF. Should Postoperative Radiation for Long Bone Metastases Cover Part or All of the Orthopedic Hardware? Results of a Large Retrospective Analysis. Adv Radiat Oncol 2021; 6:100756. [PMID: 34585024 PMCID: PMC8450200 DOI: 10.1016/j.adro.2021.100756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/12/2021] [Accepted: 07/04/2021] [Indexed: 11/25/2022] Open
Abstract
Purpose For patients with long bone metastases who undergo orthopedic stabilization surgery followed by radiotherapy (RT), it is unclear what extent of hardware coverage by the radiation field is needed for optimal tumor control. Methods and Materials Long bone metastases treated with surgical intervention followed by radiation between August 2011 to May 2019 from a single institution were reviewed. Local recurrence, defined as any in-bone recurrence, was identified by chart review. Accompanying demographic and treatment characteristics were recorded. Statistical analysis to evaluate factors associated with tumor recurrence included univariate analysis, multivariate analysis, and propensity score matching. Results Among 138 patients with 145 long bone metastases undergoing postoperative RT with a median follow-up of 29.5 months, 36 bone metastases experienced a local recurrence. Most patients (92%) were treated with conventional RT and the median delivered dose was 30 Gy (interquarile range, 20-30 Gy). On univariate analysis, whole hardware RT field coverage and higher dose (biologically effective dose 10 ≥39 Gy) were associated with reduced local recurrence (0.44 hazard ratio [HR]; 95% confidence interval [CI], 0.22%-0.86%; P = .017; 0.5 HR; 95% CI, 0.26%-0.96%; P = .038, respectively). Covariates of time from surgery to RT start, histology of primary tumor (categorized as resistant vs sensitive), intramedullary hardware placement, reaming procedure, and margin status did not reach statistical significance. To adjust for confounding effects, we also conducted a propensity score matched analysis which confirmed that whole hardware coverage was statistically associated with a decreased risk of recurrence on the matched dataset (0.24 HR; 95% CI, 0.07%-0.84%; P = .026). Conclusions In this analysis of mostly patients undergoing conventional radiation, coverage of the whole hardware was associated with reduced local recurrence for patients with long bone metastases, consistent with prior reports. Investigation of approaches to further reduce local recurrence, such as preoperative stereotactic radiation, may be warranted.
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Affiliation(s)
| | | | - Meredith Bartelstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jessica R Flynn
- Orthopaedic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Zhigang Zhang
- Orthopaedic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Zachary A Kohutek
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Adam Schmitt
- Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | | | - Maksim Vaynrub
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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37
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Wijetunga NA, dos Anjos CH, Zhi WI, Robson M, Tsai CJ, Yamada Y, Dover L, Gillespie EF, Xu AJ, Yang JT. Long-term disease control and survival observed after stereotactic ablative body radiotherapy for oligometastatic breast cancer. Cancer Med 2021; 10:5163-5174. [PMID: 34159748 PMCID: PMC8335830 DOI: 10.1002/cam4.4068] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 03/12/2021] [Accepted: 06/03/2021] [Indexed: 12/23/2022] Open
Abstract
PURPOSE We examined the characteristics of breast cancer patients with oligometastases (OM) treated with stereotactic ablative body radiotherapy (SABR) to identify factors associated with local progression, distant metastasis progression, time to subsequent therapy, progression-free survival (PFS), and overall survival (OS). METHODS We retrospectively reviewed a single-institution database of patients treated with radiotherapy between 2008 and 2018 and identified 79 patients who received SABR to OM. Twenty-seven patients had genetic testing of metastatic tumors using an institutional targeted sequencing platform. Kaplan-Meier analysis, Cox regression, and competing risk models were used to compare clinical and genetic correlates with outcomes. RESULTS Median follow-up was 50 months (IQR: 29-66) with 67% of patients alive at the last follow-up. Of the 65% of patients who progressed, 82% progressed outside of the radiation field, 18% experienced local failure, and 80% had oligoprogression. Median OS was 86 months (IQR: 29-66), and PFS was 33 months (IQR: 10-38). Less than 5 years from diagnosis to SABR and triple-negative breast cancer (TNBC) were associated with worse OS. Advanced T stage, any prior chemotherapy, and TNBC were associated with worse PFS. Alterations in CEBPB, RB1, TBX3, PTEN, and CDK4 were associated with worse survival outcomes. CONCLUSION Long-term systemic disease control and survival can be achieved with SABR for oligometastatic breast cancer. Hormone receptor-positive patients with a long disease interval from initial diagnosis and limited systemic progression history may be ideal for SABR to all sites of disease.
