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Mayr NA, Mohiuddin M, Snider JW, Zhang H, Griffin RJ, Amendola BE, Hippe DS, Perez NC, Wu X, Lo SS, Regine WF, Simone CB. Practice Patterns of Spatially Fractionated Radiation Therapy: A Clinical Practice Survey. Adv Radiat Oncol 2024; 9:101308. [PMID: 38405319 PMCID: PMC10885580 DOI: 10.1016/j.adro.2023.101308] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 06/26/2023] [Indexed: 02/27/2024] Open
Abstract
Purpose Spatially fractionated radiation therapy (SFRT) is increasingly used for bulky advanced tumors, but specifics of clinical SFRT practice remain elusive. This study aimed to determine practice patterns of GRID and Lattice radiation therapy (LRT)-based SFRT. Methods and Materials A survey was designed to identify radiation oncologists' practice patterns of patient selection for SFRT, dosing/planning, dosimetric parameter use, SFRT platforms/techniques, combinations of SFRT with conventional external beam radiation therapy (cERT) and multimodality therapies, and physicists' technical implementation, delivery, and quality procedures. Data were summarized using descriptive statistics. Group comparisons were analyzed with permutation tests. Results The majority of practicing radiation oncologists (United States, 100%; global, 72.7%) considered SFRT an accepted standard-of-care radiation therapy option for bulky/advanced tumors. Treatment of metastases/recurrences and nonmetastatic primary tumors, predominantly head and neck, lung cancer and sarcoma, was commonly practiced. In palliative SFRT, regimens of 15 to 18 Gy/1 fraction predominated (51.3%), and in curative-intent treatment of nonmetastatic tumors, 15 Gy/1 fraction (28.0%) and fractionated SFRT (24.0%) were most common. SFRT was combined with cERT commonly but not always in palliative (78.6%) and curative-intent (85.7%) treatment. SFRT-cERT time sequencing and cERT dose adjustments were variable. In curative-intent treatment, concurrent chemotherapy and immunotherapy were found acceptable by 54.5% and 28.6%, respectively. Use of SFRT dosimetric parameters was highly variable and differed between GRID and LRT. SFRT heterogeneity dosimetric parameters were more commonly used (P = .008) and more commonly thought to influence local control (peak dose, P = .008) in LRT than in GRID therapy. Conclusions SFRT has already evolved as a clinical practice pattern for advanced/bulky tumors. Major treatment approaches are consistent and follow the literature, but SFRT-cERT combination/sequencing and clinical utilization of dosimetric parameters are variable. These areas may benefit from targeted education and standardization, and knowledge gaps may be filled by incorporating identified inconsistencies into future clinical research.
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Affiliation(s)
- Nina A. Mayr
- College of Human Medicine, Michigan State University, East Lansing, Michigan
| | - Majid Mohiuddin
- Radiation Oncology Consultants and Northwestern Proton Center, Warrenville, Illinois
| | - James W. Snider
- Radiation Oncology, South Florida Proton Therapy Institute, Delray Beach, Florida
| | - Hualin Zhang
- Department of Radiation Oncology, University of Southern California, Los Angeles, California
| | - Robert J. Griffin
- Department of Radiation Oncology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | - Daniel S. Hippe
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | | | - Xiaodong Wu
- Executive Medical Physics Associates, Miami, Florida
| | - Simon S. Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington
| | - William F. Regine
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Charles B. Simone
- Department of Radiation Oncology, New York Proton Center, New York, New York
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Meiller TF, Fraser CM, Grant-Beurmann S, Humphrys M, Tallon L, Sadzewicz LD, Jabra-Rizk MA, Alfaifi A, Kensara A, Molitoris JK, Witek M, Mendes WS, Regine WF, Tran PT, Miller RC, Sultan AS. A Longitudinal Metagenomic Comparative Analysis of Oral Microbiome Shifts in Patients Receiving Proton Radiation versus Photon Radiation for Head and Neck Cancer. J Cancer Allied Spec 2024; 10:579. [PMID: 38259673 PMCID: PMC10793722 DOI: 10.37029/jcas.v10i1.579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 12/01/2023] [Indexed: 01/24/2024]
Abstract
Introduction Due to the radiation-sparing effects on salivary gland acini, changes in the composition of the oral microbiome may be a driver for improved outcomes in patients receiving proton radiation, with potentially worse outcomes in patients exposed to photon radiation therapy. To date, a head-to-head comparison of oral microbiome changes at a metagenomic level with longitudinal sampling has yet to be performed in these patient cohorts. Methods and Materials To comparatively analyze oral microbiome shifts during head and neck radiation therapy, a prospective pilot cohort study was performed at the Maryland Proton Treatment Center and the University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center. A longitudinal metagenomic comparative analysis of oral microbiome shifts was performed at three time points (pre-radiation, during radiation, and immediately post-radiation). Head and neck cancer patients receiving proton radiation (n = 4) were compared to photon radiation (n = 4). Additional control groups included healthy age- and sex-matched controls (n = 5), head and neck cancer patients who never received radiation therapy (n = 8), and patients with oral inflammatory disease (n = 3). Results Photon therapy patients presented with lower microbial alpha diversity at all timepoints, and there was a trend towards reduced species richness as compared with proton therapy. Healthy controls and proton patients exhibited overall higher and similar diversity. A more dysbiotic state was observed in patients receiving photon therapy as compared to proton therapy, in which oral microbial homeostasis was maintained. Mucositis was observed in 3/4 photon patients and was not observed in any proton patients during radiation therapy. The bacterial de novo pyrimidine biosynthesis pathway and the nitrate reduction V pathway were comparatively higher following photon exposure. These functional changes in bacterial metabolism may suggest that photon exposure produces a more permissive environment for the proliferation of pathogenic bacteria. Conclusion Oral microbiome dysbiosis in patients receiving photon radiation may be associated with increased mucositis occurrence. Proton radiation therapy for head and neck cancer demonstrates a safer side effect profile in terms of oral complications, oral microbiome dysbiosis, and functional metabolic status.
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Affiliation(s)
- Timothy F. Meiller
- Department of Oncology and Diagnostic Sciences, School of Dentistry, University of Maryland, Baltimore, United States
- University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, United States
| | - Claire M. Fraser
- Department of Medicine, University of Maryland School of Medicine, Baltimore, United States
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, United States
| | - Silvia Grant-Beurmann
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, United States
| | - Mike Humphrys
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, United States
| | - Luke Tallon
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, United States
| | - Lisa D. Sadzewicz
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, United States
| | - Mary Ann Jabra-Rizk
- Department of Oncology and Diagnostic Sciences, School of Dentistry, University of Maryland, Baltimore, United States
- Department of Microbiology and Immunology, School of Medicine, University of Maryland, Baltimore, United States
| | - Areej Alfaifi
- Department of Oncology and Diagnostic Sciences, School of Dentistry, University of Maryland, Baltimore, United States
- Department of Restorative and Prosthetic Dental Sciences, College of Dentistry King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Anmar Kensara
- Department of Advanced Oral Sciences and Therapeutics, School of Dentistry, University of Maryland, Baltimore, United States
- Department of Restorative Dentistry, College of Dentistry, Umm Al Qura University, Makkah, Saudi Arabia
| | - Jason K. Molitoris
- University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, United States
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, United States
- Maryland Proton Treatment Center, 850 W Baltimore St, Baltimore, United States
| | - Matthew Witek
- University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, United States
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, United States
- Maryland Proton Treatment Center, 850 W Baltimore St, Baltimore, United States
| | - William S. Mendes
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, United States
| | - William F. Regine
- University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, United States
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, United States
- Maryland Proton Treatment Center, 850 W Baltimore St, Baltimore, United States
| | - Phuoc T. Tran
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, United States
- Maryland Proton Treatment Center, 850 W Baltimore St, Baltimore, United States
| | - Robert C. Miller
- Department of Radiation Medicine, University of Kentucky College of Medicine, Lexington, United States
| | - Ahmed S. Sultan
- Department of Oncology and Diagnostic Sciences, School of Dentistry, University of Maryland, Baltimore, United States
- University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, United States
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Tchelebi LT, Winter KA, Abrams RA, Safran HP, Regine WF, McNulty S, Wu A, Du KL, Seaward SA, Bian SX, Aljumaily R, Shivnani A, Knoble JL, Crocenzi TS, DiPetrillo TA, Roof KS, Crane CH, Goodman KA. Analysis of Radiation Therapy Quality Assurance in NRG Oncology RTOG 0848. Int J Radiat Oncol Biol Phys 2024; 118:107-114. [PMID: 37598723 PMCID: PMC10843017 DOI: 10.1016/j.ijrobp.2023.08.014] [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: 03/08/2023] [Revised: 07/07/2023] [Accepted: 08/07/2023] [Indexed: 08/22/2023]
Abstract
PURPOSE NRG/Radiation Therapy Oncology Group 0848 is a 2-step randomized trial to evaluate the benefit of the addition of concurrent fluoropyrimidine and radiation therapy (RT) after adjuvant chemotherapy (second step) for patients with resected pancreatic head adenocarcinoma. Real-time quality assurance (QA) was performed on each patient who underwent RT. This analysis aims to evaluate adherence to protocol-specified contouring and treatment planning and to report the types and frequencies of deviations requiring revisions. METHODS AND MATERIALS In addition to a web-based contouring atlas, the protocol outlined step-by-step instructions for generating the clinical treatment volume through the creation of specific regions of interest. The planning target volume was a uniform 0.5 cm clinical treatment volume expansion. One of 2 radiation oncology study chairs independently reviewed each plan. Plans with unacceptable deviations were returned for revision and resubmitted until approved. Treatment started after final approval of the RT plan. RESULTS From 2014 to 2018, 354 patients were enrolled in the second randomization. Of these, 160 patients received RT and were included in the QA analysis. Resubmissions were more common for patients planned with 3-dimensional conformal RT (43%) than with intensity modulated RT (31%). In total, at least 1 resubmission of the treatment plan was required for 33% of patients. Among patients requiring resubmission, most only needed 1 resubmission (87%). The most common reasons for resubmission were unacceptable deviations with respect to the preoperative gross target volume (60.7%) and the pancreaticojejunostomy (47.5%). CONCLUSION One-third of patients required resubmission to meet protocol compliance criteria, demonstrating the continued need for expending resources on real-time, pretreatment QA in trials evaluating the use of RT, particularly for pancreas cancer. Rigorous QA is critically important for clinical trials involving RT to ensure that the true effect of RT is assessed. Moreover, RT QA serves as an educational process through providing feedback from specialists to practicing radiation oncologists on best practices.
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Affiliation(s)
- Leila T Tchelebi
- Northwell, New Hyde Park, New York; Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York.
| | - Kathryn A Winter
- Statistics and Data Management Center, NRG Oncology, Philadelphia, Pennsylvania
| | - Ross A Abrams
- Department of Radiation Oncology, Rush University Medical Center, Chicago, Illinois
| | - Howard P Safran
- Department of Hematology & Oncology, Rhode Island Hospital, Providence, Rhode Island
| | - William F Regine
- Department of Radiation Oncology, University of Maryland/Greenebaum Cancer Center, Baltimore, Maryland
| | - Susan McNulty
- Department of Clinical Research, NRG Oncology/IROC, Philadelphia, Pennsylvania
| | - Abraham Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kevin L Du
- Department of Radiation Oncology, Yale School of Medicine, Smilow Cancer Hospital, New Haven, Connecticut
| | - Samantha A Seaward
- Department of Radiation Oncology, Kaiser Permanente NCI Community Oncology Research Program, Vallejo, California
| | - Shelly X Bian
- Department of Radiation Oncology, USC / Norris Comprehensive Cancer Center, Los Angeles, California
| | - Raid Aljumaily
- Department of Hematology & Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Anand Shivnani
- Department of Radiation Oncology, The US Oncology Network, McKinney, Texas
| | - Jeanna L Knoble
- Department of Hematology & Oncology, Columbus NCI Community Oncology Research Program, Columbus, Ohio
| | - Todd S Crocenzi
- Department of Hematology & Oncology, Providence Portland Medical Center, Portland, Oregon
| | | | - Kevin S Roof
- Department of Radiation Oncology, Novant Health Presbyterian Center, Charlotte, North Carolina
| | - Christopher H Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Karyn A Goodman
- Department of Radiation Oncology, Mount Sinai Hospital, New York, New York.
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4
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Alexander GS, Pollock AE, Arons D, Alicia D, Molitoris JK, Regine WF, Witek ME. Positive Predictive Value of PET CT in HPV Associated Oropharyngeal Cancers Treated with Definitive Proton Therapy. Int J Radiat Oncol Biol Phys 2023; 117:e561. [PMID: 37785721 DOI: 10.1016/j.ijrobp.2023.06.1880] [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) Proton therapy (PT) offers attractive dosimetric advantages but there is emerging literature suggesting relative biological effectiveness (RBE) differences at the distal end of the Bragg peak may result in increased posttreatment FDG avidity. While the utility of PET CT is well established, lingering posttreatment inflammation from PT may affect the interpretation of posttreatment scans (PTS). We seek to characterize the positive predictive value (PPV) and negative predictive value (NPV) for residual disease/locoregional recurrence in patients undergoing definitive PT with HPV associated oropharyngeal cancer. MATERIALS/METHODS We performed a single institution retrospective analysis of patients with HPV associated oropharyngeal cancer treated with PT between 2016-2022. Patients were included if they had both pretreatment and initial posttreatment restaging PET/CT available for analysis. SUVmax was recorded in both the primary tumor and involved lymph nodes. Patients were considered to have a positive PET CT if there was an SUV decrease of less than 65% from the baseline exam or if there was SUV > 4.0 based on thresholds defined by previous studies. Chi-square analysis was used to compare patients who had a positive PTS to those who did not. RESULTS Sixty-two patients were included for analysis with a median age of 62. The entire cohort had a median follow up of 21 months (Range 2-71 months) of whom 86% received chemotherapy. Eleven patients (17%) had PTS defined as positive, of whom only one (PPV 9%) was found to have residual/locoregionally recurrent disease within an area of FDG avidity on PTS. Another patient developed a new primary tumor 9 months later in an area outside of FDG avidity on PTS. The remainder were followed with serial clinical exam with or without the compliment of repeat imaging. They remained without evidence of residual/locoregionally recurrent disease at the time of last follow up. Fifty-one patients had negative posttreatment scans, with only one patient having residual/locoregionally recurrent disease (NPV 98%). On Chi-square analysis T1-2 vs T3-4 tumor, use of CTV margin vs no margin, chemotherapy vs no chemotherapy, smoking history, and tonsil vs base of tongue subsite were not statistically significant in association with positive PTS. CONCLUSION PET/CT for post-treatment evaluation of patients treated with PT had an expectedly high NPV of 98% for residual/locoregionally recurrent disease; however, the PPV was 9% (1/11) which is much lower than would be expected with photon-based treatment. These findings may be the result of lingering acute inflammation caused by RBE differences at the distal end of the Bragg peak. Our findings are hypothesis generating and require validation with larger well-matched patient cohorts.
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Affiliation(s)
- G S Alexander
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD
| | - A E Pollock
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD
| | - D Arons
- University of Maryland School of Medicine, Baltimore, MD
| | - D Alicia
- Department of Radiation Oncology, Maryland Proton Treatment Center, Baltimore, MD
| | - J K Molitoris
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - W F Regine
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - M E Witek
- Department of Radiation Oncology, University of Maryland School of Medicine, Madison, WI
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5
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Krc RF, Mendes W, Molitoris JK, Ferris MJ, Mehra R, Papadimitriou J, Hatten K, Taylor R, Wolf J, Bentzen SM, Sun K, Regine WF, Tran PT, Witek ME. Outcomes of Patients Treated with Re-Irradiation for Recurrent Head and Neck Cancer Using Pencil Beam Scanning Proton Therapy. Int J Radiat Oncol Biol Phys 2023; 117:e594-e595. [PMID: 37785794 DOI: 10.1016/j.ijrobp.2023.06.1949] [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) Re-irradiation (re-RT) for recurrent head and neck cancer (HNC) after prior HNC radiation therapy (RT) is clinically challenging given prior radiation of nearby organs at risk (OARs). We describe clinical outcomes and toxicity of pencil beam scanning proton therapy (PBS-PT) for recurrent HNC. MATERIALS/METHODS We performed a retrospective analysis of recurrent HNC patients treated at a single institution with PBS-PT. Baseline demographic, disease and treatment characteristics were recorded. Local control (LC), locoregional control (LRC), progression free survival (PFS), distant metastasis free survival (DMFS), and overall survival (OS) were estimated using the Kaplan-Meier method. UVA was completed using logistic regression, and MVA was performed using a backward elimination model. We also report acute and late grade 3+ toxicity outcomes, graded per CTCAE v5.0. RESULTS A total of 89 patients treated with PBS-PT for recurrent HNC between 2016 and 2022 were included. Primary sites included oropharynx (30.0%), oral cavity (22.5%), sinonasal cavity (15.7%), larynx (12.4%) and nasopharynx (6.7%). The most common tumor histology was SCC (73.0%). Median time to re-RT was 47 months. Median dose of PBS-PT was 60 Gy (range: 40-72) with 50.6% receiving BID treatment. Median GTV volume was 30cc (range 4.8-1083cc). 24% of patients received concurrent systemic therapy (46% cytotoxic, 4.5% immunotherapy). Median follow-up after PBS-PT was 8 months (range: 0-71), and median OS was 13 months (95% CI: 9.3-16.7). The median PFS and DMFS were 7 months (95% CI 5.0-9.0) and 9 months (95% CI 5.3-12.7) respectively. The 1- and 2-year LC rates were 80.8% (95% CI: 70.8-90.8) and 66.2% (95% CI: 50.7-81.7). The 1- and 2-year DMFS were 41.0% (95% CI: 30.0-52.0) and 26.3% (95% CI: 15.7-36.9). On UVA and MVA, smaller GTV volume was associated with improved OS (HR 1.002, p = .004), DMFS (HR 1.002, p = 0.004) and PFS (HR 1.002, p = 0.014). In addition, shorter time to re-RT was associated with worse LRC (HR 1.003, p = 0.002), and higher KPS was associated with improved PFS (HR 0.57, p = 0.04). There were 31 acute grade 3 toxicity events (21 patients), the most common being odynophagia (9.0%) followed mucositis (5.6%), dehydration and dermatitis (both 4.5%). One patient had grade 4 toxicity, laryngeal edema requiring intubation 40 days after completion of re-RT. One patient had acute grade 5 toxicity, an oropharyngeal bleed 74 days after completion of re-RT. There were 35 late toxicity events (n = 27), the most common being dysphagia (n = 7, 7.9%). One patient suffered late grade 5 osteoradionecrosis, which resulted in sepsis. CONCLUSION PBS-PT for recurrent HNC results in effective disease control and favorable toxicity. Patients with smaller GTV volume appear to have improved OS, PFS and DMFS, and may be better candidates. Those with shorter time to re-RT also have worse LRC. However, distant failure (DF) comprises a major failure pattern, and biomarkers to identify patients at risk for DF may improve clinical decision making.
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Affiliation(s)
- R F Krc
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD
| | - W Mendes
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - J K Molitoris
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - M J Ferris
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - R Mehra
- University of Maryland Cancer Center, Baltimore, MD, United States
| | | | - K Hatten
- University of Maryland, Baltimore, MD
| | - R Taylor
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - J Wolf
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - S M Bentzen
- Division of Biostatistics and Bioinformatics, University of Maryland Greenebaum Cancer Center, and Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - K Sun
- Division of Biostatistics and Bioinformatics, University of Maryland Greenebaum Cancer Center, and Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - W F Regine
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - P T Tran
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - M E Witek
- Department of Radiation Oncology, University of Maryland School of Medicine, Madison, WI
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Shukla H, Shukla HD, Dukic T, Roy S, Lamichhane N, Molitoris JK, Carrier F, Regine WF. Pancreatic Cancer Derived 3-D Organoids as Clinical Tool to Predict Response to Radiation and Chemo-Radiation Therapy. Int J Radiat Oncol Biol Phys 2023; 117:e259. [PMID: 37784993 DOI: 10.1016/j.ijrobp.2023.06.1211] [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) Pancreatic cancer (PC) is the fourth leading cause of cancer death in both men and women. The standard of care for patients with locally advanced PC of chemotherapy, stereotactic radiotherapy (RT) or chemo-radiation-therapy has shown highly variable and limited success rates. However, three-dimensional (3D) Pancreatic tumor organoids (PTOs) have shown promise to study tumor response to drugs, and emerging treatments under in vitro conditions. We investigated the potential for using 3D organoids to evaluate the precise radiation and drug dose responses of in vivo PC tumors. MATERIALS/METHODS PTOs were created from mouse pancreatic tumor tissues, and their microenvironment was compared to that of in vivo tumors using immunohistochemical staining. The organoids and in vivo PC tumors were treated with fractionated X-ray RT, 3-bromopyruvate (3BP) anti-tumor drug, and with a combination of 3BP + fractionated RT. We quantified treatment response by metabolic imaging and immunofluorescence of αSMA and vimentin markers. RESULTS Pancreatic tumor organoids (PTOs) exhibited a similar fibrotic microenvironment and molecular response (as seen by apoptosis biomarker expression) as in vivo tumors. Untreated tumor organoids and in vivo tumor both exhibited proliferative growth of 6 folds the original size after 10 days, whereas no growth was seen for organoids and in vivo tumors treated with 8 (Gray) Gy of fractionated RT. Tumor organoids showed reduced growth rates of 3.2x and 1.8x when treated with 4 and 6 Gy fractionated RT, respectively. Interestingly, combination of 100 µM of 3BP + 4 Gy of RT showed pronounced growth inhibition as compared to 3-BP alone or 4 Gy of radiation alone. Further, we observed overexpression of OCT-4, SOX2, Nanog cancer stem cell markers (CSC) indicated presence of cancer stem cells in tumor organoids which might have some role in resistance to therapies and recurrence in pancreatic cancer. CONCLUSION PTOs produced a similar microenvironment and exhibited similar growth characteristics as in vivo tumors following treatment, indicating their potential for predicting in vivo tumor sensitivity and response to RT and combined chemo-RT treatments. Cancer stem cells in pancreatic cancer could be playing a role in resistance to therapies and recurrence in pancreatic cancer.
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Affiliation(s)
- H Shukla
- Dept of Radiation Oncology, School of Medicine, University of Maryland, Baltimore, MD
| | - H D Shukla
- 655 West Baltimore Street, Bressler Research Building 8-025, Baltimore, MD
| | - T Dukic
- Division of Translational Radiation Sciences, Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore MD 21201, Baltimore, MD
| | - S Roy
- 1Division of Translational Radiation Sciences, Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD 21201 2 New G Lab Pharma, 701 East Pratt Street, Columbus Center, Baltimore, MD 21202., Baltimore, MD
| | - N Lamichhane
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - J K Molitoris
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - F Carrier
- University of Maryland, Baltimore, MD
| | - W F Regine
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
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7
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Alexander GS, Pollock AE, Arons D, Ferris MJ, Molitoris JK, Regine WF, Witek ME. Post-treatment PET/CT for p16-positive oropharynx cancer treated with definitive proton therapy. J Clin Imaging Sci 2023; 13:31. [PMID: 37810180 PMCID: PMC10559439 DOI: 10.25259/jcis_74_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 09/07/2023] [Indexed: 10/10/2023] Open
Abstract
Objectives Given emerging data suggesting that uncertainty in the relative biologic effectiveness at the distal end of the Bragg peak results in increased mucosal injury in patients with oropharynx cancer receiving adjuvant proton therapy, we evaluated the results of post-treatment positron emission tomography-computed tomography (PET/CT) in patients with p16-positive oropharynx cancer (p16+OPC) treated with definitive intensity-modulated proton therapy (IMPT). Material and Methods A retrospective cohort study of patients with p16+OPC treated with definitive IMPT between 2016 and 2022 was performed at a single institution. Patients with PET/CT scans within 6 months following completion of IMPT were included in the study. Positive post-treatment scans were defined by a maximum standard uptake values (SUVmax) >4.0 or a <65% reduction in SUVmax in either the primary tumor or lymph node. The Fisher's exact test was used to evaluate factors associated with positive post-treatment PET/ CT values. Results Sixty-two patients were included for analysis. Median follow-up was 21 months (range: 3-71 months) with a median time to post-treatment PET/CT of 3 months (range: 2-6 months). Median post-treatment SUVmax of the primary disease and nodal disease was 0 (mean: 0.8, range: 0-7.7) and 0 (mean: 0.7, range: 0-9.5), respectively. Median post-treatment percent reduction in SUVmax for the primary site and lymph node was 100% (mean: 94%, range: 31.3-100%) and 100% (mean: 89%, range: 23-100%), respectively. Eleven patients had a positive post-treatment PET/CT with one biopsy-proven recurrence. Negative and positive predictive values (NPV and PPV) were 98% and 9.1%, respectively. There were no factors associated with positive post-treatment PET/CT. Conclusion Similar to patients treated with photon-based radiation therapy, post-treatment PET/CT has a high NPV for patients with p16+OPC treated with definitive proton therapy and should be used to guide patient management. Additional patients and more events are needed to confirm the PPV of a post-treatment PET/CT in this favorable patient cohort.
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Affiliation(s)
- Gregory S. Alexander
- Department of Radiation Oncology, University of Maryland, Baltimore, United States
| | - Ariel Eve Pollock
- Department of Radiation Oncology, University of Maryland, Baltimore, United States
| | - Danielle Arons
- School of Medicine, University of Maryland, Baltimore, United States
| | - Matthew J. Ferris
- Department of Radiation Oncology, University of Maryland, Baltimore, United States
| | - Jason K. Molitoris
- Department of Radiation Oncology, University of Maryland, Baltimore, United States
| | - William F. Regine
- Department of Radiation Oncology, University of Maryland, Baltimore, United States
| | - Matthew E. Witek
- Department of Radiation Medicine, Medstar Georgetown University Hospital, Washington, United States
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Witek ME, Morris CG, Alexander GS, Dontu P, Koroulakis AI, Regine WF, Mendenhall WM. Multi-institutional study of clinical outcomes of patients with head and neck cancer presenting with cN3 disease. Head Neck 2023; 45:1149-1155. [PMID: 36855018 DOI: 10.1002/hed.27326] [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: 08/23/2022] [Revised: 02/02/2023] [Accepted: 02/10/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND To evaluate disease control, toxicities, and variables associated with clinical outcomes for patients with head and neck squamous cell carcinoma and clinical N3 disease (HNSCC N3) treated with definitive chemoradiation therapy. METHODS We performed a retrospective review of patients with HNSCC N3 treated at two high-volume academic centers between 1996 and 2019. RESULTS We identified 85 patients with a median follow-up of 2.8 years. Five-year overall survival, regional control, and freedom from distant metastases rates were 38%, 80%, and 80%, respectively. Severe complications were identified in 19% of patients. CONCLUSIONS Favorable regional control is achievable with definitive chemoradiation therapy for patients with HNSCC N3 disease. Distant metastases are a common pattern of failure and should be a focus of prospective study.
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Affiliation(s)
- Matthew E Witek
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Gregory S Alexander
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Pragnya Dontu
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Antony I Koroulakis
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - William F Regine
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - William M Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida, USA
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Pollock AE, Arons D, Alexander GS, Alicia D, Birkman KM, Molitoris JK, Mehra R, Cullen KJ, Hatten KM, Taylor RJ, Wolf JS, Regine WF, Witek ME. Gross tumor volume margin and local control in p16-positive oropharynx cancer patients treated with intensity modulated proton therapy. Head Neck 2023; 45:1088-1096. [PMID: 36840723 DOI: 10.1002/hed.27308] [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: 08/15/2022] [Revised: 01/24/2023] [Accepted: 02/06/2023] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND To determine if the extent of high-dose gross tumor volume (GTV) to clinical target volume (CTV) expansion is associated with local control in patients with p16-positive oropharynx cancer (p16+ OPC) treated with definitive intensity modulated proton therapy (IMPT). METHODS We performed a retrospective analysis of patients with p16+ OPC treated with IMPT at a single institution between 2016 and 2021. Patients with a pre-treatment PET-CT and restaging PET-CT within 4 months following completion of IMPT were analyzed. RESULTS Sixty patients were included for analysis with a median follow-up of 17 months. The median GTV to CTV expansion was 5 mm (IQR: 2 mm). Thirty-three percent of patients (20 of 60) did not have a GTV to CTV expansion. There was one local failure within the expansion group (3%). CONCLUSION Excellent local control was achieved using IMPT for p16+ OPC independent of GTV expansion. IMPT with minimal target expansions represent a potential harm-minimization technique for p16-positive oropharynx cancer.
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Affiliation(s)
- Ariel E Pollock
- Department of Radiation Oncology, University of Maryland, School of Medicine, Baltimore, Maryland, USA
| | - Danielle Arons
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Gregory S Alexander
- Department of Radiation Oncology, University of Maryland, School of Medicine, Baltimore, Maryland, USA
| | - David Alicia
- Department of Radiation Oncology, University of Maryland, School of Medicine, Baltimore, Maryland, USA
| | - Kayla M Birkman
- Department of Radiation Oncology, University of Maryland, School of Medicine, Baltimore, Maryland, USA
| | - Jason K Molitoris
- Department of Radiation Oncology, University of Maryland, School of Medicine, Baltimore, Maryland, USA
| | - Ranee Mehra
- Department of Medicine, University of Maryland, School of Medicine, Baltimore, Maryland, USA
| | - Kevin J Cullen
- Department of Medicine, University of Maryland, School of Medicine, Baltimore, Maryland, USA
| | - Kyle M Hatten
- Department of Otolaryngology, Head and Neck Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Rodney J Taylor
- Department of Otolaryngology, Head and Neck Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jeffrey S Wolf
- Department of Otolaryngology, Head and Neck Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - William F Regine
- Department of Radiation Oncology, University of Maryland, School of Medicine, Baltimore, Maryland, USA
| | - Matthew E Witek
- Department of Radiation Oncology, University of Maryland, School of Medicine, Baltimore, Maryland, USA
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10
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Shukla HD, Dukic T, Roy S, Bhandary B, Gerry A, Poirier Y, Lamichhane N, Molitoris J, Carrier F, Banerjee A, Regine WF, Polf JC. Pancreatic cancer derived 3D organoids as a clinical tool to evaluate the treatment response. Front Oncol 2023; 12:1072774. [PMID: 36713532 PMCID: PMC9879007 DOI: 10.3389/fonc.2022.1072774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 11/29/2022] [Indexed: 01/13/2023] Open
Abstract
Background and purpose Pancreatic cancer (PC) is the fourth leading cause of cancer death in both men and women. The standard of care for patients with locally advanced PC of chemotherapy, stereotactic radiotherapy (RT), or chemo-radiation-therapy has shown highly variable and limited success rates. However, three-dimensional (3D) Pancreatic tumor organoids (PTOs) have shown promise to study tumor response to drugs, and emerging treatments under in vitro conditions. We investigated the potential for using 3D organoids to evaluate the precise radiation and drug dose responses of in vivo PC tumors. Methods PTOs were created from mouse pancreatic tumor tissues, and their microenvironment was compared to that of in vivo tumors using immunohistochemical and immunofluorescence staining. The organoids and in vivo PC tumors were treated with fractionated X-ray RT, 3-bromopyruvate (3BP) anti-tumor drug, and combination of 3BP + fractionated RT. Results Pancreatic tumor organoids (PTOs) exhibited a similar fibrotic microenvironment and molecular response (as seen by apoptosis biomarker expression) as in vivo tumors. Untreated tumor organoids and in vivo tumor both exhibited proliferative growth of 6 folds the original size after 10 days, whereas no growth was seen for organoids and in vivo tumors treated with 8 (Gray) Gy of fractionated RT. Tumor organoids showed reduced growth rates of 3.2x and 1.8x when treated with 4 and 6 Gy fractionated RT, respectively. Interestingly, combination of 100 µM of 3BP + 4 Gy of RT showed pronounced growth inhibition as compared to 3-BP alone or 4 Gy of radiation alone. Further, positive identification of SOX2, SOX10 and TGFβ indicated presence of cancer stem cells in tumor organoids which might have some role in resistance to therapies in pancreatic cancer. Conclusions PTOs produced a similar microenvironment and exhibited similar growth characteristics as in vivo tumors following treatment, indicating their potential for predicting in vivo tumor sensitivity and response to RT and combined chemo-RT treatments.