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Affiliation(s)
- N. Ari Wijetunga
- Department of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Carlos H. dos Anjos
- Department of MedicineDivision of Solid Tumor OncologyBreast Medicine ServiceMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - W. Iris Zhi
- Department of MedicineDivision of Solid Tumor OncologyBreast Medicine ServiceMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Mark Robson
- Department of MedicineDivision of Solid Tumor OncologyBreast Medicine ServiceMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - C. Jillian Tsai
- Department of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
- Precision Radiation for Oligometastatic and Metastatic Disease (PROMISE) ProgramDepartment of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Yoshiya Yamada
- Department of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
- Precision Radiation for Oligometastatic and Metastatic Disease (PROMISE) ProgramDepartment of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Laura Dover
- Department of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
- Precision Radiation for Oligometastatic and Metastatic Disease (PROMISE) ProgramDepartment of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Erin F. Gillespie
- Department of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
- Precision Radiation for Oligometastatic and Metastatic Disease (PROMISE) ProgramDepartment of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Amy J. Xu
- Department of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
- Precision Radiation for Oligometastatic and Metastatic Disease (PROMISE) ProgramDepartment of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Jonathan T. Yang
- Department of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
- Precision Radiation for Oligometastatic and Metastatic Disease (PROMISE) ProgramDepartment of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
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Mathis NJ, Yang JT, Vaynrub M, Santos Martin E, Kotecha R, Panoff J, Salner AL, McIntosh AF, Gupta R, Gulati A, Yerramilli D, Xu A, Bartelstein M, Guttmann D, Yamada Y, Pfister DG, Lin D, Lapen K, Lipitz-Snyderman A, Gillespie EF. Multidisciplinary consensus recommendations for the management of non-spine bone metastases: Results of a modified Delphi process in a community-academic partnership. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.e24092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e24092 Background: Local therapy for bone metastases is becoming increasingly complex, but national guidelines remain limited. We leveraged a community-academic partnership to develop consensus recommendations for multidisciplinary treatment of non-spine bone metastases which are generalizable to diverse practice settings. Methods: We convened a group of 15 physicians (9 radiation oncologists, 2 orthopaedic surgeons, 2 medical oncologists, 1 interventional radiologist, 1 interventional pain specialist) treating bone metastases across 4 institutions from Apr 2020-Feb 2021. We distributed a survey to identify questions warranting consensus development in the treatment of non-spine bone metastases. A literature review was conducted to inform answer statements, and evidence was rated using the Strength of Recommendation Taxonomy. A modified Delphi process was employed to reach consensus defined (a priori) as ³75% of respondents indicating “agree” or “strongly agree”. Results: A total of 16 questions were identified, including indications for multidisciplinary discussion or referral (n=4), appropriate use and duration of RT (n=4), and handling of systemic therapies during RT (n=5). After 2 rounds of modified Delphi process, consensus has been reached on 9 questions (see Table). Strength of Recommendation was rated A (1/9, 11%), B (5/9, 56%), or C (3/9, 33%). Conclusions: Our consensus process provides guidance for management of non-spine bone metastases that expands upon current guidelines. We also highlight areas where prospective trials are needed, including the role of RT prior to stabilization surgery and the selection of patients for ablative treatment. [Table: see text]
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Affiliation(s)
- Noah J Mathis
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Diana Lin
- Penn State College of Medicine, Hershey, PA
| | - Kaitlyn Lapen
- Memorial Sloan Kettering Cancer Center, New York, NY
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Wijetunga NA, Boire AA, Yamada Y, Malani R, Diaz M, Pentsova E, Yang JT. Cerebrospinal fluid circulating tumor cells as a predictive biomarker for proton craniospinal irradiation for leptomeningeal metastases. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.2011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
2011 Background: Leptomeningeal metastasis (LM) involves seeding of tumor cells to the cerebrospinal fluid (CSF) and the leptomeninges. Proton craniospinal irradiation (pCSI) has been shown to be potentially effective for patients with solid tumor LM. We evaluated whether CSF circulating tumor cells (CSF-CTC) and neuroimaging correlate with outcomes in patients with LM treated with pCSI. Methods: We reviewed a single-institution retrospective database of patients treated with pCSI for LM between 2018-2020 who had ≥ 3 months (mos.) follow-up and identified 58 patients. Pre-pCSI CSF-CTC using CellSearch and magnetic resonance imaging (MRI) data, and post-pCSI CSF-CTC nadir before initiation of new cancer-directed therapy were assessed. The optimal cutoff for pre-pCSI CSF-CTC was determined using maximally selected rank statistics. Kaplan Meier analysis was used to identify univariate correlates with CNS progression free survival (CNS PFS) and overall survival (OS), calculated from start of pCSI. Multivariate Cox proportional hazards modeling was used to test independence of univariate associations. Results: The median follow-up for patients who were censored (n = 15, 26%) was 15 mos. (interquartile range (IQR): 9 -21). Most patients were diagnosed with lung (n = 27, 47%) or breast cancer (n = 22, 38%). The median CNS PFS and OS were 6 mos. (IQR: 3 – 9) and 8 mos. (IQR: 5 – 18), respectively. Of the 49 patients with pre-pCSI CSF-CTCs analyzed, CSF-CTCs were identified in 43 (88%). Pre-pCSI CSF-CTC< 53/3mL was associated with improved CNS PFS (11.8 vs 6.0 mos., p = 0.01), and a trend toward improved OS (16.7 vs 7.7 mos., p = 0.08). On pre-pCSI MRI, patients with parenchymal brain metastases (n = 33, 57%) had worse OS (6.7 vs 12.7 mos., p = 0.01) but not CNS PFS. Patients with both brain and spine LM (n = 42, 72%) compared to those only one site or no visible disease (n = 16, 28%) showed worse CNS PFS (5.8 vs 7.5 mos., p = 0.03) and OS (7.7 vs 16.7 mos., p = 0.05). In a multivariate model, pre-pCSI CSF-CTC was significantly associated with CNS PFS (p = 0.03) while brain and spine LM on MRI was not (p = 0.20) No patient had an increase in CSF-CTC immediately post-pCSI, and in those with both detectable pre-pCSI CSF-CTCsand a post-pCSImeasurement(n = 29, 50%), the median decrease at nadir was 37/3mL (range: 0-200) occurring at a median of 1.6 mos. (range: 0.5 -5.2). A decrease in CSF-CTC > 37/3mL was associated with improved CNS PFS (7.1 vs 4.4 mos., p = 0.04) but not OS (12.5 vs.7.7 mos., p = 0.2). Conclusions: Proton CSI is an effective treatment for patients with solid tumor LM and can result in prolonged disease control in some patients. Lower CSF-CTC count prior to pCSI and larger changes after pCSI are predictive of survival outcomes, arguing for early pCSI intervention for solid tumor LMD. Early treatment escalation after pCSI can be considered for patients with high pre-pCSI CSF-CTC and a smaller nadir post-pCSI.