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Affiliation(s)
- Hem D Shukla
- Division of Translational Radiation Sciences, Department of Radiation Oncology, University of Maryland, School of Medicine, Baltimore, MD, United States,*Correspondence: Hem D Shukla,
| | - Tijana Dukic
- Division of Translational Radiation Sciences, Department of Radiation Oncology, University of Maryland, School of Medicine, Baltimore, MD, United States
| | - Sanjit Roy
- Division of Translational Radiation Sciences, Department of Radiation Oncology, University of Maryland, School of Medicine, Baltimore, MD, United States
| | - Binny Bhandary
- Division of Translational Radiation Sciences, Department of Radiation Oncology, University of Maryland, School of Medicine, Baltimore, MD, United States
| | - Andrew Gerry
- Division of Translational Radiation Sciences, Department of Radiation Oncology, University of Maryland, School of Medicine, Baltimore, MD, United States
| | - Yannick Poirier
- Division of Medical Physics, Department of Radiation Oncology, University of Maryland, School of Medicine, Baltimore, MD, United States
| | - Narottam Lamichhane
- Division of Medical Physics, Department of Radiation Oncology, University of Maryland, School of Medicine, Baltimore, MD, United States
| | - Jason Molitoris
- Division of Translational Radiation Sciences, Department of Radiation Oncology, University of Maryland, School of Medicine, Baltimore, MD, United States
| | - France Carrier
- Division of Translational Radiation Sciences, Department of Radiation Oncology, University of Maryland, School of Medicine, Baltimore, MD, United States
| | - Aditi Banerjee
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, United States
| | - William F. Regine
- Division of Translational Radiation Sciences, Department of Radiation Oncology, University of Maryland, School of Medicine, Baltimore, MD, United States
| | - Jerimy C. Polf
- Division of Medical Physics, Department of Radiation Oncology, University of Maryland, School of Medicine, Baltimore, MD, United States
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11
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Yang AH, Urrunaga NH, Siddiqui O, Wu A, Schliep M, Mossahebi S, Shetty K, Regine WF, Molitoris JK, Lominadze Z. Proton beam stereotactic body radiotherapy and hypofractionated therapy with pencil beam scanning is safe and effective for advanced hepatocellular carcinoma and intrahepatic cholangiocarcinoma: A single center experience. J Radiosurg SBRT 2023; 9:43-52. [PMID: 38029012 PMCID: PMC10681150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 08/17/2023] [Indexed: 12/01/2023]
Abstract
Background Proton beam therapy (PBT) is a non-surgical treatment that spares adjacent tissues compared to photon radiation and useful for Hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (iCCA). We present a single center experience in HCC and iCCA treated with Pencil Beam Scanning (PBS) PBT. Methods Forty-four consecutive patients (22 patients in each group) receiving PBT were included and reviewed. PBT was delivered with hypofractionated or stereotactic body radiation therapy (SBRT) using PBS. Tumor size was approximated by clinical target volume (CTV). Outcomes were evaluated with Kaplan-Meier and liver toxicity was determined by MELD-Na and albumin-bilirubin (ALBI) grade. Results Median follow up was 38.7 months, fourteen (35%) had multifocal disease and median CTV was 232.5cc. Four (9%) and 40 (91%) patients received SBRT and hypofractionated radiation, respectively. Two year overall survival was statistically higher for HCC (entire group: 68.9% months [95% CI: 61.3 - 76.3%]; iCCA: 49.8% [95% CI: 38.5% - 61.1%]; HCC: 89.4% [95% CI: 82.3 - 96.5%]; P <0.005). There was no statistical difference in progression-free survival or freedom from local failure. Biologically Equivalent Dose (BED) was greater than or equal to 80.5Gy in 37 (84%) patients. All iCCA patients had stable or improved ALBI grade following treatment. ALBI grade was stable in 83% of HCC patients and average MELD-Na score remained stable. Tumor size, pretreatment liver function, and total radiation dose were not associated with liver toxicity. Conclusions PBT for unresectable HCC and iCCA is safe and effective, even for large and multifocal tumors. Liver function was preserved even in those with baseline cirrhosis in this advanced population with large tumors.
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Affiliation(s)
- Alexander H. Yang
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nathalie H. Urrunaga
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Osman Siddiqui
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Angela Wu
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Matthew Schliep
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Sina Mossahebi
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kirti Shetty
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - William F. Regine
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jason K. Molitoris
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Zurabi Lominadze
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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12
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Mayr NA, Snider JW, Regine WF, Mohiuddin M, Hippe DS, Peñagarícano J, Mohiuddin M, Kudrimoti MR, Zhang H, Limoli CL, Le QT, Simone CB. An International Consensus on the Design of Prospective Clinical–Translational Trials in Spatially Fractionated Radiation Therapy. Adv Radiat Oncol 2022; 7:100866. [PMID: 35198833 PMCID: PMC8843999 DOI: 10.1016/j.adro.2021.100866] [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] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 11/12/2021] [Indexed: 12/17/2022] Open
Abstract
Purpose Spatially fractionated radiation therapy (SFRT), which delivers highly nonuniform dose distributions instead of conventionally practiced homogeneous tumor dose, has shown high rates of clinical response with minimal toxicities in large-volume primary or metastatic malignancies. However, prospective multi-institutional clinical trials in SFRT are lacking, and SFRT techniques and dose parameters remain variable. Agreement on dose prescription, technical administration, and clinical and translational design parameters for SFRT trials is essential to enable broad participation and successful accrual to rigorously test the SFRT approach. We aimed to develop a consensus for the design of multi-institutional clinical trials in SFRT, tailored to specific primary tumor sites, to help facilitate development and enhance the feasibility of such trials. Methods and Materials Primary tumor sites with sufficient pilot experience in SFRT were identified, and fundamental trial design questions were determined. For each tumor site, a comprehensive consensus effort was established through disease-specific expert panels. Clinical trial design criteria included eligibility, SFRT technology and technique, dose and fractionation, target- and normal-tissue dose parameters, systemic therapies, clinical trial endpoints, and translational science considerations. Iterative appropriateness rank voting, expert panel consensus reviews and discussions, and public comment posting were used for consensus development. Results Clinical trial criteria were developed for head and neck cancer and soft-tissue sarcoma. Final consensus among the 22 trial design categories each (a total of 163 criteria) was high to moderate overall. Uniform patient cohorts of advanced bulky disease, standardization of SFRT technologies and dosimetry and physics parameters, and collection of translational correlates were considered essential to trial design. Final guideline recommendations and the degree of agreement are presented and discussed. Conclusions This consensus provides design guidelines for the development of prospective multi-institutional clinical trials testing SFRT in advanced head and neck cancer and soft-tissue sarcoma through in-advance harmonization of the fundamental clinical trial design among SFRT experts, potential investigators, and the SFRT community.
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Affiliation(s)
- Nina A. Mayr
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington
- Tumor Heterogeneity Imaging and Radiomics Laboratory, University of Washington School of Medicine, Seattle, Washington
- Corresponding author: Nina A. Mayr, MD
| | - James W. Snider
- Department of Radiation Oncology, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - William F. Regine
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Majid Mohiuddin
- Radiation Oncology Consultants and Northwestern Proton Center, Warrenville, Illinois
| | - Daniel S. Hippe
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | | | - Mahesh R. Kudrimoti
- Department of Radiation Medicine, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Hualin Zhang
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Charles L. Limoli
- Department of Radiation Oncology, University of California School of Medicine, Irvine, Irvine, California
| | - Quynh-Thu Le
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Charles B. Simone
- Department of Radiation Oncology, New York Proton Center, New York, New York
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13
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Sood A, Bivona L, Mahkzoumi Z, Hausner P, Miller K, Regine WF, Snider J, Ng VY. Beyond the dermis-high-risk invasive squamous cell carcinoma: a retrospective review. J Wound Care 2021; 29:556-561. [PMID: 33052788 DOI: 10.12968/jowc.2020.29.10.556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Most cutaneous squamous cell carcinomas (cSCC) are low risk and can be treated with simple excision or ablation. High-risk cSCC require invasive treatment, including radical surgery. We present our experience in treating invasive cSCC of the pelvis and extremities. METHOD A retrospective review of the data of patients with invasive cSCC, indicated for surgery between 2014 and 2018, from a single institution was carried out. RESULTS A total of 19 patients (nine men, 10 women) were included in the study. Mean age was 62 years; mean tumour size was 8.6cm). Of the 19 patients, five patients with paraplegia with cSCC arising from hard-to-heal ulcers died of infection or bleeding after surgery or systemic therapy. Also, nine patients with localised cSCC underwent margin-negative resection with or without radiation; one patient experienced disease relapse. Of the participants, two patients with previous transplants and multifocal aggressive cSCC underwent numerous resections but succumbed to disease, and two patients who presented with locally recurrent disease after previous positive margin resection and radiation underwent re-resection but developed recurrent disease. CONCLUSIONS Prognosis for invasive cSCC largely depends on clinical setting. Tumours arising from ulcers in patients with paraplegia have a poor prognosis regardless of treatment. Invasive cSCC in transplant patients are often multifocal and often recur. Debulking procedures are associated with local recurrence despite radiation. Patients presenting with localised disease have a favourable prognosis with wide resection, flap coverage and adjuvant therapy.
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Affiliation(s)
- Anshum Sood
- Greenebaum Cancer Center, University of Maryland Medical Center, Baltimore, MD, USA
| | - Louis Bivona
- Greenebaum Cancer Center, University of Maryland Medical Center, Baltimore, MD, USA
| | - Zaineb Mahkzoumi
- Greenebaum Cancer Center, University of Maryland Medical Center, Baltimore, MD, USA
| | - Petr Hausner
- Greenebaum Cancer Center, University of Maryland Medical Center, Baltimore, MD, USA
| | - Kenneth Miller
- Greenebaum Cancer Center, University of Maryland Medical Center, Baltimore, MD, USA
| | - William F Regine
- Greenebaum Cancer Center, University of Maryland Medical Center, Baltimore, MD, USA
| | - James Snider
- Greenebaum Cancer Center, University of Maryland Medical Center, Baltimore, MD, USA
| | - Vincent Y Ng
- Greenebaum Cancer Center, University of Maryland Medical Center, Baltimore, MD, USA
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14
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Rao AD, Sun K, Zhu M, Mossahebi S, Sabouri P, Houser T, Jatczak J, Zakhary M, Regine WF, Miller RC, Bentzen S, Mishra MV. Plan quality effects of maximum monitor unit constraints in pencil beam scanning proton therapy for central nervous system and skull base tumors. Radiother Oncol 2021; 160:18-24. [PMID: 33753157 DOI: 10.1016/j.radonc.2021.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 02/08/2021] [Accepted: 03/10/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE/OBJECTIVE(S) With reports of CNS toxicity in patients treated with proton therapy at doses lower than would be expected based on photon data, it has been proposed that heavy monitor unit (MU) weighting of pencil beam scanning (PBS) proton therapy spots may potentially increase the risk of toxicity. We evaluated the impact of maximum MU weighting per spot (maxMU/spot) restrictions on PBS plan quality, prior to implementing clinic-wide maxMU/spot restrictions. MATERIALS/METHODS PBS plans of 11 patients, of which 3 plans included boosts, for a total of 14 PBS sample cases were included. Per sample case, a single dosimetrist created 4 test plans, gradually reducing the maxMU/spot in the plan. Test Plan 1, unrestricted in maxMU/spot, was the reference for all restricted plan comparisons (comparison sets 2 vs. 1; 3 vs. 1; and 4 vs. 1). The impact of MU/spot restrictions on plan quality metrics were analyzed with Wilcoxon signed rank test analyses. Treatment delivery time was modeled for a representative case. RESULTS A total of 14 PBS sample cases, 7 (50%) single-field optimized, 7 (50%) multi-field optimized, 9 (64%) delivering > 3500 cGy, 9 (64%) with 3 beams, and 7 (50%) without a range shifter were included. There were no differences in plan quality metrics of target coverage (V95% and V100% prescription), conformality and gradient indices, hot spot volume (V105% prescription), and dose to normal brain (V10%/30%/50%/70%/90%/100% prescription) with reductions of allowable maxMU/spot across all comparison sets (p > 0.05). Max MU/spot restrictions did not increase treatment delivery time when analyzed for a representative case. CONCLUSION MaxMU/spot restrictions within the thresholds evaluated in this study did not degrade overall plan quality metrics. Future studies should evaluate spot weighting with linear energy transfer/relative biologic effectiveness-informed planning to determine if spot weighting manipulation impacts clinical outcomes and mitigates toxicity.
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Affiliation(s)
- Avani Dholakia Rao
- Department of Radiation Oncology, University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, USA
| | - Kai Sun
- Department of Radiation Oncology, University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, USA; Division of Biostatistics and Bioinformatics, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, USA
| | - Mingyao Zhu
- Department of Radiation Oncology, University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, USA
| | - Sina Mossahebi
- Department of Radiation Oncology, University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, USA
| | - Pouya Sabouri
- Department of Radiation Oncology, University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, USA
| | - Thomas Houser
- Department of Radiation Oncology, University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, USA
| | - Jenna Jatczak
- Department of Radiation Oncology, University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, USA
| | - Mark Zakhary
- Department of Radiation Oncology, University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, USA
| | - William F Regine
- Department of Radiation Oncology, University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, USA.
| | - Robert C Miller
- Department of Radiation Oncology, University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, USA
| | - Søren Bentzen
- Department of Radiation Oncology, University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, USA; Division of Biostatistics and Bioinformatics, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, USA
| | - Mark V Mishra
- Department of Radiation Oncology, University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, USA
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15
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Snider JW, Molitoris J, Shyu S, Diwanji T, Rice S, Kowalski E, Decesaris C, Remick JS, Yi B, Zhang B, Hall A, Hanna N, Ng VY, Regine WF. Spatially Fractionated Radiotherapy (GRID) Prior to Standard Neoadjuvant Conventionally Fractionated Radiotherapy for Bulky, High-Risk Soft Tissue and Osteosarcomas: Feasibility, Safety, and Promising Pathologic Response Rates. Radiat Res 2021; 194:707-714. [PMID: 33064802 DOI: 10.1667/rade-20-00100.1] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 09/10/2020] [Indexed: 11/03/2022]
Abstract
Spatially fractionated radiotherapy (GRID) has been utilized primarily in the palliative and definitive treatment of bulky tumors. Delivered in the modern era primarily with megavoltage photon therapy, this technique offers the promise of safe dose escalation with potential immunogenic, bystander and microvasculature effects that can augment a conventionally fractionated course of radiotherapy. At the University of Maryland, an institutional standard has arisen to incorporate a single fraction of GRID radiation in large (>8 cm), high-risk soft tissue and osteosarcomas prior to a standard fractionated course. Herein, we report on the excellent pathologic responses and apparent safety of this regimen in 26 consecutive patients.
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Affiliation(s)
- James W Snider
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Jason Molitoris
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Susan Shyu
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Tejan Diwanji
- University of Miami School of Medicine, Miami, Florida
| | | | - Emily Kowalski
- University of Maryland School of Medicine, Baltimore, Maryland
| | | | - Jill S Remick
- University of Maryland Medical Center, Baltimore, Maryland
| | - Byongyong Yi
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Baoshe Zhang
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Andrea Hall
- University of Maryland Medical Center, Baltimore, Maryland
| | - Nader Hanna
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Vincent Y Ng
- University of Maryland School of Medicine, Baltimore, Maryland
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16
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Kowalski ES, Remick JS, Sun K, Alexander GS, Khairnar R, Morse E, Cherng HR, Berg LJ, Poirier Y, Lamichhane N, Becker S, Chen S, Molitoris JK, Kwok Y, Regine WF, Mishra MV. Immune checkpoint inhibition in patients treated with stereotactic radiation for brain metastases. Radiat Oncol 2020; 15:245. [PMID: 33109224 PMCID: PMC7590444 DOI: 10.1186/s13014-020-01644-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [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: 05/14/2020] [Accepted: 08/12/2020] [Indexed: 12/14/2022] Open
Abstract
Purpose Stereotactic radiation therapy (SRT) and immune checkpoint inhibitors (ICI) may act synergistically to improve treatment outcomes but may also increase the risk of symptomatic radiation necrosis (RN). The objective of this study was to compare outcomes for patients undergoing SRT with and without concurrent ICI. Methods and materials Patients treated for BMs with single or multi-fraction SRT were retrospectively reviewed. Concurrent ICI with SRT (SRT-ICI) was defined as administration within 3 months of SRT. Local control (LC), radiation necrosis (RN) risk and distant brain failure (DBF) were estimated by the Kaplan-Meier method and compared between groups using the log-rank test. Wilcoxon rank sum and Chi-square tests were used to compare covariates. Multivariate cox regression analysis (MVA) was performed. Results One hundred seventy-nine patients treated with SRT for 385 brain lesions were included; 36 patients with 99 lesions received SRT-ICI. Median follow up was 10.3 months (SRT alone) and 7.7 months (SRT- ICI) (p = 0.08). Lesions treated with SRT-ICI were more commonly squamous histology (17% vs 8%) melanoma (20% vs 2%) or renal cell carcinoma (8% vs 6%), (p < 0.001). Non-small cell lung cancer (NSCLC) compromised 60% of patients receiving ICI (n = 59). Lesions treated with SRT-ICI had significantly improved 1-year local control compared to SRT alone (98 and 89.5%, respectively (p = 0.0078). On subset analysis of NSCLC patients alone, ICI was also associated with improved 1 year local control (100% vs. 90.1%) (p = 0.018). On MVA, only tumor size ≤2 cm was significantly associated with LC (HR 0.38, p = 0.02), whereas the HR for concurrent ICI with SRS was 0.26 (p = 0.08). One year DBF (41% vs. 53%; p = 0.21), OS (58% vs. 56%; p = 0.79) and RN incidence (7% vs. 4%; p = 0.25) were similar for SRT alone versus SRT-ICI, for the population as a whole and those patients with NSCLC. Conclusion These results suggest SRT-ICI may improve local control of brain metastases and is not associated with an increased risk of symptomatic radiation necrosis in a cohort of predominantly NSCLC patients. Larger, prospective studies are necessary to validate these findings and better elucidate the impact of SRT-ICI on other disease outcomes.