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Affiliation(s)
| | | | | | - Rachna Malani
- Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Maria Diaz
- Memorial Sloan Kettering Cancer Center, New York, NY
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Wang KS, Yu G, Xu C, Meng XH, Zhou J, Zheng C, Deng Z, Shang L, Liu R, Su S, Zhou X, Li Q, Li J, Wang J, Ma K, Qi J, Hu Z, Tang P, Deng J, Qiu X, Li BY, Shen WD, Quan RP, Yang JT, Huang LY, Xiao Y, Yang ZC, Li Z, Wang SC, Ren H, Liang C, Guo W, Li Y, Xiao H, Gu Y, Yun JP, Huang D, Song Z, Fan X, Chen L, Yan X, Li Z, Huang ZC, Huang J, Luttrell J, Zhang CY, Zhou W, Zhang K, Yi C, Wu C, Shen H, Wang YP, Xiao HM, Deng HW. Accurate diagnosis of colorectal cancer based on histopathology images using artificial intelligence. BMC Med 2021; 19:76. [PMID: 33752648 PMCID: PMC7986569 DOI: 10.1186/s12916-021-01942-5] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 02/16/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Accurate and robust pathological image analysis for colorectal cancer (CRC) diagnosis is time-consuming and knowledge-intensive, but is essential for CRC patients' treatment. The current heavy workload of pathologists in clinics/hospitals may easily lead to unconscious misdiagnosis of CRC based on daily image analyses. METHODS Based on a state-of-the-art transfer-learned deep convolutional neural network in artificial intelligence (AI), we proposed a novel patch aggregation strategy for clinic CRC diagnosis using weakly labeled pathological whole-slide image (WSI) patches. This approach was trained and validated using an unprecedented and enormously large number of 170,099 patches, > 14,680 WSIs, from > 9631 subjects that covered diverse and representative clinical cases from multi-independent-sources across China, the USA, and Germany. RESULTS Our innovative AI tool consistently and nearly perfectly agreed with (average Kappa statistic 0.896) and even often better than most of the experienced expert pathologists when tested in diagnosing CRC WSIs from multicenters. The average area under the receiver operating characteristics curve (AUC) of AI was greater than that of the pathologists (0.988 vs 0.970) and achieved the best performance among the application of other AI methods to CRC diagnosis. Our AI-generated heatmap highlights the image regions of cancer tissue/cells. CONCLUSIONS This first-ever generalizable AI system can handle large amounts of WSIs consistently and robustly without potential bias due to fatigue commonly experienced by clinical pathologists. It will drastically alleviate the heavy clinical burden of daily pathology diagnosis and improve the treatment for CRC patients. This tool is generalizable to other cancer diagnosis based on image recognition.
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Affiliation(s)
- K S Wang
- Department of Pathology, Xiangya Hospital, Central South University, Changsha, 410078, Hunan, China
- Department of Pathology, School of Basic Medical Science, Central South University, Changsha, 410013, Hunan, China
| | - G Yu
- Department of Biomedical Engineering, School of Basic Medical Science, Central South University, Changsha, 410013, Hunan, China
| | - C Xu
- Department of Biostatistics and Epidemiology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, USA
| | - X H Meng
- Laboratory of Molecular and Statistical Genetics, College of Life Sciences, Hunan Normal University, Changsha, 410081, Hunan, China
| | - J Zhou
- Department of Pathology, Xiangya Hospital, Central South University, Changsha, 410078, Hunan, China
- Department of Pathology, School of Basic Medical Science, Central South University, Changsha, 410013, Hunan, China
| | - C Zheng
- Department of Pathology, Xiangya Hospital, Central South University, Changsha, 410078, Hunan, China
- Department of Pathology, School of Basic Medical Science, Central South University, Changsha, 410013, Hunan, China
| | - Z Deng
- Department of Pathology, Xiangya Hospital, Central South University, Changsha, 410078, Hunan, China
- Department of Pathology, School of Basic Medical Science, Central South University, Changsha, 410013, Hunan, China
| | - L Shang
- Department of Pathology, Xiangya Hospital, Central South University, Changsha, 410078, Hunan, China
| | - R Liu
- Department of Pathology, Xiangya Hospital, Central South University, Changsha, 410078, Hunan, China
| | - S Su
- Department of Pathology, Xiangya Hospital, Central South University, Changsha, 410078, Hunan, China
| | - X Zhou
- Department of Pathology, Xiangya Hospital, Central South University, Changsha, 410078, Hunan, China
| | - Q Li
- Department of Pathology, Xiangya Hospital, Central South University, Changsha, 410078, Hunan, China
| | - J Li
- Department of Pathology, Xiangya Hospital, Central South University, Changsha, 410078, Hunan, China
| | - J Wang
- Department of Pathology, Xiangya Hospital, Central South University, Changsha, 410078, Hunan, China
| | - K Ma
- Department of Pathology, School of Basic Medical Science, Central South University, Changsha, 410013, Hunan, China
| | - J Qi
- Department of Pathology, School of Basic Medical Science, Central South University, Changsha, 410013, Hunan, China
| | - Z Hu
- Department of Pathology, School of Basic Medical Science, Central South University, Changsha, 410013, Hunan, China
| | - P Tang
- Department of Pathology, School of Basic Medical Science, Central South University, Changsha, 410013, Hunan, China
| | - J Deng
- Department of Deming Department of Medicine, Tulane Center of Biomedical Informatics and Genomics, Tulane University School of Medicine, 1440 Canal Street, Suite 1610, New Orleans, LA, 70112, USA
| | - X Qiu
- Centers of System Biology, Data Information and Reproductive Health, School of Basic Medical Science, School of Basic Medical Science, Central South University, Changsha, 410008, Hunan, China
| | - B Y Li
- Centers of System Biology, Data Information and Reproductive Health, School of Basic Medical Science, School of Basic Medical Science, Central South University, Changsha, 410008, Hunan, China
| | - W D Shen
- Centers of System Biology, Data Information and Reproductive Health, School of Basic Medical Science, School of Basic Medical Science, Central South University, Changsha, 410008, Hunan, China
| | - R P Quan
- Centers of System Biology, Data Information and Reproductive Health, School of Basic Medical Science, School of Basic Medical Science, Central South University, Changsha, 410008, Hunan, China
| | - J T Yang
- Centers of System Biology, Data Information and Reproductive Health, School of Basic Medical Science, School of Basic Medical Science, Central South University, Changsha, 410008, Hunan, China
| | - L Y Huang
- Centers of System Biology, Data Information and Reproductive Health, School of Basic Medical Science, School of Basic Medical Science, Central South University, Changsha, 410008, Hunan, China
| | - Y Xiao
- Centers of System Biology, Data Information and Reproductive Health, School of Basic Medical Science, School of Basic Medical Science, Central South University, Changsha, 410008, Hunan, China
| | - Z C Yang
- Department of Pharmacology, Xiangya School of Pharmaceutical Sciences, Central South University, Changsha, 410078, Hunan, China
| | - Z Li
- School of Life Sciences, Central South University, Changsha, 410013, Hunan, China
| | - S C Wang
- College of Information Science and Engineering, Hunan Normal University, Changsha, 410081, Hunan, China
| | - H Ren
- Department of Pathology, Gongli Hospital, Second Military Medical University, Shanghai, 200135, China
- Department of Pathology, the Peace Hospital Affiliated to Changzhi Medical College, Changzhi, 046000, China
| | - C Liang
- Pathological Laboratory of Adicon Medical Laboratory Co., Ltd, Hangzhou, 310023, Zhejiang, China
| | - W Guo
- Department of Pathology, First Affiliated Hospital of Hunan Normal University, The People's Hospital of Hunan Province, Changsha, 410005, Hunan, China
| | - Y Li
- Department of Pathology, First Affiliated Hospital of Hunan Normal University, The People's Hospital of Hunan Province, Changsha, 410005, Hunan, China
| | - H Xiao
- Department of Pathology, the Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Y Gu
- Department of Pathology, the Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - J P Yun
- Department of Pathology, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, China
| | - D Huang
- Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
| | - Z Song
- Department of Pathology, Chinese PLA General Hospital, Beijing, 100853, China
| | - X Fan
- Department of Pathology, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, China
| | - L Chen
- Department of Pathology, The first affiliated hospital, Air Force Medical University, Xi'an, 710032, China
| | - X Yan
- Institute of Pathology and southwest cancer center, Southwest Hospital, Third Military Medical University, Chongqing, 400038, China
| | - Z Li
- Department of Pathology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Z C Huang
- Department of Biomedical Engineering, School of Basic Medical Science, Central South University, Changsha, 410013, Hunan, China
| | - J Huang
- Department of Anatomy and Neurobiology, School of Basic Medical Science, Central South University, Changsha, 410013, Hunan, China
| | - J Luttrell
- School of Computing Sciences and Computer Engineering, University of Southern Mississippi, Hattiesburg, MS, 39406, USA
| | - C Y Zhang
- School of Computing Sciences and Computer Engineering, University of Southern Mississippi, Hattiesburg, MS, 39406, USA
| | - W Zhou
- College of Computing, Michigan Technological University, Houghton, MI, 49931, USA
| | - K Zhang
- Department of Computer Science, Bioinformatics Facility of Xavier NIH RCMI Cancer Research Center, Xavier University of Louisiana, New Orleans, LA, 70125, USA
| | - C Yi
- Department of Pathology, Ochsner Medical Center, New Orleans, LA, 70121, USA
| | - C Wu
- Department of Statistics, Florida State University, Tallahassee, FL, 32306, USA
| | - H Shen
- Department of Deming Department of Medicine, Tulane Center of Biomedical Informatics and Genomics, Tulane University School of Medicine, 1440 Canal Street, Suite 1610, New Orleans, LA, 70112, USA
- Division of Biomedical Informatics and Genomics, Deming Department of Medicine, Tulane University School of Medicine, New Orleans, LA, 70112, USA
| | - Y P Wang
- Department of Deming Department of Medicine, Tulane Center of Biomedical Informatics and Genomics, Tulane University School of Medicine, 1440 Canal Street, Suite 1610, New Orleans, LA, 70112, USA
- Department of Biomedical Engineering, Tulane University, New Orleans, LA, 70118, USA
| | - H M Xiao
- Centers of System Biology, Data Information and Reproductive Health, School of Basic Medical Science, School of Basic Medical Science, Central South University, Changsha, 410008, Hunan, China.
| | - H W Deng
- Department of Deming Department of Medicine, Tulane Center of Biomedical Informatics and Genomics, Tulane University School of Medicine, 1440 Canal Street, Suite 1610, New Orleans, LA, 70112, USA.