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Affiliation(s)
- Emily S Kowalski
- Department of Radiation Oncology, University of Maryland School of Medicine, 850 W. Baltimore Street, Baltimore, MD, 21202, USA
| | - Jill S Remick
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Kai Sun
- Department of Radiation Oncology, University of Maryland School of Medicine, 850 W. Baltimore Street, Baltimore, MD, 21202, USA
| | - Gregory S Alexander
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Rahul Khairnar
- Department of Pharmaceuticals Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Emily Morse
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Hua-Ren Cherng
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Lars J Berg
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Yannick Poirier
- Department of Radiation Oncology, University of Maryland School of Medicine, 850 W. Baltimore Street, Baltimore, MD, 21202, USA
| | - Narottam Lamichhane
- Department of Radiation Oncology, University of Maryland School of Medicine, 850 W. Baltimore Street, Baltimore, MD, 21202, USA
| | - Stewart Becker
- Department of Radiation Oncology, University of Maryland School of Medicine, 850 W. Baltimore Street, Baltimore, MD, 21202, USA
| | - Shifeng Chen
- Department of Radiation Oncology, University of Maryland School of Medicine, 850 W. Baltimore Street, Baltimore, MD, 21202, USA
| | - Jason K Molitoris
- Department of Radiation Oncology, University of Maryland School of Medicine, 850 W. Baltimore Street, Baltimore, MD, 21202, USA
| | - Young Kwok
- Department of Radiation Oncology, University of Maryland School of Medicine, 850 W. Baltimore Street, Baltimore, MD, 21202, USA
| | - William F Regine
- Department of Radiation Oncology, University of Maryland School of Medicine, 850 W. Baltimore Street, Baltimore, MD, 21202, USA
| | - Mark V Mishra
- Department of Radiation Oncology, University of Maryland School of Medicine, 850 W. Baltimore Street, Baltimore, MD, 21202, USA.
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17
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Koroulakis A, Molitoris J, Kaiser A, Hanna N, Bafford A, Jiang Y, Bentzen S, Regine WF. Reirradiation for Rectal Cancer Using Pencil Beam Scanning Proton Therapy: A Single Institutional Experience. Adv Radiat Oncol 2020; 6:100595. [PMID: 33490730 PMCID: PMC7807140 DOI: 10.1016/j.adro.2020.10.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 10/05/2020] [Indexed: 12/18/2022] Open
Abstract
Purpose Reirradiation for rectal cancer (RC) after prior pelvic radiation therapy (RT) has been shown to be safe and effective. However, limited data exist for proton therapy (PT), including pencil beam scanning proton therapy (PBS-PT). We hypothesize that PT is safe and feasible for re-treatment and may allow for decreased toxicity and treatment escalation. Methods and materials A single-institution, retrospective, institutional review board–approved analysis of all patients with RC and prior pelvic RT receiving PBS-PT reirradiation was performed. Data on patient and treatment characteristics and outcomes were collected. Local progression, progression-free survival, overall survival, and late grade >3 toxicity were estimated using the Kaplan-Meier method. Results Twenty-eight patients (median follow-up: 28.6 months) received PBS-PT reirradiation between 2016 and 2019, including 18 patients with recurrent RC (median prior dose: 54.0 Gy) and 10 patients with de novo RC and variable prior RT. The median reirradiation dose was 44.4 Gy (range, 16.0-60.0 Gy; 21 of 28 twice daily), and 24 of 28 patients received concurrent chemotherapy. Six underwent surgical resection. Three (10.7%) experienced grade 3 acute toxicities, and 1 did not complete RT owing to toxicity. Four (14.2%) had late grade <3 toxicity, including 1 grade 5 toxicity in a patient with a prior RT-related injury. The 1-year local progression, progression-free survival, and overall survival rates were 33.7% (95% confidence interval [CI], 14.5%-52.9%), 45.0% (95% CI, 26.2%-63.8%), and 81.8% (95% CI, 67.3%-96.3%), respectively. Conclusions This is the largest series using PT for reirradiation for RC and the first study using PBS-PT. Low acute toxicity rates and acceptable late toxicity support PBS-PT as an option for this high-risk patient population, with a need for continued follow-up.
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Affiliation(s)
- Antony Koroulakis
- University of Maryland Medical Center, Radiation Oncology, Baltimore, Maryland
| | - Jason Molitoris
- University of Maryland School of Medicine, Radiation Oncology, Baltimore, Maryland
| | - Adeel Kaiser
- University of Maryland School of Medicine, Radiation Oncology, Baltimore, Maryland
| | - Nader Hanna
- University of Maryland School of Medicine, Surgical Oncology, Baltimore, Maryland
| | - Andrea Bafford
- University of Maryland School of Medicine, Surgical Oncology, Baltimore, Maryland
| | - Yixing Jiang
- University of Maryland School of Medicine, Medical Oncology, Baltimore, Maryland
| | - Søren Bentzen
- University of Maryland School of Medicine, Radiation Oncology, Baltimore, Maryland
| | - William F Regine
- University of Maryland School of Medicine, Radiation Oncology, Baltimore, Maryland
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18
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Bitterman DS, Winter KA, Hong TS, Fuchs CS, Regine WF, Abrams RA, Safran H, Hoffman JP, Benson AB, Kasunic T, Mulcahy M, Strauss JF, DiPetrillo T, Stella PJ, Chen Y, Plastaras JP, Crane CH. Impact of Diabetes and Insulin Use on Prognosis in Patients With Resected Pancreatic Cancer: An Ancillary Analysis of NRG Oncology RTOG 9704. Int J Radiat Oncol Biol Phys 2020; 109:201-211. [PMID: 32858111 DOI: 10.1016/j.ijrobp.2020.08.042] [Citation(s) in RCA: 2] [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] [Received: 02/07/2020] [Revised: 07/31/2020] [Accepted: 08/14/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE Diabetes mellitus (DM) has been proposed to be tumorigenic; however, prior studies of the association between DM and survival are conflicting. The goal of this ancillary analysis of RTOG 9704, a randomized controlled trial of adjuvant chemotherapy in pancreatic cancer, was to determine the prognostic effects of DM and insulin use on survival. METHODS AND MATERIALS Eligible patients from RTOG 9704 with available data on DM and insulin use were included. Overall survival (OS) and disease-free survival (DFS) were estimated using the Kaplan-Meier method, and variable levels were compared using log-rank test. Cox proportional hazards models were created to assess the associations among DM, insulin use, and body mass index phenotypes on outcomes. RESULTS Of 538 patients enrolled from 1998 to 2002, 238 patients were eligible with analyzable DM and insulin use data. Overall 34% of patients had DM and 66% did not. Of patients with DM, 64% had insulin-dependent DM, and 36% had non-insulin-dependent DM. On univariable analysis, neither DM nor insulin dependence were associated with OS or DFS (P > .05 for all). On multivariable analysis, neither DM, insulin use, nor body mass index were independently associated with OS or DFS. Nonwhite race (hazard ratio [HR], 2.18; 95% confidence interval [CI], 1.35-3.50; P = .0014), nodal involvement (HR, 1.74; 95% CI, 1.24-2.45; P = .0015), and carbohydrate antigen 19-9 (CA19-9) ≥90 U/mL (HR, 3.61; 95% CI, 2.32-5.63; P < .001) were associated with decreased OS. Nonwhite race (HR, 1.67; 95% CI, 1.05-2.63; P = .029) and CA19-9 ≥90 U/mL (HR, 2.86; 95% CI, 1.85-4.40; P < .001) were associated with decreased DFS. CONCLUSIONS DM and insulin use were not associated with OS or DFS in patients with pancreatic cancer in this study. Race, nodal involvement, and increased CA19-9 were significant predictors of outcomes. These data might apply to the more modern use of neoadjuvant therapies for potentially resectable pancreatic cancer.
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Affiliation(s)
| | - Kathryn A Winter
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | - Theodore S Hong
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts
| | | | - William F Regine
- University of Maryland/Greenebaum Cancer Center, Baltimore, Maryland
| | | | | | | | | | | | | | - James F Strauss
- Texas Health Resources Presbyterian Hospital Dallas (accrual under University of Texas/Presbyterian Hospital), Dallas, Texas
| | | | - Philip J Stella
- St. Joseph Mercy Hospital (accrual under Michigan Cancer Research Consortium CCOP), Ypsilanti, Michigan
| | | | - John P Plastaras
- University of Pennsylvania/Abramson Cancer Center, Philadelphia, Pennsylvania
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19
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DeCesaris CM, Berger M, Choi JI, Carr SR, Burrows WM, Regine WF, Simone CB, Molitoris JK. Pathologic complete response (pCR) rates and outcomes after neoadjuvant chemoradiotherapy with proton or photon radiation for adenocarcinomas of the esophagus and gastroesophageal junction. J Gastrointest Oncol 2020; 11:663-673. [PMID: 32953150 DOI: 10.21037/jgo-20-205] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Pathologic complete response (pCR) after neoadjuvant chemoradiotherapy (nCRT) is associated with improved survival in patients treated for esophageal cancer. While proton beam therapy (PBT) has been demonstrated to reduce toxicities with nCRT, no data comparing pCR rates between modalities exist to date. We investigated pCR rates in patients with distal esophageal/GEJ adenocarcinomas undergoing trimodality therapy with nCRT-PBT or photon-based nCRT with the hypothesis that pathologic responses with PBT would be at least as high as with photon therapy. Methods A single-institutional review of patients with distal esophageal adenocarcinoma treated with trimodality therapy from 2015-2018 using PBT was completed. PBT patients were matched 1:2 to patients treated with photons. Chi square and two-sample t-tests were utilized to compare characteristics, and the Kaplan Meier method was used to estimate oncologic endpoints. Results Eighteen consecutive PBT patients were identified and compared to 36 photon patients. All patients received concurrent chemotherapy; 98% with carboplatin/paclitaxel. Most patients were male (91%) and White (89%); median age was 62 years (range, 31-76 years). Median radiation dose in both cohorts was 50.4 Gy (range, 41.4-50.4 Gy); all courses were delivered in 1.8Gy fractions. Age, gender and race were well balanced. Patients treated with PBT had a significantly higher pre-treatment nodal stage (N) and AJCC 7th edition stage grouping (P=0.02, P=0.03). Despite this, tumoral and nodal clearance and pCR rates were equivalent between cohorts (P=0.66, P=0.11, P=0.63, respectively). Overall pCR and individual primary and nodal clearance rates, overall survival (OS), locoregional control (LRC), and distant metastatic control did not significantly differ between modalities (all P>0.05). Major perioperative events were balanced; however, there were 5 (14%) perioperative deaths in the photon cohort compared to 0 (0%) in the proton cohort (P=0.06). Conclusions The use of PBT in trimodality therapy for distal esophageal adenocarcinoma yields pCR rates comparable to photon radiation and historical controls. Pathologic responses and oncologic outcomes in this study did not differ significantly between modalities despite PBT patients having higher AJCC stages and nodal disease burdens.
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Affiliation(s)
- Cristina M DeCesaris
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Melanie Berger
- University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Shamus R Carr
- Department of Thoracic Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Whitney M Burrows
- Department of Thoracic Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - William F Regine
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Jason K Molitoris
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
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20
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Remick JS, Kowalski E, Khairnar R, Sun K, Morse E, Cherng HRR, Poirier Y, Lamichhane N, Becker SJ, Chen S, Patel AN, Kwok Y, Nichols E, Mohindra P, Woodworth GF, Regine WF, Mishra MV. A multi-center analysis of single-fraction versus hypofractionated stereotactic radiosurgery for the treatment of brain metastasis. Radiat Oncol 2020; 15:128. [PMID: 32466775 PMCID: PMC7257186 DOI: 10.1186/s13014-020-01522-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 03/24/2020] [Indexed: 12/22/2022] Open
Abstract
Background Hypofractionated-SRS (HF-SRS) may allow for improved local control and a reduced risk of radiation necrosis compared to single-fraction-SRS (SF-SRS). However, data comparing these two treatment approaches are limited. The purpose of this study was to compare clinical outcomes between SF-SRS versus HF-SRS across our multi-center academic network. Methods Patients treated with SF-SRS or HF-SRS for brain metastasis from 2013 to 2018 across 5 radiation oncology centers were retrospectively reviewed. SF-SRS dosing was standardized, whereas HF-SRS dosing regimens were variable. The co-primary endpoints of local control and radiation necrosis were estimated using the Kaplan Meier method. Multivariate analysis using Cox proportional hazards modeling was performed to evaluate the impact of select independent variables on the outcomes of interest. Propensity score adjustments were used to reduce the effects confounding variables. To assess dose response for HF-SRS, Biologic Effective Dose (BED) assuming an α/β of 10 (BED10) was used as a surrogate for total dose. Results One-hundred and fifty six patients with 335 brain metastasis treated with SF-SRS (n = 222 lesions) or HF-SRS (n = 113 lesions) were included. Prior whole brain radiation was given in 33% (n = 74) and 34% (n = 38) of lesions treated with SF-SRS and HF-SRS, respectively (p = 0.30). After a median follow up time of 12 months in each cohort, the adjusted 1-year rate of local control and incidence of radiation necrosis was 91% (95% CI 86–96%) and 85% (95% CI 75–95%) (p = 0.26) and 10% (95% CI 5–15%) and 7% (95% CI 0.1–14%) (p = 0.73) for SF-SRS and HF-SRS, respectively. For lesions > 2 cm, the adjusted 1 year local control was 97% (95% CI 84–100%) for SF-SRS and 64% (95% CI 43–85%) for HF-SRS (p = 0.06). On multivariate analysis, SRS fractionation was not associated with local control and only size ≤2 cm was associated with a decreased risk of developing radiation necrosis (HR 0.21; 95% CI 0.07–0.58, p < 0.01). For HF-SRS, 1 year local control was 100% for lesions treated with a BED10 ≥ 50 compared to 77% (95% CI 65–88%) for lesions that received a BED10 < 50 (p = 0.09). Conclusions In this comparison study of dose fractionation for the treatment of brain metastases, there was no difference in local control or radiation necrosis between HF-SRS and SF-SRS. For HF-SRS, a BED10 ≥ 50 may improve local control.
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Affiliation(s)
- Jill S Remick
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Emily Kowalski
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Rahul Khairnar
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Kai Sun
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Emily Morse
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Hua-Ren R Cherng
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Yannick Poirier
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Narottam Lamichhane
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Stewart J Becker
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Shifeng Chen
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Akshar N Patel
- Chesapeake Oncology Hematology Associates, Glen Bernie, MD, USA
| | - Young Kwok
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Elizabeth Nichols
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Graeme F Woodworth
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - William F Regine
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mark V Mishra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA.