- Centers of System Biology, Data Information and Reproductive Health, School of Basic Medical Science, School of Basic Medical Science, Central South University, Changsha, 410008, Hunan, China.
- Division of Biomedical Informatics and Genomics, Deming Department of Medicine, Tulane University School of Medicine, New Orleans, LA, 70112, USA.
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Wijetunga NA, Boire A, Young RJ, Yamada Y, Wolden S, Yu H, Kris M, Seidman A, Betof-Warner A, Diaz M, Reiner A, Malani R, Pentsova E, Yang JT. Quantitative cerebrospinal fluid circulating tumor cells are a potential biomarker of response for proton craniospinal irradiation for leptomeningeal metastasis. Neurooncol Adv 2021; 3:vdab181. [PMID: 34993483 PMCID: PMC8717892 DOI: 10.1093/noajnl/vdab181] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Leptomeningeal metastasis (LM) involves cerebrospinal fluid (CSF) seeding of tumor cells. Proton craniospinal irradiation (pCSI) is potentially effective for solid tumor LM. We evaluated whether circulating tumor cells (CTCs) in the CSF (CTCCSF), blood (CTCblood), and neuroimaging correlate with outcomes after pCSI for LM. METHODS We describe a single-institution consecutive case series of 58 patients treated with pCSI for LM. Pre-pCSI CTCs, the change in CTC post-pCSI (Δ CTC), and MRIs were examined. Central nervous system progression-free survival (CNS-PFS) and overall survival (OS) from pCSI were determined using Kaplan Meier analysis, Cox proportional-hazards regression, time-dependent ROC analysis, and joint modeling of time-varying effects and survival outcomes. RESULTS The median CNS-PFS and OS were 6 months (IQR: 4-9) and 8 months (IQR: 5-13), respectively. Pre-pCSI CTCCSF < 53/3mL was associated with improved CNS-PFS (12.0 vs 6.0 months, P < .01). Parenchymal brain metastases (n = 34, 59%) on pre-pCSI MRI showed worse OS (7.0 vs 13 months, P = .01). Through joint modeling, CTCCSF was significantly prognostic of CNS-PFS (P < .01) and OS (P < .01). A Δ CTC-CSF≥37 cells/3mL, the median Δ CTC-CSF at nadir, showed improved CNS-PFS (8.0 vs 5.0 months, P = .02) and further stratified patients into favorable and unfavorable subgroups (CNS-PFS 8.0 vs 4.0 months, P < .01). No associations with CTCblood were found. CONCLUSION We found the best survival observed in patients with low pre-pCSI CTCCSF and intermediate outcomes for patients with high pre-pCSI CTCCSF but large Δ CTC-CSF. These results favor additional studies incorporating pCSI and CTCCSF measurement earlier in the LM treatment paradigm.
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Affiliation(s)
- N Ari Wijetunga
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Adrienne Boire
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Robert J Young
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Yoshiya Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Suzanne Wolden
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Helena Yu
- Thoracic Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Mark Kris
- Thoracic Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Andrew Seidman
- Breast Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Allison Betof-Warner
- Melanoma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Maria Diaz
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Anne Reiner
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Rachna Malani
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Elena Pentsova
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jonathan T Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Hsiao KY, Li WC, Chang CH, Lin MHC, Yang JT, Wang PC, Chen KH. An Evaluation of the ACEP Guideline for Mild Head Injuries in Taiwan. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791702400204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction Traumatic brain injury (TBI) is an important issue in the emergency department. In the United States, the American College of Emergency Physicians (ACEP) published clinical guideline to select patients with mild head injuries for head computed tomography (CT) scans in 2008. The aim of this study was to identify the possible benefits of compliance with these guidelines for mild head injury patients in Taiwan. Method This was a secondary analysis on our previous study published for association of hypertension and head injuries. In our previous study, we collected data about 1290 patients with head injuries who received brain CT scans in the emergency department from September 2012 to August 2013 for a study regarding the association between head injury and hypertension. In present study, we subjected this data to further analysis to try to validate the ACEP clinical policy for mild head injuries. Results Of these 1,290 patients, 154 were found to have brain haemorrhage on the initial brain CT scan, and 5 were in need of neurosurgical intervention. A total of 859 patients met the ACEP guideline criteria, and 117 of these had brain haemorrhages. The sensitivity and specificity of the ACEP guideline to predict brain haemorrhage were 75.97% (95% confidence interval [CI], 68.44% to 82.48%) and 34.68% (95% CI, 31.91% to 37.53%), respectively. In predicting neurosurgical intervention, the sensitivity and specificity of the guideline were 100% (95% CI, 47.82% to 100%) and 33.54% (95% CI, 30.96% to 36.2%), respectively. Conclusion Although adoption of the ACEP clinical policy may reduce the number of brain CT scans in mild head injury patients who may need neurosurgical interventions, it is not a good selection tool in Taiwan.