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21
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Abrams RA, Winter KA, Safran H, Goodman KA, Regine WF, Berger AC, Gillin MT, Philip PA, Lowy AM, Wu A, DiPetrillo TA, Corn BW, Seaward SA, Haddock MG, Song S, Jiang Y, Fisher BJ, Katz AW, Mehta S, Willett CG, Crane CH. Results of the NRG Oncology/RTOG 0848 Adjuvant Chemotherapy Question-Erlotinib+Gemcitabine for Resected Cancer of the Pancreatic Head: A Phase II Randomized Clinical Trial. Am J Clin Oncol 2020; 43:173-179. [PMID: 31985516 PMCID: PMC7280743 DOI: 10.1097/coc.0000000000000633] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [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] [Indexed: 01/10/2023]
Abstract
PURPOSE NRG/RTOG 0848 was designed to determine whether adjuvant radiation with fluoropyrimidine sensitization improved survival following gemcitabine-based adjuvant chemotherapy for patients with resected pancreatic head adenocarcinoma. In step 1 of this protocol, patients were randomized to adjuvant gemcitabine versus the combination of gemcitabine and erlotinib. This manuscript reports the final analysis of these step 1 data. METHODS Eligibility-within 10 weeks of curative intent pancreaticoduodenectomy with postoperative CA19-9<180. Gemcitabine arm-6 cycles of gemcitabine. Gemcitabine+erlotinib arm-gemcitabine and erlotinib 100 mg/d. Two hundred deaths provided 90% power (1-sided α=0.15) to detect the hypothesized OS signal (hazard ratio=0.72) in favor of the arm 2. RESULTS From November 17, 2009 to February 28, 2014, 163 patients were randomized and evaluable for arm 1 and 159 for arm 2. Median age was 63 (39 to 86) years. CA19-9 ≤90 in 93%. Arm 1: 32 patients (20%) grade 4 and 2 (1%) grade 5 adverse events; arm 2, 27 (17%) grade 4 and 3 (2%) grade 5. GI adverse events, arm 1: 22% grade ≥3 and arm 2: 28%, (P=0.22). The median follow-up (surviving patients) was 42.5 months (min-max: <1 to 75). With 203 deaths, the median and 3-year OS (95% confidence interval) are 29.9 months (21.7, 33.4) and 39% (30, 45) for arm 1 and 28.1 months (20.7, 30.9) and 39% (31, 47) for arm 2 (log-rank P=0.62). Hazard ratio (95% confidence interval) comparing OS of arm 2 to arm 1 is 1.04 (0.79, 1.38). CONCLUSIONS The addition of adjuvant erlotinib to gemcitabine did not provide a signal for increased OS in this trial.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Benjamin W. Corn
- Tel Aviv Sourasky Medical Center (at time work was completed); Shaare Zedek Medical Center (current)
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22
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Reyngold M, Winter KA, Regine WF, Abrams RA, Safran H, Hoffman JP, Mowat RB, Hayes JP, Kessel IL, DiPetrillo T, Narayan S, Chen Y, Ben-Josef E, Delouya G, Suh JH, Meyer J, Haddock MG, Feldman M, Gaur R, Yost K, Peterson RA, Sherr DL, Moughan J, Crane CH. Marital Status and Overall Survival in Patients with Resectable Pancreatic Cancer: Results of an Ancillary Analysis of NRG Oncology/RTOG 9704. Oncologist 2019; 25:e477-e483. [PMID: 32162826 DOI: 10.1634/theoncologist.2019-0562] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 10/23/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Several registry-based analyses suggested a survival advantage for married versus single patients with pancreatic cancer. The mechanisms underlying the association of marital status and survival are likely multiple and complex and, therefore, may be obscured in analyses generated from large population-based databases. The goal of this research was to characterize this potential association of marital status with outcomes in patients with resected pancreatic cancer who underwent combined modality adjuvant therapy on a prospective clinical trial. MATERIALS AND METHODS This is an ancillary analysis of 367 patients with known marital status treated on NRG Oncology/RTOG 97-04. Survival analysis was performed using the Kaplan-Meier method and compared using the log-rank test. Multivariate analysis was performed using the Cox proportional hazards regression model. RESULTS Of 367 patients, 271 (74%) were married or partnered and 96 (26%) were single. Married or partnered patients were more likely to be male. There was no association between marital status and overall survival (OS) or disease-free survival (DFS) on univariate (hazard ratio [HR], 1.09 and 1.01, respectively) or multivariate analyses (HR, 1.05 and 0.98, respectively). Married or partnered male patients did not have improved survival compared with female or single patients. CONCLUSION Ancillary analysis of data from NRG Oncology/RTOG 97-04 demonstrated no association between marital and/or partner status and OS or DFS in patients with resected pancreatic cancer who received adjuvant postoperative chemotherapy followed by concurrent external beam radiation therapy and chemotherapy. Clinical trial identification number. NCT00003216. IMPLICATIONS FOR PRACTICE Several population-based studies have shown an epidemiological link between marital status and survival in patients with pancreatic cancer. A better understanding of this association could offer an opportunity to improve outcomes through psychosocial interventions designed to mitigate the negative effects of not being married. Based on the results of this analysis, patients who have undergone a resection and are receiving adjuvant therapy on a clinical trial are unlikely to benefit from such interventions. Further efforts to study the association between marital status and survival should be focused on less selected subgroups of patients with pancreatic cancer.
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Affiliation(s)
- Marsha Reyngold
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Kathryn A Winter
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania, USA
| | - William F Regine
- University of Maryland Marlene and Stewart Greenebaum Cancer Center, Baltimore, Maryland, USA
| | - Ross A Abrams
- Rush University Medical Center, Chicago, Illinois, USA
| | - Howard Safran
- Rhode Island Hospital, Providence, Rhode Island, USA
| | - John P Hoffman
- Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - Rex B Mowat
- Toledo Community Hospital Oncology Program, Community Clinical Oncology Program, Toledo, Ohio, USA
| | - John P Hayes
- Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Ivan L Kessel
- University of Texas Medical Branch, Galveston, Texas, USA
| | | | - Samir Narayan
- Michigan Cancer Research Consortium, Grand Rapid, Michigan, USA
| | | | - Edgar Ben-Josef
- University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, USA
| | - Guila Delouya
- Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - John H Suh
- Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Joshua Meyer
- Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | | | | | - Rakesh Gaur
- Kansas City Community Clinical Oncology Program, Prairie Village, Kansas, USA
| | - Kathleen Yost
- Grand Rapids Community Clinical Oncology Program, Grand Rapids, Michigan, USA
| | | | - David L Sherr
- The Brooklyn Hospital Center, New York, New York, USA
| | - Jennifer Moughan
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania, USA
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23
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Yu NY, Sio TT, Mohindra P, Regine WF, Miller RC, Mahajan A, Keole SR. The Insurance Approval Process for Proton Beam Therapy Must Change: Prior Authorization Is Crippling Access to Appropriate Health Care. Int J Radiat Oncol Biol Phys 2019; 104:737-739. [PMID: 31204659 DOI: 10.1016/j.ijrobp.2019.04.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 04/10/2019] [Accepted: 04/13/2019] [Indexed: 01/18/2023]
Affiliation(s)
- Nathan Y Yu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Terence T Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Pranshu Mohindra
- Department of Radiation Oncology and Maryland Proton Treatment Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - William F Regine
- Department of Radiation Oncology and Maryland Proton Treatment Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Robert C Miller
- Department of Radiation Oncology and Maryland Proton Treatment Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Sameer R Keole
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona.
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24
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Morganti AG, Cellini F, Buwenge M, Arcelli A, Alfieri S, Calvo FA, Casadei R, Cilla S, Deodato F, Di Gioia G, Di Marco M, Fuccio L, Bertini F, Guido A, Herman JM, Macchia G, Maidment BW, Miller RC, Minni F, Passoni P, Valentini C, Re A, Regine WF, Reni M, Falconi M, Valentini V, Mattiucci GC. Adjuvant chemoradiation in pancreatic cancer: impact of radiotherapy dose on survival. BMC Cancer 2019; 19:569. [PMID: 31185957 PMCID: PMC6560746 DOI: 10.1186/s12885-019-5790-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 05/31/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND To evaluate the impact of radiation dose on overall survival (OS) in patients treated with adjuvant chemoradiation (CRT) for pancreatic ductal adenocarcinoma (PDAC). METHODS A multicenter retrospective analysis on 514 patients with PDAC (T1-4; N0-1; M0) treated with surgical resection with macroscopically negative margins (R0-1) followed by adjuvant CRT was performed. Patients were stratified into 4 groups based on radiotherapy doses (group 1: < 45 Gy, group 2: ≥ 45 and < 50 Gy, group 3: ≥ 50 and < 55 Gy, group 4: ≥ 55 Gy). Adjuvant chemotherapy was prescribed to 141 patients. Survival functions were plotted using the Kaplan-Meier method and compared through the log-rank test. RESULTS Median follow-up was 35 months (range: 3-120 months). At univariate analysis, a worse OS was recorded in patients with higher preoperative Ca 19.9 levels (≥ 90 U/ml; p < 0.001), higher tumor grade (G3-4, p = 0.004), R1 resection (p = 0.004), higher pT stage (pT3-4, p = 0.002) and positive nodes (p < 0.001). Furthermore, patients receiving increasing doses of CRT showed a significantly improved OS. In groups 1, 2, 3, and 4, median OS was 13.0 months, 21.0 months, 22.0 months, and 28.0 months, respectively (p = 0.004). The significant impact of higher dose was confirmed by multivariate analysis. CONCLUSIONS Increasing doses of CRT seems to favorably impact on OS in adjuvant setting. The conflicting results of randomized trials on adjuvant CRT in PDAC could be due to < 45 Gy dose generally used.
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Affiliation(s)
- Alessio G. Morganti
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, S. Orsola-Malpighi Hospital, via Giuseppe Massarenti 9, 40138 Bologna, Italy
| | - Francesco Cellini
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Istituto di Radiologia, Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Roma, Italy
| | - Milly Buwenge
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, S. Orsola-Malpighi Hospital, via Giuseppe Massarenti 9, 40138 Bologna, Italy
| | - Alessandra Arcelli
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, S. Orsola-Malpighi Hospital, via Giuseppe Massarenti 9, 40138 Bologna, Italy
| | - Sergio Alfieri
- Istituto di Clinica Chirurgica, Fondazione Policlinico A. Gemelli IRCCS - Università Cattolica Sacro Cuore, Roma, Italy
| | - Felipe A. Calvo
- Department of Oncology, Hospital General Universitario Gregorio Marañón, Complutense University, Madrid, Spain
| | - Riccardo Casadei
- Department of Medical and Surgical Sciences – DIMEC, University of Bologna, Bologna, Italy
| | - Savino Cilla
- Unit of Medical Physics, Fondazione Giovanni Paolo II, Campobasso, Italy
| | | | - Giancarmine Di Gioia
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, S. Orsola-Malpighi Hospital, via Giuseppe Massarenti 9, 40138 Bologna, Italy
| | - Mariacristina Di Marco
- Department of Experimental, Diagnostic, and Specialty Medicine - DIMES, Sant’Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Lorenzo Fuccio
- Department of Medical and Surgical Sciences – DIMEC, University of Bologna, Bologna, Italy
| | - Federica Bertini
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, S. Orsola-Malpighi Hospital, via Giuseppe Massarenti 9, 40138 Bologna, Italy
| | - Alessandra Guido
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine-DIMES, University of Bologna, S. Orsola-Malpighi Hospital, via Giuseppe Massarenti 9, 40138 Bologna, Italy
| | - Joseph M. Herman
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland USA
| | | | - Bert W. Maidment
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia USA
| | - Robert C. Miller
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN USA
| | - Francesco Minni
- Department of Medical and Surgical Sciences – DIMEC, University of Bologna, Bologna, Italy
| | | | - Chiara Valentini
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Alessia Re
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Istituto di Radiologia, Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Roma, Italy
| | - William F. Regine
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD USA
| | | | - Massimo Falconi
- Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Hospital, University “Vita e Salute”, Milan, Italy
| | - Vincenzo Valentini
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Istituto di Radiologia, Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Roma, Italy
| | - Gian Carlo Mattiucci
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Istituto di Radiologia, Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Roma, Italy
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Remick JS, Bentzen SM, Simone CB, Nichols E, Suntharalingam M, Regine WF. Downstream Effect of a Proton Treatment Center on an Academic Medical Center. Int J Radiat Oncol Biol Phys 2019; 104:756-764. [PMID: 30885776 DOI: 10.1016/j.ijrobp.2019.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 02/22/2019] [Accepted: 03/11/2019] [Indexed: 12/25/2022]
Abstract
PURPOSE To quantify the effects of opening a proton center (PC) on an academic medical center (AMC)/radiation oncology department. METHODS AND MATERIALS Radiation treatment volume and relative value units from fiscal year 2015 (FY15) to FY17 were retrospectively analyzed at the AMC and 2 community-based centers. To quantify new patient referrals to the AMC, we reviewed the electronic medical record for all patients seen at the PC since consults were initiated in November 2015 (n = 1173). Patients were excluded if the date of entry into the AMC electronic medical record predated their PC consultation. Hospital resource use and professional and technical charges were obtained for these patients. Academic growth, philanthropy, and resident education were evaluated based on grant submissions, clinical trial enrollment, philanthropy, and pediatric case exposure, respectively, from PC opening through FY17. RESULTS From FY15 to FY17, radiation fractions at the AMC and the 2 community sites decreased by 14% (95% confidence interval [CI], 12%-16%, P < .001) and increased by 19% (95% CI, 16%-23%, P < .001) and 2% (95% CI, -1.1 to 4.3%, P = NS), respectively; the number of new starts decreased by 3% (95% CI, -13% to 7%, P = NS) and 2% (95% CI, -20% to 16%, P = NS) and increased by 13% (95% CI -2% to 27%, P = NS), respectively. At the AMC, technical and professional relative value units decreased by 5% and 14%, respectively. The PC made 561 external referrals to the AMC, which resulted in $2.38 million technical and $2.13 million professional charges at the AMC. Fifteen grant submissions ($12.83 million) resulted in 6 awards ($3.26 million). Twenty-two clinical trials involving proton therapy were opened, on which a total of 5% (n = 54) of patients enrolled during calendar years 2017 and 2018. The PC was involved in gift donations of $1.6 million. There was a nonsignificant 37% increase in number of pediatric cases. CONCLUSIONS Despite a slight decline in AMC photon patient volumes and relative value units, a positive downstream effect was associated with the addition of a PC, which benefited the AMC.
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Affiliation(s)
- Jill S Remick
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland
| | - Søren M Bentzen
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Charles B Simone
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Elizabeth Nichols
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Mohan Suntharalingam
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - William F Regine
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland.
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Sours Rhodes C, Zhang H, Patel K, Mistry N, Kwok Y, D'Souza WD, Regine WF, Gullapalli RP. The Feasibility of Integrating Resting-State fMRI Networks into Radiotherapy Treatment Planning. J Med Imaging Radiat Sci 2018; 50:119-128. [PMID: 30777232 DOI: 10.1016/j.jmir.2018.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 08/26/2018] [Accepted: 09/12/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Functional magnetic resonance imaging (fMRI) presents the ability to selectively protect functionally significant regions of the brain when primary brain tumors are treated with radiation therapy. Previous research has focused on task-based fMRI of language and sensory networks; however, there has been limited investigation on the inclusion of resting-state fMRI into the design of radiation treatment plans. METHODS AND MATERIALS In this pilot study of 9 patients with primary brain tumors, functional data from the default mode network (DMN), a network supporting cognitive functioning, was obtained from resting-state fMRI and retrospectively incorporated into the design of radiation treatment plans. We compared the dosimetry of these fMRI DMN avoidance treatment plans with standard of care treatment plans to demonstrate feasibility. In addition, we used normal tissue complication probability models to estimate the relative benefit of fMRI DMN avoidance treatment plans over standard of care treatment plans in potentially reducing memory loss, a surrogate for cognitive function. RESULTS On average, we achieved 20% (P = 0.002) and 12% (P = 0.002) reductions in the mean and maximum doses, respectively, to the DMN without compromising the dose coverage to the planning tumor volume or the dose-volume constraints to organs at risk. Normal tissue complication probability models revealed that when the fMRI DMN was considered during radiation treatment planning, the probability of developing memory loss was lowered by more than 20%. CONCLUSION In this pilot study, we demonstrated the feasibility of including rs-MRI data into the design of radiation treatment plans to spare cognitively relevant brain regions during radiation therapy. These results lay the groundwork for future clinical trials that incorporate such treatment planning methods to investigate the long-term behavioral impact of this reduction in dose to the cognitive areas and their neural networks that support cognitive performance.
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Affiliation(s)
- Chandler Sours Rhodes
- Department of Diagnostic Radiology & Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Hao Zhang
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Kruti Patel
- Radiation Oncology, Greater Baltimore Medical Center, Towson, Maryland, USA
| | - Nilesh Mistry
- Siemens Healthcare, Raleigh-Durham, North Carolina, USA
| | - Young Kwok
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Warren D D'Souza
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - William F Regine
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Rao P Gullapalli
- Department of Diagnostic Radiology & Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA.