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Affiliation(s)
- KY Hsiao
- Chang Gung Memorial Hospital, Department of Emergency Medicine; and Chang Gung University of Science and Technology, Department of Nursing, Chiayi, Taiwan
| | - WC Li
- Chang Gung Memorial Hospital, Department of Occupation Medicine, Taipei, Taiwan
| | - CH Chang
- Chang Gung University of Science and Technology, College of Nursing &the Chronic Diseases and Health Promotion Research Center, Chiayi Campus, Chiayi, Taiwan
| | - MHC Lin
- Chang Gung Memorial Hospital, Department of Neurosurgery, Chiayi, Taiwan
| | - JT Yang
- Chang Gung Memorial Hospital, Department of Neurosurgery, Chiayi; and Chang Gung University, College of Medicine, Tao-Yuan, Taiwan
| | - PC Wang
- Chang Gung Memorial Hospital, Department of Cardiology, Chiayi, Taiwan
| | - KH Chen
- Chang Gung University, College of Medicine, Tao-Yuan; and Chang Gung Memorial Hospital, Department of Physical Medicine and Rehabilitation, Chiayi, Taiwan
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Yeh SI, Huang YC, Cheng CH, Cheng CM, Yang JT. Development of a millimetrically scaled biodiesel transesterification device that relies on droplet-based co-axial fluidics. Sci Rep 2016; 6:29288. [PMID: 27426677 PMCID: PMC4947928 DOI: 10.1038/srep29288] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 06/17/2016] [Indexed: 11/09/2022] Open
Abstract
In this study, we investigated a fluidic system that adheres to new concepts of energy production. To improve efficiency, cost, and ease of manufacture, a millimetrically scaled device that employs a droplet-based co-axial fluidic system was devised to complete alkali-catalyzed transesterification for biodiesel production. The large surface-to-volume ratio of the droplet-based system, and the internal circulation induced inside the moving droplets, significantly enhanced the reaction rate of immiscible liquids used here – soybean oil and methanol. This device also decreased the molar ratio between methanol and oil to near the stoichiometric coefficients of a balanced chemical equation, which enhanced the total biodiesel volume produced, and decreased the costs of purification and recovery of excess methanol. In this work, the droplet-based co-axial fluidic system performed better than other methods of continuous-flow production. We achieved an efficiency that is much greater than that of reported systems. This study demonstrated the high potential of droplet-based fluidic chips for energy production. The small energy consumption and low cost of the highly purified biodiesel transesterification system described conforms to the requirements of distributed energy (inexpensive production on a moderate scale) in the world.
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Affiliation(s)
- S I Yeh
- Department of Mechanical Engineering, National Taiwan University, No. 1, Sec. 4, Roosevelt Road, Taipei, Taiwan
| | - Y C Huang
- Department of Mechanical Engineering, National Taiwan University, No. 1, Sec. 4, Roosevelt Road, Taipei, Taiwan
| | - C H Cheng
- Department of Mechanical Engineering, National Taiwan University, No. 1, Sec. 4, Roosevelt Road, Taipei, Taiwan
| | - C M Cheng
- Institute of Biomedical Engineering, National Tsing Hua University, No.101, Sec. 2, Guangfu Road, Hsinchu, Taiwan
| | - J T Yang
- Department of Mechanical Engineering, National Taiwan University, No. 1, Sec. 4, Roosevelt Road, Taipei, Taiwan
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Yang JT, Xu JY, Jiao J, Zhang R, Han SF, Qin LQ. [Effects of leucine on adipogenesis in 3T3-L1 preadipocytes during and after differentiation]. Zhonghua Yu Fang Yi Xue Za Zhi 2016; 50:535-40. [PMID: 27256735 DOI: 10.3760/cma.j.issn.0253-9624.2016.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To observe the effects of leucine on adipogenesis in 3T3-L1 preadipocyte during and after differentiation, and to investigate possible mechanisms. METHODS Respectively, 0.0 (control), 0.5, 1.0 and 2.0 mmol/L leucine was added in 3T3-L1 cells and cell proliferation was measured by MTT. Then, 3T3-L1 preadipocyte was induced to differentiate. Leucine was added during whole differentiation period, or after differentiation for 4 days. The cells were stained with Oil Red O dye to observe lipid droplet. The culture media were collected and used to determine glycerol contents. Meanwhile, protein expressions related to lypolytic enzymes, leptin signaling pathway were determined by Western blot. RESULTS MTT result showed that cell viabilities were (100.00±12.10)%, (102.73±12.38)%, (103.94±14.65)%, (108.70±5.05)% in 0.0, 0.5, 1.0 and 2.0 mmol/L leucine groups, respectively, there were no significant differences in cell proliferation among 4 groups (F=1.07, P=0.383). When 0.0, 0.5, 1.0 and 2.0 mmol/L leucine was added during differentiation, the relative number of lipid droplet was 1.00±0.06, 0.94±0.09, 0.82±0.08 and 0.79±0.04, respectively (F=11.74, P<0.001), and it was significantly lower in 1.0 and 2.0 mmol/L leucine groups than in control group (P=0.002 and P<0.001, respectively). There was no significant difference in lipid droplet when leucine was added after differentiation (F=0.16, P=0.924). When leucine was added during differentiation, the increment of glyceride contents in medium was (65.04 ± 11.75), (71.45 ± 23.71), (79.37 ± 17.63) and (110.32 ± 25.36) μmol/L, respectively (F=2.92, P=0.100). And it was significantly higher in 2.0 mmol/L leucine group (110.32 ± 25.36) μmol/L than in control group (65.04 ± 11.75) μmol/L (t=2.73, P=0.026). No significant difference of the increment of glyceride contents among 4 groups was observed when leucine was added after differentiation (F=0.80, P=0.528). Western blot results showed that leucine treatment during differentiation upregulated expression level of hormone-sensitive lipase phosphorylation (after 0.0 and 2.0 mmol/L leucine treatment,the protein levels were 1.00 ± 0.08 vs. 2.54 ± 0.27, P<0.001) , and downregulated the protein expression levels of perilipin A, leptin and leptin-related pathway, such as leptin receptor, Janus kinase 2 and suppressor of cytokine signaling-3 (after 0.0 and 2.0 mmol/L leucine was added, the protein levels were (1.00 ± 0.03) vs. (0.31 ± 0.07) , (1.00 ± 0.08) vs. (0.22±0.07) , (1.00±0.07) vs. (0.21 ± 0.04) , (1.00 ± 0.03) vs. (0.35 ± 0.05) , (1.00 ± 0.06) vs. (0.34 ± 0.05) , P<0.001). Leucine treatment after differentiation had no effects on these protein expressions (all P>0.05). CONCLUSION Leucine inhibits adipogenesis during 3T3-L1 preadipocyte differentiation by the regulation of lypolytic enzymes and leptin signaling pathway; however, leucine has no effect on adipogenesis when differentiation completed.
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Affiliation(s)
- J T Yang
- Department of Nutrition and Food Hygiene, School of Public Health, Soochow University, Suzhou 215123, China
| | - J Y Xu
- School of Radiation Medicine and Protection of Soochow University, Collaborative Innovation Center of Radiation Medicine of Jiangsu Higher Education Institutions, Suzhou 215123, China
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Yu IF, Yu YH, Chen LY, Fan SK, Chou HYE, Yang JT. A portable microfluidic device for the rapid diagnosis of cancer metastatic potential which is programmable for temperature and CO2. Lab Chip 2014; 14:3621-3628. [PMID: 25075570 DOI: 10.1039/c4lc00502c] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
If metastasis of lung cancer can be found and treated early, a victim might have an improved chance to prevail over it, but routine examinations such as chest radiography, computed tomography and biopsy cannot characterize the metastatic potential of lung cancer cells; critical diagnoses to define optimal therapeutic strategies are thus lost. We designed a portable microfluidic device for the rapid diagnosis of cancer metastatic potential. Featuring a micro system to control temperature and a bicarbonate buffered environment, our device discriminates a rate of surface detachment as an index of the migratory ability of cells cultured on pH-responsive chitosan. We labeled metastatic subpopulations of lung cancer cell lines, and verified that our device is capable of separating cells according to their metastatic ability. As only few cells are needed, a patient's specimen from biopsies, e.g. from fine-needle aspiration, can be processed on site to offer immediate information to physicians. We expect that our design will provide valuable information in pre-operative evaluations to assist the definition of therapeutic plans for lung cancer, as well as for metastatic tumors of other types.
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Affiliation(s)
- I F Yu
- Department of Mechanical Engineering, College of Engineering, National Taiwan University, Taipei 106, Taiwan.
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Huang CJ, Fang WF, Ke MS, Chou HYE, Yang JT. A biocompatible open-surface droplet manipulation platform for detection of multi-nucleotide polymorphism. Lab Chip 2014; 14:2057-62. [PMID: 24789224 DOI: 10.1039/c4lc00089g] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
We present a novel and simple method to manipulate droplets applicable to an open-surface microfluidic platform. The platform comprised a control module for pneumatic droplets and a superhydrophobic polydimethylsiloxane (PDMS) membrane. With pneumatic suction to cause deflection of the flexible PDMS-based superhydrophobic membrane, the sample and reagent droplets on the membrane become transported and mixed. A facile one-step laser micromachining technique serves to fabricate a superhydrophobic surface; a contact angle of 150° and a hysteresis angle of 4° were achieved without chemical modification. Relative to previous open-surface microfluidic systems, this platform is capable of simultaneous and precise delivery of droplets in two-dimensional (2D) manipulation. Droplets were manipulated with suction, which avoided interference from an external driving energy (e.g. heat, light, electricity) to affect the bio-sample inside the droplets. Two common bio-samples, namely protein and DNA, verified the performance of the platform. Based on the experimental results, operations on protein can be implemented without adsorption on the surface of the platform. Another striking result is the visual screening for multi-nucleotide polymorphism with hybridization-mediated growth of gold-nanoparticle (AuNP) probes. The detection results are observable with the naked eye, without the aid of advanced instruments. The entire procedure only takes 5 min from the addition of the sample and reagent to obtaining the results, which is much quicker than the traditional method. The total sample volume consumed in each operation is only 10 μL, which is significantly less than what is required in a large system. According to this approach, the proposed platform is suitable for biological and chemical applications.
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Affiliation(s)
- C J Huang
- Department of Mechanical Engineering, National Taiwan University, Taipei 106, Taiwan.