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Nathenson MJ, Barysauskas CM, Nathenson RA, Regine WF, Hanna N, Sausville E. Surgical resection for recurrent retroperitoneal leiomyosarcoma and liposarcoma. World J Surg Oncol 2018; 16:203. [PMID: 30309356 PMCID: PMC6182828 DOI: 10.1186/s12957-018-1505-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 09/28/2018] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Retroperitoneal soft tissue sarcomas (STS) include a number of histologies but are rare, with approximately 3000 cases in the USA per year. Retroperitoneal STS have a high incidence of local and distant recurrence. The purpose of this study was to review the University of Maryland Medical Center's (UMMC) treatment experience of retroperitoneal STS, where the patient population served represents a diverse socioeconomic and ethnic catchment. METHODS IRB approval was obtained. We constructed a de-identified database of patients diagnosed with retroperitoneal liposarcomas (LPS) or leiomyosarcomas (LMS) treated at UMMC between 2000 and 2013. A total of 49 patients (Pts) with retroperitoneal STS met our eligibility criteria. Kaplan-Meier plots were used to graphically portray progression-free survival (PFS) and overall survival (OS). The log-rank test was used to compare time-to-event distributions. RESULTS The median OS for all patients (Pts) was 6.3 years, and the 2-year OS rate was 81%. The median PFS for all Pts was 1.8 years, and the 2-year PFS rate was 45%. There was no difference in OS and PFS among LMS and LPS patients; the median OS for LMS was 3.8 years vs. LPS 6.4 years (p = 0.33), and the median PFS for LMS was 1.2 years vs. LPS 2.5 years (p = 0.28). There was a significant difference between histology and race (p = 0.001). LPS were primarily Caucasian 86% vs. 14% black, whereas LMS were primarily black 52% vs. 33% Caucasian. OS was influenced by functional status, gender, American Joint Committee on Cancer (AJCC) stage, grade, histology, tumor size, and extent of resection. PFS was influenced by AJCC stage, grade, and extent of resection. Neither adjuvant chemotherapy (1 Pt) nor neoadjuvant/adjuvant radiation therapy (18 Pts) influenced OS or PFS. There was a non-significant difference that Pts who could undergo resection of local recurrence had improved 2-year OS, with 100% LMS and LPS compared to 2-year OS of 71% (LMS) and 78% (LPS) not undergoing resection of local recurrence. CONCLUSIONS This study suggests a higher incidence of leiomyosarcoma in the African-American population. This study confirms the prognostic importance of grade, tumor size, AJCC stage, histology, and extent of resection in patient outcomes, at a large substantially diverse academic medical center. Future research into the biological features of liposarcoma and leiomyosarcoma Pts imparting these characteristics will be important to define.
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Affiliation(s)
- Michael J Nathenson
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215 USA
| | - Constance M Barysauskas
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215 USA
| | - Robert A Nathenson
- University of Pennsylvania, 3440 Market Street Philadelphia, Philadelphia, PA 19146 USA
| | - William F Regine
- University of Maryland, Greenebaum Cancer Center, South Greene Street Suite 9d10 Baltimore, Baltimore, MD 21201 USA
| | - Nader Hanna
- University of Maryland, Greenebaum Cancer Center, South Greene Street Suite 9d10 Baltimore, Baltimore, MD 21201 USA
| | - Edward Sausville
- University of Maryland, Greenebaum Cancer Center, South Greene Street Suite 9d10 Baltimore, Baltimore, MD 21201 USA
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Chiaramonte D, Kaiser A, McMath G, Simone CB, Regine WF, Berman B. Integrative Wellness for Patients Receiving Proton Therapy: A Patient-Centered Collaboration. J Altern Complement Med 2018; 24:1012-1013. [PMID: 30247956 DOI: 10.1089/acm.2018.0172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Delia Chiaramonte
- 1 Center for Integrative Medicine, University of Maryland School of Medicine , Baltimore, MD
| | - Adeel Kaiser
- 2 Maryland Proton Treatment Center, University of Maryland Medical Center , Baltimore, MD
| | | | - C B Simone
- 2 Maryland Proton Treatment Center, University of Maryland Medical Center , Baltimore, MD
| | - William F Regine
- 2 Maryland Proton Treatment Center, University of Maryland Medical Center , Baltimore, MD
| | - Brian Berman
- 1 Center for Integrative Medicine, University of Maryland School of Medicine , Baltimore, MD
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Mattiucci GC, Morganti AG, Cellini F, Buwenge M, Casadei R, Farioli A, Alfieri S, Arcelli A, Bertini F, Calvo FA, Cammelli S, Fuccio L, Giaccherini L, Guido A, Herman JM, Macchia G, Maidment BW, Miller RC, Minni F, Regine WF, Reni M, Partelli S, Falconi M, Valentini V. Prognostic Impact of Presurgical CA19-9 Level in Pancreatic Adenocarcinoma: A Pooled Analysis. Transl Oncol 2018; 12:1-7. [PMID: 30237099 PMCID: PMC6143718 DOI: 10.1016/j.tranon.2018.08.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 08/26/2018] [Accepted: 08/29/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND: Presurgical carbohydrate antigen 19-9 (CA19-9) level predicts overall survival (OS) in resected pancreatic adenocarcinoma (PaC). The aim of this pooled analysis was to evaluate if presurgical CA19-9 level can also predict local control (LC) and distant metastasis-free survival (DMFS). METHODS: Seven hundred patients with PaC from eight institutions who underwent surgical resection ± adjuvant treatment between 2000 and 2014 were analyzed. Patients were divided based on four presurgical CA19-9 level cutoffs (5, 37, 100, 353 U/ml). Weibull regression model to identify independent predictors of OS on 404 patients with complete information was fitted. RESULTS: Median follow-up was 17 months (range: 2-225 months). Univariate analysis showed a better prognosis in pT1-2, pN0, diameter <30 mm, or grade 1 tumors and in patients undergoing R0 resection, distal pancreatectomy, or adjuvant chemotherapy and with lower CA19-9 levels. Five-year OS, LC, and DMFS were as follows: CA19-9 <5.0: 5.7%, 47.2%, 17.0%; CA19-9 5.1-37.0: 37.9%, 63.3%, 46.0%; CA19-9 37.1-100.0: 27.1%, 59.4%, 39.0%; CA19-9 100.1-353.0: 17.4%, 43.4%, 26.7%; CA19-9 >353.1: 10.9%, 50.2%, and 23.4%, respectively. At multivariate analysis, CA19-9 >100 and <353 level (P=.002), CA19-9 ≥353.1 (P<.001) level, G3 tumor (P=.002), and tumor diameter >30 mm (P<.001) correlated with worse OS. Patients treated with postoperative chemoradiation doses >50.0 Gy showed improved OS (P<.001). CONCLUSION: Presurgical CA19-9 predicts both OS and pattern of failure. Therefore, CA19-9 should be included in predictive models in order to customize treatments based on prognostic factors. Moreover, future studies should stratify patients according to presurgical CA19-9 level.
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Affiliation(s)
- Gian Carlo Mattiucci
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Istituto di Radiologia, Fondazione Policlinico A. Gemelli IRCCS - Università Cattolica Sacro Cuore, Roma, Italia
| | - Alessio G Morganti
- Radiation Oncology Center, Dept of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, Bologna, Italy
| | - Francesco Cellini
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Istituto di Radiologia, Fondazione Policlinico A. Gemelli IRCCS - Università Cattolica Sacro Cuore, Roma, Italia.
| | - Milly Buwenge
- Radiation Oncology Center, Dept of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, Bologna, Italy
| | - Riccardo Casadei
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Andrea Farioli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Sergio Alfieri
- Istituto di Clinica Chirurgica, Fondazione Policlinico A. Gemelli IRCCS - Università Cattolica Sacro Cuore, Roma, Italia
| | - Alessandra Arcelli
- Radiation Oncology Center, Dept of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, Bologna, Italy
| | - Federica Bertini
- Radiation Oncology Center, Dept of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, Bologna, Italy
| | - Felipe A Calvo
- Department of Oncology, Hospital General Universitario Gregorio Marañón, Complutense University, Madrid, Spain
| | - Silvia Cammelli
- Radiation Oncology Center, Dept of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, Bologna, Italy
| | - Lorenzo Fuccio
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Lucia Giaccherini
- Radiation Oncology Center, Dept of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, Bologna, Italy
| | - Alessandra Guido
- Radiation Oncology Center, Dept of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, Bologna, Italy
| | - Joseph M Herman
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Mariland, USA
| | - Gabriella Macchia
- Radiotherapy Unit, General Oncology Unit, Fondazione Giovanni Paolo II, Campobasso, Italy
| | - Bert W Maidment
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia, USA
| | - Robert C Miller
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Francesco Minni
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - William F Regine
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Michele Reni
- Department of Medical Oncology, IRCCS Ospedale S. Raffaele, Milan, Italy
| | - Stefano Partelli
- Department of Medical Oncology, IRCCS Ospedale S. Raffaele, Milan, Italy
| | - Massimo Falconi
- Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Hospital, University "Vita e Salute", Milan, Italy
| | - Vincenzo Valentini
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per immagini, Radioterapia Oncologica ed Ematologia, Istituto di Radiologia, Fondazione Policlinico A. Gemelli IRCCS - Università Cattolica Sacro Cuore, Roma, Italia
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Regine WF, Winter K, Abrams RA, Safran H, Kessel IL, Chen Y, Fugazzi JA, Donnelly ED, DiPetrillo TA, Narayan S, Plastaras JP, Gaur R, Delouya G, Suh JH, Meyer JE, Haddock MG, Didolkar MS, Padula GDA, Johnson D, Hoffman JP, Crane CH. Postresection CA19-9 and margin status as predictors of recurrence after adjuvant treatment for pancreatic carcinoma: Analysis of NRG oncology RTOG trial 9704. Adv Radiat Oncol 2018; 3:154-162. [PMID: 29904740 PMCID: PMC6000159 DOI: 10.1016/j.adro.2018.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 01/16/2018] [Indexed: 12/30/2022] Open
Abstract
Purpose NRG Oncology RTOG 9704 was the first adjuvant trial to validate the prognostic value of postresection CA19-9 levels for survival in patients with pancreatic carcinoma. The data resulting from this study also provide information about predictors of recurrence that may be used to tailor individualized management in this disease setting. This secondary analysis assessed the prognostic value of postresection CA19-9 and surgical margin status (SMS) in predicting patterns of disease recurrence. Methods and materials This multicenter cooperative trial included participants who were enrolled as patients at oncology treatment sites in the United States and Canada. The study included 451 patients analyzable for SMS, of whom 385 were eligible for postresection CA19-9 analysis. Postresection CA19-9 was analyzed at cut points of 90, 180, and continuously. Patterns of disease recurrence included local/regional recurrence (LRR) and distant failure (DF). Multivariable analyses included treatment, tumor size, and nodal status. To adjust for multiple comparisons, a P value of ≤ .01 was considered statistically significant and > .01 to ≤ .05 to be a trend. Results For CA19-9, 132 (34%) patients were Lewis antigen-negative (no CA19-9 expression), 200 (52%) had levels <90, and 220 (57%) had levels <180. A total of 188 patients (42%) had negative margins, 152 (34%) positive, and 111 (25%) unknown. On univariate analysis, CA19-9 cut at 90 was associated with increases in LRR (trend) and DF. Results were similar at the 180 cut point. SMS was not associated with an increase in LRR on univariate or multivariate analyses. On multivariable analysis, CA19-9 ≥ 90 was associated with increased LRR and DF. Results were similar at the 180 cut point. Conclusions In this prospective evaluation, postresection CA19-9 was a significant predictor of both LRR and DF, whereas SMS was not. These findings support consideration of adjuvant radiation therapy dose intensification in patients with elevated postresection CA19-9.
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Affiliation(s)
| | - Kathryn Winter
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | | | | | - Ivan L Kessel
- University of Texas Medical Branch, Galveston, Texas
| | - Yuhchyau Chen
- University of Rochester Medical Center, Rochester, New York
| | - James A Fugazzi
- Toledo Community Hospital Oncology Program CCOP, Toledo, Ohio
| | | | | | - Samir Narayan
- Michigan Cancer Research Consortium CCOP, Ann Arbor, Michigan
| | - John P Plastaras
- University of Pennsylvania Medical Center, Philadelphia, Pennsylvania
| | | | - Guila Delouya
- Centre Hospitalier de l'Université de Montréal-Notre Dame, Montreal, Quebec
| | - John H Suh
- Cleveland Clinic Foundation, Cleveland, Ohio
| | | | | | | | | | | | | | - Christopher H Crane
- The University of Texas MD Anderson Cancer Center, Houston, Texas.,Memorial Sloan Kettering Cancer Center, New York, New York
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Tsai AK, Vyfhuis MAL, Francis M, Merechi F, Burke AP, Regine WF. Radiation-induced undifferentiated pleomorphic sarcoma of the heart: A case report. Pract Radiat Oncol 2018; 8:136-139. [PMID: 29305110 DOI: 10.1016/j.prro.2017.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 10/19/2017] [Accepted: 10/25/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Alexander K Tsai
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Melissa A L Vyfhuis
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Martha Francis
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Fikru Merechi
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Allen P Burke
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland
| | - William F Regine
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland.
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Lawrence YR, Moughan J, Magliocco AM, Klimowicz AC, Regine WF, Mowat RB, DiPetrillo TA, Small W, Simko JP, Golan T, Winter KA, Guha C, Crane CH, Dicker AP. Expression of the DNA repair gene MLH1 correlates with survival in patients who have resected pancreatic cancer and have received adjuvant chemoradiation: NRG Oncology RTOG Study 9704. Cancer 2017; 124:491-498. [PMID: 29053185 DOI: 10.1002/cncr.31058] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 08/26/2017] [Accepted: 09/06/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND The majority of patients with pancreatic cancer who undergo curative resection experience rapid disease recurrence. In previous small studies, high expression of the mismatch-repair protein mutL protein homolog 1 (MLH1) in pancreatic cancers was associated with better outcomes. The objective of this study was to validate the association between MLH1 expression and survival in patients who underwent resection of pancreatic cancer and received adjuvant chemoradiation. METHODS Samples were obtained from the NRG Oncology Radiation Therapy Oncology Group 9704 prospective, randomized trial (clinicaltrials.gov identifier NCT00003216), which compared 2 adjuvant protocols in patients with pancreatic cancer who underwent resection. Tissue microarrays were prepared from formalin-fixed, paraffin-embedded, resected tumor tissues. MLH1 expression was quantified using fluorescence immunohistochemistry and automated quantitative analysis, and expression was dichotomized above and below the median value. RESULTS Immunohistochemical staining was successfully performed on 117 patients for MLH1 (60 and 57 patients from the 2 arms). The characteristics of the participants who had tissue samples available were similar to those of the trial population as a whole. At the time of analysis, 84% of participants had died, with a median survival of 17 months. Elevated MLH1 expression levels in tumor nuclei were significantly correlated with longer disease-free and overall survival in each arm individually and in both arms combined. Two-year overall survival was 16% in patients who had low MLH1 expression levels and 53% in those who had high MLH1 expression levels (P < .0001 for both arms combined). This association remained true on a multivariate analysis that allowed for lymph node status (hazard ratio, 0.41; 95% confidence interval, 0.27-0.63; P < .0001). CONCLUSIONS In the current sample, MLH1 expression was correlated with long-term survival. Further studies should assess whether MLH1 expression predicts which patients with localized pancreatic cancer may benefit most from aggressive, multimodality treatment. Cancer 2018;124:491-8. © 2017 American Cancer Society.
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Affiliation(s)
- Yaacov R Lawrence
- Department of Oncology, Chaim Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel HaShomer, Israel.,Department of Radiation Oncology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jennifer Moughan
- Statistics and Data Management Center, NRG Oncology, Philadelphia, Pennsylvania
| | - Anthony M Magliocco
- Department of Anatomic Pathology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | | | | | | | - Thomas A DiPetrillo
- Department of Radiation Oncology, Rhode Island Hospital/The Warren Alpert Medical School of Brown University, Providence, Rhode, Island
| | - William Small
- Department of Radiation Oncology, Loyola University Medical Center, Chicago, Illinois
| | - Jeffry P Simko
- Department of Pathology, University of California-San Francisco Medical Center, San Francisco, California
| | - Talia Golan
- Department of Oncology, Chaim Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel HaShomer, Israel
| | - Kathryn A Winter
- Statistics and Data Management Center, NRG Oncology, Philadelphia, Pennsylvania
| | - Chandan Guha
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, New York
| | | | - Adam P Dicker
- Department of Radiation Oncology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
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Abstract
Brain metastases are the most common intracranial malignancy. Incidence of brain metastases has risen as systemic therapies have improved and patients with metastatic disease live longer. Whole-brain radiation therapy, for many years, has been the standard treatment approach. Stereotactic radiosurgery has become an increasingly popular option because of its relatively short, convenient, and noninvasive treatment course. Although recently published data have renewed interest in use of whole-brain radiation therapy or systemic therapies for control of micrometastatic disease, stereotactic radiosurgery continues to be an important modality, capable of delivering ablative doses of radiation for long-term control of macroscopic disease. The purpose of this review is to explore the different paradigms for incorporation of stereotactic radiosurgery into management of brain metastases. Current uses for stereotactic radiosurgery include delivery as a boost with whole-brain radiation therapy; alone for patients with a limited number of brain metastases; in pre- or postoperative settings; and in combination with systemic, targeted, and immune-based therapies. Mature prospective data on use of stereotactic radiosurgery in combination with whole-brain radiation therapy is available; however, prospective, randomized data on stereotactic radiosurgery for patients with a greater number of brain metastases, its use in pre- and postoperative settings, and its use in combination with systemic therapies are limited. Data from ongoing and future studies are needed to define the appropriate use of stereotactic radiosurgery in these settings.