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Lin LC, Yang JT, Weng HH, Hsiao CT, Lai SL, Fann WC. Predictors of early clinical deterioration after acute ischemic stroke. Am J Emerg Med 2010; 29:577-81. [PMID: 20825831 DOI: 10.1016/j.ajem.2009.12.019] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2009] [Revised: 12/14/2009] [Accepted: 12/15/2009] [Indexed: 12/18/2022] Open
Abstract
The measurements for predicting early deterioration of stroke patients is controversial. We studied laboratory measurements and previously identified risk factors to identify factors or predictors of early deterioration after stroke. A prospective observational study of 196 patients with first-time acute ischemic stroke was performed. Demographic data, patient histories, laboratory measurements, and initial stroke severity assessments were recorded. Patients with early deterioration in National Institutes of Health Stroke Scale scores (increase ≥3 points within 3 days) were defined as having stroke-in-evolution (SIE). Thirty patients were diagnosed with SIE. An initial National Institutes of Health Stroke Scale score of 12 or higher, a Glasgow Coma Scale score of 12 or lower, d-dimers more than 1000, or blood urea nitrogen/creatinine (BUN/Cr) ratio higher than 15 were more frequent in SIE patients. After multivariate analysis, only a BUN/Cr higher than 15 was independent predictor of SIE. These patients were 3.41-fold more likely to have SIE (P = .008). These findings suggest that BUN/Cr may be a novel predictor of SIE, potentially useful in emergency departments.
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Affiliation(s)
- Leng C Lin
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi, Chang Gung University College of Medicine, Taiwan
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Ting SC, Yang JT. Pitching stabilization via caudal fin-wave propagation in a forward-sinking parrot cichlid (Cichlasoma citrinellum x Cichlasoma synspilum). ACTA ACUST UNITED AC 2008; 211:3147-59. [PMID: 18805814 DOI: 10.1242/jeb.020263] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Caudal fin-wave propagation (CFP) is a commonly observed behavior in a fish but has been little investigated. Our objective is to understand the function of a CFP for a forward-sinking parrot cichlid that adopts a tilted-down swimming posture. We utilized stereoscopic digital particle-image velocimetry to measure the velocity fields in the wake of both the caudal fin and the pectoral fins and to evaluate the corresponding hydrodynamic forces. The tilted-down posture of this fish is inherently unstable because of the presence of the head-down pitching moment induced from the buoyant force of the body. The down-stroke of the pectoral fins results also in a head-down pitching moment that destabilizes the fish. Our results indicate that a CFP facilitates the pitching stabilization of a fish. In a forward-sinking parrot cichlid, a CFP produces periodic jets (CFP jets) that are oriented laterally and posterodorsally, which result in both thrust and negative lift that induce a head-up pitching moment. The CFP jets are initially trapped by the ventral part of the caudal fin, strengthened and reoriented by the dorsally propagating fin wave, and expelled near the dorsal part of the caudal fin.
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Affiliation(s)
- S C Ting
- Department of Power Mechanical Engineering, National Tsing Hua University, Hsinchu, Taiwan
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Affiliation(s)
- W Moffitt
- DEPARTMENT OF CHEMISTRY, HARVARD UNIVERSITY, CAMBRIDGE, MASSACHUSETTS
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Fung KM, Samara ENS, Wong C, Metwalli A, Krlin R, Bane B, Liu CZ, Yang JT, Pitha JV, Culkin DJ, Kropp BP, Penning TM, Lin HK. Increased expression of type 2 3alpha-hydroxysteroid dehydrogenase/type 5 17beta-hydroxysteroid dehydrogenase (AKR1C3) and its relationship with androgen receptor in prostate carcinoma. Endocr Relat Cancer 2006; 13:169-80. [PMID: 16601286 DOI: 10.1677/erc.1.01048] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.4] [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] [Indexed: 11/27/2022]
Abstract
Type 2 3alpha-hydroxysteroid dehydrogenase (3alpha-HSD) is a multi-functional enzyme that possesses 3alpha-, 17beta- and 20alpha-HSD, as well as prostaglandin (PG) F synthase activities and catalyzes androgen, estrogen, progestin and PG metabolism. Type 2 3alpha-HSD was cloned from human prostate, is a member of the aldo-keto reductase (AKR) superfamily and was named AKR1C3. In androgen target tissues such as the prostate, AKR1C3 catalyzes the conversion of Delta(4)-androstene-3,17-dione to testosterone, 5alpha-dihydrotestosterone to 5alpha-androstane-3alpha,17beta-diol (3alpha-diol), and 3alpha-diol to androsterone. Thus AKR1C3 may regulate the balance of androgens and hence trans-activation of the androgen receptor in these tissues. Tissue distribution studies indicate that AKR1C3 transcripts are highly expressed in human prostate. To measure AKR1C3 protein expression and its distribution in the prostate, we raised a monoclonal antibody specifically recognizing AKR1C3. This antibody allowed us to distinguish AKR1C3 from other AKR1C family members in human tissues. Immunoblot analysis showed that this monoclonal antibody binds to one species of protein in primary cultures of prostate epithelial cells and in LNCaP prostate cancer cells. Immunohistochemistry with this antibody on human prostate detected strong nuclear immunoreactivity in normal stromal and smooth muscle cells, perineurial cells, urothelial (transitional) cells, and endothelial cells. Normal prostate epithelial cells were only faintly immunoreactive or negative. Positive immunoreactivity was demonstrated in primary prostatic adenocarcinoma in 9 of 11 cases. Variable increases in immunoreactivity for AKR1C3 was also demonstrated in non-neoplastic changes in the prostate including chronic inflammation, atrophy and urothelial (transitional) cell metaplasia. We conclude that elevated expression of AKR1C3 is highly associated with prostate carcinoma. Although the biological significance of elevated AKR1C3 in prostatic carcinoma is uncertain, AKR1C3 may be responsible for the trophic effects of androgens and/or PGs on prostatic epithelial cells.
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Affiliation(s)
- K-M Fung
- Department of Urology, University of Oklahoma Health Sciences Center, 920 Stanton L Young Blvd, WP3150, Oklahoma City, OK 73104, USA
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