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Affiliation(s)
- Shahed N Badiyan
- University of Maryland School of Medicine, Baltimore, MD; and Miami Cancer Institute, Baptist Health South Florida, Miami, FL
| | - William F Regine
- University of Maryland School of Medicine, Baltimore, MD; and Miami Cancer Institute, Baptist Health South Florida, Miami, FL
| | - Minesh Mehta
- University of Maryland School of Medicine, Baltimore, MD; and Miami Cancer Institute, Baptist Health South Florida, Miami, FL
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Giacomelli I, Scartoni D, Mohammadi H, Regine WF, Chuong MD. Does lymphocyte-to-monocyte ratio before, during, or after definitive chemoradiation for locally advanced pancreatic cancer predict for clinical outcomes? J Gastrointest Oncol 2017; 8:721-727. [PMID: 28890823 DOI: 10.21037/jgo.2017.06.14] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Elevated pre-treatment lymphocyte (L) to monocyte (M) ratio (LMR) in peripheral blood has been suggested to correlate with improved survival in some malignancies, but data in the context of pancreatic cancer (PC) is limited. The aim of this study was to evaluate the prognostic significance of LMR before, during and after definitive chemoradiotherapy (CRT) for locally advanced pancreatic cancer (LAPC). METHODS We retrospectively reviewed 57 patients with LAPC treated with definitive CRT at a single institution from 2005 to 2013. Complete blood counts were obtained before (TP1), during the third week (TP2) and at the end of CRT (TP3). Univariate analysis (UVA) included gender, age, body mass index, pre-treatment CA19-9, T stage, N stage, induction chemotherapy (ICT), absolute L count (TP1, TP2, TP3), absolute M count (TP1, TP2, TP3), LMR (TP1, TP2, TP3), and relative LMR changes (TP2 ÷ TP1, TP3 ÷ TP1, TP3 ÷ TP2). RESULTS Median follow-up was 14 months. Twelve patients received ICT. Median LMR was 2.7 (range, 0.8-5.25), 1.4 (range, 0.3-5) and 0.98 (range, 0.3-3.4) at TP1, TP2 and TP3, respectively. Superior PFS was significantly associated with an absolute M count during CRT <0.1 (P=0.04) while pre-CRT L count ≥1.1 trended towards significance (P=0.09). Superior OS was significantly associated with change in LMR (TP3 ÷ TP2) > 0.32 (P<0.0001) while pre-CRT LMR ≥2.6 trended towards significance (P=0.06). CONCLUSIONS Factors significantly associated with overall survival (OS) and progression-free survival (PFS) were change in LMR at the end of CRT and absolute M count during CRT. This analysis suggests treatment-time-specific immune system parameters may affect clinical outcomes and warrant continued investigation.
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Affiliation(s)
- Irene Giacomelli
- Proton Treatment Center, APSS (Azienda Provinciale per i Servizi Sanitari), Trento, Italy
| | - Daniele Scartoni
- Proton Treatment Center, APSS (Azienda Provinciale per i Servizi Sanitari), Trento, Italy
| | - Homan Mohammadi
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - William F Regine
- Radiation Oncology Department, University of Maryland, Baltimore MD, USA
| | - Michael D Chuong
- Radiation Oncology Department, Miami Cancer Institute at Baptist Health South Florida, Miami, Florida, USA
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Snider JW, Mutaf Y, Nichols E, Hall A, Vadnais P, Regine WF, Feigenberg SJ. Projected Improvements in Accelerated Partial Breast Irradiation Using a Novel Breast Stereotactic Radiotherapy Device: A Dosimetric Analysis. Technol Cancer Res Treat 2017; 16:1031-1037. [PMID: 28705082 PMCID: PMC5762064 DOI: 10.1177/1533034617718961] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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] [Indexed: 12/22/2022] Open
Abstract
Accelerated partial breast irradiation has caused higher than expected rates of poor cosmesis. At our institution, a novel breast stereotactic radiotherapy device has demonstrated dosimetric distributions similar to those in brachytherapy. This study analyzed comparative dose distributions achieved with the device and intensity-modulated radiation therapy accelerated partial breast irradiation. Nine patients underwent computed tomography simulation in the prone position using device-specific immobilization on an institutional review board–approved protocol. Accelerated partial breast irradiation target volumes (planning target volume_10mm) were created per the National Surgical Adjuvant Breast and Bowel Project B-39 protocol. Additional breast stereotactic radiotherapy volumes using smaller margins (planning target volume_3mm) were created based on improved immobilization. Intensity-modulated radiation therapy and breast stereotactic radiotherapy accelerated partial breast irradiation plans were separately generated for appropriate volumes. Plans were evaluated based on established dosimetric surrogates of poor cosmetic outcomes. Wilcoxon rank sum tests were utilized to contrast volumes of critical structures receiving a percentage of total dose (Vx). The breast stereotactic radiotherapy device consistently reduced dose to all normal structures with equivalent target coverage. The ipsilateral breast V20-100 was significantly reduced (P < .05) using planning target volume_10mm, with substantial further reductions when targeting planning target volume_3mm. Doses to the chest wall, ipsilateral lung, and breast skin were also significantly lessened. The breast stereotactic radiotherapy device’s uniform dosimetric improvements over intensity-modulated accelerated partial breast irradiation in this series indicate a potential to improve outcomes. Clinical trials investigating this benefit have begun accrual.
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Affiliation(s)
- James W Snider
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Yildirim Mutaf
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Elizabeth Nichols
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Andrea Hall
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Patrick Vadnais
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - William F Regine
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Steven J Feigenberg
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
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Hepel JT, Heron DE, Mundt AJ, Yashar C, Feigenberg S, Koltis G, Regine WF, Prasad D, Patel S, Sharma N, Hebert M, Wallis N, Kuettel M. Comparison of Onsite Versus Online Chart Reviews as Part of the American College of Radiation Oncology Accreditation Program. J Oncol Pract 2017; 13:e516-e521. [PMID: 28301278 DOI: 10.1200/jop.2016.015230] [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
PURPOSE Accreditation based on peer review of professional standards of care is essential in ensuring quality and safety in administration of radiation therapy. Traditionally, medical chart reviews have been performed by a physical onsite visit. The American College of Radiation Oncology Accreditation Program has remodeled its process whereby electronic charts are reviewed remotely. METHODS Twenty-eight radiation oncology practices undergoing accreditation had three charts per practice undergo both onsite and online review. Onsite review was performed by a single reviewer for each practice. Online review consisted of one or more disease site-specific reviewers for each practice. Onsite and online reviews were blinded and scored on a 100-point scale on the basis of 20 categories. A score of less than 75 was failing, and a score of 75 to 79 was marginal. Any failed charts underwent rereview by a disease site team leader. RESULTS Eighty-four charts underwent both onsite and online review. The mean scores were 86.0 and 86.9 points for charts reviewed onsite and online, respectively. Comparison of onsite and online reviews revealed no statistical difference in chart scores ( P = .43). Of charts reviewed, 21% had a marginal (n = 8) or failing (n = 10) score. There was no difference in failing charts ( P = .48) or combined marginal and failing charts ( P = .13) comparing onsite and online reviews. CONCLUSION The American College of Radiation Oncology accreditation process of online chart review results in comparable review scores and rate of failing scores compared with traditional on-site review. However, the modern online process holds less potential for bias by using multiple reviewers per practice and allows for greater oversight via disease site team leader rereview.
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Affiliation(s)
- Jaroslaw T Hepel
- Rhode Island Hospital, Brown University, Providence, RI; Tufts Medical Center, Tufts University, Boston, MA; University of Pittsburgh Medical Center, University of Pittsburgh Cancer Institute, Pittsburgh; Penn State Hershey St Joseph Cancer Center, Reading, PA; University of California San Diego, La Jolla CA; University of Maryland School of Medicine, Baltimore; American College of Radiation Oncology, Bethesda, MD; Private Practice, Apex, NC; Roswell Park Cancer Institute, State University of New York at Buffalo, Buffalo, NY; University of Washington Medical Center, Seattle, WA; and Nacogdoches Medical Center, Nacogdoches, TX
| | - Dwight E Heron
- Rhode Island Hospital, Brown University, Providence, RI; Tufts Medical Center, Tufts University, Boston, MA; University of Pittsburgh Medical Center, University of Pittsburgh Cancer Institute, Pittsburgh; Penn State Hershey St Joseph Cancer Center, Reading, PA; University of California San Diego, La Jolla CA; University of Maryland School of Medicine, Baltimore; American College of Radiation Oncology, Bethesda, MD; Private Practice, Apex, NC; Roswell Park Cancer Institute, State University of New York at Buffalo, Buffalo, NY; University of Washington Medical Center, Seattle, WA; and Nacogdoches Medical Center, Nacogdoches, TX
| | - Arno J Mundt
- Rhode Island Hospital, Brown University, Providence, RI; Tufts Medical Center, Tufts University, Boston, MA; University of Pittsburgh Medical Center, University of Pittsburgh Cancer Institute, Pittsburgh; Penn State Hershey St Joseph Cancer Center, Reading, PA; University of California San Diego, La Jolla CA; University of Maryland School of Medicine, Baltimore; American College of Radiation Oncology, Bethesda, MD; Private Practice, Apex, NC; Roswell Park Cancer Institute, State University of New York at Buffalo, Buffalo, NY; University of Washington Medical Center, Seattle, WA; and Nacogdoches Medical Center, Nacogdoches, TX
| | - Catheryn Yashar
- Rhode Island Hospital, Brown University, Providence, RI; Tufts Medical Center, Tufts University, Boston, MA; University of Pittsburgh Medical Center, University of Pittsburgh Cancer Institute, Pittsburgh; Penn State Hershey St Joseph Cancer Center, Reading, PA; University of California San Diego, La Jolla CA; University of Maryland School of Medicine, Baltimore; American College of Radiation Oncology, Bethesda, MD; Private Practice, Apex, NC; Roswell Park Cancer Institute, State University of New York at Buffalo, Buffalo, NY; University of Washington Medical Center, Seattle, WA; and Nacogdoches Medical Center, Nacogdoches, TX
| | - Steven Feigenberg
- Rhode Island Hospital, Brown University, Providence, RI; Tufts Medical Center, Tufts University, Boston, MA; University of Pittsburgh Medical Center, University of Pittsburgh Cancer Institute, Pittsburgh; Penn State Hershey St Joseph Cancer Center, Reading, PA; University of California San Diego, La Jolla CA; University of Maryland School of Medicine, Baltimore; American College of Radiation Oncology, Bethesda, MD; Private Practice, Apex, NC; Roswell Park Cancer Institute, State University of New York at Buffalo, Buffalo, NY; University of Washington Medical Center, Seattle, WA; and Nacogdoches Medical Center, Nacogdoches, TX
| | - Gordon Koltis
- Rhode Island Hospital, Brown University, Providence, RI; Tufts Medical Center, Tufts University, Boston, MA; University of Pittsburgh Medical Center, University of Pittsburgh Cancer Institute, Pittsburgh; Penn State Hershey St Joseph Cancer Center, Reading, PA; University of California San Diego, La Jolla CA; University of Maryland School of Medicine, Baltimore; American College of Radiation Oncology, Bethesda, MD; Private Practice, Apex, NC; Roswell Park Cancer Institute, State University of New York at Buffalo, Buffalo, NY; University of Washington Medical Center, Seattle, WA; and Nacogdoches Medical Center, Nacogdoches, TX
| | - William F Regine
- Rhode Island Hospital, Brown University, Providence, RI; Tufts Medical Center, Tufts University, Boston, MA; University of Pittsburgh Medical Center, University of Pittsburgh Cancer Institute, Pittsburgh; Penn State Hershey St Joseph Cancer Center, Reading, PA; University of California San Diego, La Jolla CA; University of Maryland School of Medicine, Baltimore; American College of Radiation Oncology, Bethesda, MD; Private Practice, Apex, NC; Roswell Park Cancer Institute, State University of New York at Buffalo, Buffalo, NY; University of Washington Medical Center, Seattle, WA; and Nacogdoches Medical Center, Nacogdoches, TX
| | - Dheerendra Prasad
- Rhode Island Hospital, Brown University, Providence, RI; Tufts Medical Center, Tufts University, Boston, MA; University of Pittsburgh Medical Center, University of Pittsburgh Cancer Institute, Pittsburgh; Penn State Hershey St Joseph Cancer Center, Reading, PA; University of California San Diego, La Jolla CA; University of Maryland School of Medicine, Baltimore; American College of Radiation Oncology, Bethesda, MD; Private Practice, Apex, NC; Roswell Park Cancer Institute, State University of New York at Buffalo, Buffalo, NY; University of Washington Medical Center, Seattle, WA; and Nacogdoches Medical Center, Nacogdoches, TX
| | - Shilpen Patel
- Rhode Island Hospital, Brown University, Providence, RI; Tufts Medical Center, Tufts University, Boston, MA; University of Pittsburgh Medical Center, University of Pittsburgh Cancer Institute, Pittsburgh; Penn State Hershey St Joseph Cancer Center, Reading, PA; University of California San Diego, La Jolla CA; University of Maryland School of Medicine, Baltimore; American College of Radiation Oncology, Bethesda, MD; Private Practice, Apex, NC; Roswell Park Cancer Institute, State University of New York at Buffalo, Buffalo, NY; University of Washington Medical Center, Seattle, WA; and Nacogdoches Medical Center, Nacogdoches, TX
| | - Navesh Sharma
- Rhode Island Hospital, Brown University, Providence, RI; Tufts Medical Center, Tufts University, Boston, MA; University of Pittsburgh Medical Center, University of Pittsburgh Cancer Institute, Pittsburgh; Penn State Hershey St Joseph Cancer Center, Reading, PA; University of California San Diego, La Jolla CA; University of Maryland School of Medicine, Baltimore; American College of Radiation Oncology, Bethesda, MD; Private Practice, Apex, NC; Roswell Park Cancer Institute, State University of New York at Buffalo, Buffalo, NY; University of Washington Medical Center, Seattle, WA; and Nacogdoches Medical Center, Nacogdoches, TX
| | - Mary Hebert
- Rhode Island Hospital, Brown University, Providence, RI; Tufts Medical Center, Tufts University, Boston, MA; University of Pittsburgh Medical Center, University of Pittsburgh Cancer Institute, Pittsburgh; Penn State Hershey St Joseph Cancer Center, Reading, PA; University of California San Diego, La Jolla CA; University of Maryland School of Medicine, Baltimore; American College of Radiation Oncology, Bethesda, MD; Private Practice, Apex, NC; Roswell Park Cancer Institute, State University of New York at Buffalo, Buffalo, NY; University of Washington Medical Center, Seattle, WA; and Nacogdoches Medical Center, Nacogdoches, TX
| | - Norman Wallis
- Rhode Island Hospital, Brown University, Providence, RI; Tufts Medical Center, Tufts University, Boston, MA; University of Pittsburgh Medical Center, University of Pittsburgh Cancer Institute, Pittsburgh; Penn State Hershey St Joseph Cancer Center, Reading, PA; University of California San Diego, La Jolla CA; University of Maryland School of Medicine, Baltimore; American College of Radiation Oncology, Bethesda, MD; Private Practice, Apex, NC; Roswell Park Cancer Institute, State University of New York at Buffalo, Buffalo, NY; University of Washington Medical Center, Seattle, WA; and Nacogdoches Medical Center, Nacogdoches, TX
| | - Michael Kuettel
- Rhode Island Hospital, Brown University, Providence, RI; Tufts Medical Center, Tufts University, Boston, MA; University of Pittsburgh Medical Center, University of Pittsburgh Cancer Institute, Pittsburgh; Penn State Hershey St Joseph Cancer Center, Reading, PA; University of California San Diego, La Jolla CA; University of Maryland School of Medicine, Baltimore; American College of Radiation Oncology, Bethesda, MD; Private Practice, Apex, NC; Roswell Park Cancer Institute, State University of New York at Buffalo, Buffalo, NY; University of Washington Medical Center, Seattle, WA; and Nacogdoches Medical Center, Nacogdoches, TX
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Choi W, Xue M, Lane BF, Kang MK, Patel K, Regine WF, Klahr P, Wang J, Chen S, D'Souza W, Lu W. Individually optimized contrast-enhanced 4D-CT for radiotherapy simulation in pancreatic ductal adenocarcinoma. Med Phys 2017; 43:5659. [PMID: 27782710 DOI: 10.1118/1.4963213] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE To develop an individually optimized contrast-enhanced (CE) 4D-computed tomography (CT) for radiotherapy simulation in pancreatic ductal adenocarcinomas (PDA). METHODS Ten PDA patients were enrolled. Each underwent three CT scans: a 4D-CT immediately following a CE 3D-CT and an individually optimized CE 4D-CT using test injection. Three physicians contoured the tumor and pancreatic tissues. Image quality scores, tumor volume, motion, tumor-to-pancreas contrast, and contrast-to-noise ratio (CNR) were compared in the three CTs. Interobserver variations were also evaluated in contouring the tumor using simultaneous truth and performance level estimation. RESULTS Average image quality scores for CE 3D-CT and CE 4D-CT were comparable (4.0 and 3.8, respectively; P = 0.082), and both were significantly better than that for 4D-CT (2.6, P < 0.001). Tumor-to-pancreas contrast results were comparable in CE 3D-CT and CE 4D-CT (15.5 and 16.7 Hounsfield units (HU), respectively; P = 0.21), and the latter was significantly higher than in 4D-CT (9.2 HU, P = 0.001). Image noise in CE 3D-CT (12.5 HU) was significantly lower than in CE 4D-CT (22.1 HU, P = 0.013) and 4D-CT (19.4 HU, P = 0.009). CNRs were comparable in CE 3D-CT and CE 4D-CT (1.4 and 0.8, respectively; P = 0.42), and both were significantly better in 4D-CT (0.6, P = 0.008 and 0.014). Mean tumor volumes were significantly smaller in CE 3D-CT (29.8 cm3, P = 0.03) and CE 4D-CT (22.8 cm3, P = 0.01) than in 4D-CT (42.0 cm3). Mean tumor motion was comparable in 4D-CT and CE 4D-CT (7.2 and 6.2 mm, P = 0.17). Interobserver variations were comparable in CE 3D-CT and CE 4D-CT (Jaccard index 66.0% and 61.9%, respectively) and were worse for 4D-CT (55.6%) than CE 3D-CT. CONCLUSIONS CE 4D-CT demonstrated characteristics comparable to CE 3D-CT, with high potential for simultaneously delineating the tumor and quantifying tumor motion with a single scan.
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Affiliation(s)
- Wookjin Choi
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York 10065 and Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland 21201
| | - Ming Xue
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland 21201
| | - Barton F Lane
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland 21201
| | - Min Kyu Kang
- Department of Radiation Oncology, Kyungpook National University School of Medicine, Daegu 41944, South Korea
| | - Kruti Patel
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland 21201
| | - William F Regine
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland 21201
| | - Paul Klahr
- Philips Healthcare, Highland Heights, Ohio 44143
| | - Jiahui Wang
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland 21201
| | - Shifeng Chen
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland 21201
| | - Warren D'Souza
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland 21201
| | - Wei Lu
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York 10065 and Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland 21201
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Molitoris JK, Edelman MJ, Regine WF, Feigenberg SJ. Whole-Brain Radiation in the Treatment of Brain Metastases in ALK-Positive Non–Small-Cell Lung Cancer. J Clin Oncol 2017; 35:809-810. [DOI: 10.1200/jco.2016.69.7227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Jason K. Molitoris
- Jason K. Molitoris, University of Maryland Medical Center, Baltimore, MD; Martin J. Edelman, University of Maryland Greenebaum Cancer Center, Baltimore, MD; and William F. Regine and Steven J. Feigenberg, University of Maryland School of Medicine, Baltimore, MD
| | - Martin J. Edelman
- Jason K. Molitoris, University of Maryland Medical Center, Baltimore, MD; Martin J. Edelman, University of Maryland Greenebaum Cancer Center, Baltimore, MD; and William F. Regine and Steven J. Feigenberg, University of Maryland School of Medicine, Baltimore, MD
| | - William F. Regine
- Jason K. Molitoris, University of Maryland Medical Center, Baltimore, MD; Martin J. Edelman, University of Maryland Greenebaum Cancer Center, Baltimore, MD; and William F. Regine and Steven J. Feigenberg, University of Maryland School of Medicine, Baltimore, MD
| | - Steven J. Feigenberg
- Jason K. Molitoris, University of Maryland Medical Center, Baltimore, MD; Martin J. Edelman, University of Maryland Greenebaum Cancer Center, Baltimore, MD; and William F. Regine and Steven J. Feigenberg, University of Maryland School of Medicine, Baltimore, MD
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Mishra MV, Aggarwal S, Bentzen SM, Knight N, Mehta MP, Regine WF. Establishing Evidence-Based Indications for Proton Therapy: An Overview of Current Clinical Trials. Int J Radiat Oncol Biol Phys 2017; 97:228-235. [DOI: 10.1016/j.ijrobp.2016.10.045] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 10/18/2016] [Accepted: 10/31/2016] [Indexed: 11/30/2022]
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Snider JW, Mutaf Y, Nichols E, Hall A, Vadnais P, Regine WF, Feigenberg SJ. Dosimetric Improvements with a Novel Breast Stereotactic Radiotherapy Device for Delivery of Preoperative Partial-Breast Irradiation. Oncology 2016; 92:21-30. [PMID: 27898429 DOI: 10.1159/000449388] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 08/12/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Partial-breast irradiation (PBI) with external-beam radiotherapy has produced higher than expected rates of fair-to-poor cosmesis. Worsened outcomes have been correlated with larger volumes of breast tissue exposed to radiation. A novel breast-specific stereotactic radiotherapy (BSRT) device (BSRTD) has been developed at our institution and has shown promise in delivering highly conformal dose distributions. We compared normal tissue sparing with this device with that achieved with intensity-modulated radiation therapy (IMRT)-PBI. METHODS Fifteen women previously treated with breast conservation therapy were enrolled on an institutional review board-approved protocol. Each of them underwent CT simulation in the prone position using the BSRTD-specific immobilization system. Simulated postoperative and preoperative treatment volumes were generated based on surgical bed/clip position. Blinded planners generated IMRT-PBI plans and BSRT plans for each set of volumes. These plans were compared based on clinically validated markers for cosmetic outcome and toxicity using a Wilcoxon rank-sum test. RESULTS The BSRT plans consistently reduced the volumes receiving each of several dose levels (Vx) to breast tissue, the chest wall, the lung, the heart, and the skin in both preoperative and postoperative settings (p < 0.05). Preoperative BSRT yielded particularly dramatic improvements. CONCLUSION The novel BSRTD has demonstrated significant dosimetric benefits over IMRT-PBI. Further investigation is currently proceeding through initial clinical trials.
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Affiliation(s)
- James W Snider
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
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Nichols E, Kesmodel SB, Bellavance E, Drogula C, Tkaczuk K, Cohen RJ, Citron W, Morgan M, Staats P, Feigenberg S, Regine WF. Preoperative Accelerated Partial Breast Irradiation for Early-Stage Breast Cancer: Preliminary Results of a Prospective, Phase 2 Trial. Int J Radiat Oncol Biol Phys 2016; 97:747-753. [PMID: 28244410 DOI: 10.1016/j.ijrobp.2016.11.030] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 11/07/2016] [Accepted: 11/19/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE To assess the feasibility of utilizing 3-dimensional conformal accelerated partial-breast irradiation (APBI) in the preoperative setting followed by standard breast-conserving therapy. PATIENTS AND METHODS This was a prospective trial testing the feasibility of preoperative APBI followed by lumpectomy for patients with early-stage invasive ductal breast cancer. Eligible patients had T1-T2 (<3 cm), N0 tumors. Patients received 38.5 Gy in 3.85-Gy fractions delivered twice daily. Surgery was performed >21 days after radiation therapy. Adjuvant therapy was given as per standard of care. RESULTS Twenty-seven patients completed treatment. With a median follow-up of 3.6 years (range, 0.5-5 years), there have been no local or regional failures. A complete pathologic response according to hematoxylin and eosin stains was seen in 4 patients (15%). There were 4 grade 3 seromas. Patient-reported cosmetic outcome was rated as good to excellent in 79% of patients after treatment. CONCLUSIONS Preoperative 3-dimensional conformal radiation therapy-APBI is feasible and well tolerated in select patients with early-stage breast cancer, with no reported local recurrences and good to excellent cosmetic results. The pathologic response rates associated with this nonablative APBI dose regimen are particularly encouraging and support further exploration of this paradigm.
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Affiliation(s)
- Elizabeth Nichols
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland.
| | - Susan B Kesmodel
- Department of Surgical Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Emily Bellavance
- Department of Surgical Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Cynthia Drogula
- Department of Surgical Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Katherine Tkaczuk
- Department of Medical Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Randi J Cohen
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Wendla Citron
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Michelle Morgan
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Paul Staats
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Steven Feigenberg
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - William F Regine
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
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Arnold SM, Kudrimoti M, Dressler EV, Gleason JF, Silver NL, Regine WF, Valentino J. Using low-dose radiation to potentiate the effect of induction chemotherapy in head and neck cancer: Results of a prospective phase 2 trial. Adv Radiat Oncol 2016; 1:252-259. [PMID: 28740895 PMCID: PMC5514161 DOI: 10.1016/j.adro.2016.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 06/20/2016] [Accepted: 06/22/2016] [Indexed: 11/08/2022] Open
Abstract
Purpose Low-dose fractionated radiation therapy (LDFRT) induces effective cell killing through hyperradiation sensitivity and potentiates effects of chemotherapy. We report our second investigation of LDFRT as a potentiator of the chemotherapeutic effect of induction carboplatin and paclitaxel in locally advanced squamous cell cancer of the head and neck (SCCHN). Experimental design Two cycles of induction therapy were given every 21 days: paclitaxel (75 mg/m2) on days 1, 8, and 15; carboplatin (area under the curve 6) day 1; and LDFRT 50 cGy fractions (2 each on days 1, 2, 8, and 15). Objectives included primary site complete response rate; secondary included overall survival, progression-free survival (PFS), disease-specific survival, and toxicity. Results A total of 24 evaluable patients were enrolled. Primary sites included oropharynx (62.5%), larynx (20.8%), oral cavity (8.3%), and hypopharynx (8.3%). Grade 3/4 toxicities included neutropenia (20%), leukopenia (32%), dehydration/hypotension (8%), anemia (4%), infection (4%), pulmonary/allergic rhinitis (4%), and diarrhea (4%). Primary site response rate was 23/24 (95.8%): 15/24 (62.5%) complete response, 8/24 (33.3%) partial response, and 1/24 (4.2%) stable disease. With median follow-up of 7.75 years, 9-year rates for overall survival were 49.4% (95% confidence interval [CI], 30.5-79.9), PFS was 72.2% (CI, 55.3-94.3), and disease-specific survival was 65.4% (44.3-96.4). Conclusion Chemopotentiating LDFRT combined with paclitaxel and carboplatin is effective in SCCHN and provided an excellent median overall survival of 107.2 months, with median PFS not yet reached in this locally advanced SCCHN cohort. This compares favorably to prior investigations and caused fewer grade 3 and 4 toxicities than more intensive, 3-drug induction regimens. This trial demonstrates the innovative use of LDFRT as a potentiator of chemotherapy.
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Affiliation(s)
- Susanne M Arnold
- Department of Internal Medicine, Division of Medical Oncology, University of Kentucky, Markey Cancer Center, Lexington, Kentucky
| | - Mahesh Kudrimoti
- Department of Radiation Medicine, University of Kentucky, Markey Cancer Center, Lexington, Kentucky
| | - Emily V Dressler
- Division of Cancer Biostatistics, University of Kentucky, Markey Cancer Center, Lexington, Kentucky
| | | | | | - William F Regine
- Department of Radiation Oncology, University of Maryland, Baltimore, Maryland
| | - Joseph Valentino
- Department of Otolaryngology Head and Neck Surgery, University of Kentucky, Markey Cancer Center, Lexington, Kentucky
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Huhn JL, Regine WF, Valentino JP, Meigooni AS, Kudrimoti M, Mohiuddin M. Spatially Fractionated GRID Radiation Treatment of Advanced Neck Disease Associated with Head and Neck Cancer. Technol Cancer Res Treat 2016; 5:607-12. [PMID: 17121437 DOI: 10.1177/153303460600500608] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [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: 11/15/2022] Open
Abstract
Advanced nodal disease associated with head and neck cancer warrants aggressive, often multi-modality therapy to maximize local-regional control. The expansion of a novel treatment paradigm developed by our institution includes the addition of a single-fraction of high dose spatially-fractionated radiation (GRID) to a conventional course of treatment. Between 1995 and 2002 a series of 27 patients (median age 65) with bulky N2-3 disease were treated. Median nodal tumor size was 7 cm. Two groups of patients were evaluated. Group 1 (N=14) patients received a median neck dose 69 Gy (range 54–79 Gy) plus GRID treatment. Group 2 (N=13) patients received a median neck dose of 59 Gy (range 54–72 Gy) plus GRID treatment followed by planned neck dissection. Patients were evaluated for local-regional control, pathological response, survival, and morbidity. Median time to follow-up for Group 1 was 10 months (range 3–44 months). Neck control was 93%. Disease specific survival was 50%. Morbidity was limited to soft-tissue related damage and was mild. Median time to follow-up for Group 2 was 38 months (range 5–116 months). Pathologic complete response rate was 85%. Overall neck control rate was 92%. Disease specific survival was 85%. Surgical morbidity was limited to three wound healing complications. GRID treatment may be safely added to conventional treatment management of locally advanced neck disease related to cancer with acceptable morbidity. It may improve pathologic complete response rates in those patients who undergo planned neck dissection, possibly leading to improved survival. In patients with inoperable bulky disease, addition of GRID enhances local-regional control.
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Affiliation(s)
- Jeniffer L Huhn
- University of Kentucky, 800 Rose St. N15, Lexington, KY 40536, USA.
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Affiliation(s)
- William F. Regine
- Department of Radiation Oncology University of Maryland University Center Rm GGK0101 22 South Greene St. Baltimore, MD 21201–1595, USA
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Lin JY, Diwanji TP, Snider JW, Knight N, Regine WF. Cancer Screening Patterns and Concerns in Caregivers of Patients Undergoing Radiation Therapy. J Oncol Pract 2016; 12:e405-12. [PMID: 26931401 DOI: 10.1200/jop.2015.009290] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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 Evolving cancer screening guidelines can confuse the public. Caregivers of patients undergoing radiation oncology may represent a promising outreach target for disseminating and clarifying screening information. We aimed to: (1) determine the incidence of cancer screening in this cohort, and (2) identify barriers to and deficiencies in screening. METHODS We distributed a 21-item survey on cancer screening history and related concerns to caregivers ≥ 18 years old at one urban and two suburban radiation oncology centers. Reported screening habits were compared with American Cancer Society/American Urological Association guidelines for breast, cervical, colon, and prostate cancer. Statistical analysis included Pearson χ(2) tests. RESULTS A total of 209 caregivers (median age, 55.5 years; 146 women) were surveyed. Although 92% had primary care physicians (PCPs), only 58% reported being informed about recommended screening intervals. Participants ≤ 49 years old were less likely to report PCP discussion of cancer screening than older participants (41% and 66%, respectively; P = .006). Ninety-eight respondents (47%) had one or more screening concern(s). Among screening-eligible caregivers, 23 (18%) reported not undergoing regular colonoscopies. Fourteen women (13%) did not have Papanicolaou smears at recommended intervals, and 21 (18%) did not have annual mammograms. Six men (21%) did not undergo annual prostate screening. Decreased recommended screening with colonoscopy and mammography correlated with younger age. CONCLUSION This survey of relatively unexplored caregivers identified cancer screening deficiencies and concerns that might be addressed by targeted interventions. With approximately 60% of patients with cancer receiving radiation therapy, advice in the radiation oncology setting could positively affect cancer screening behaviors in caregivers.
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Affiliation(s)
- Jolinta Y Lin
- University of Maryland Medical Center, and University of Maryland School of Medicine, Baltimore, MD
| | - Tejan P Diwanji
- University of Maryland Medical Center, and University of Maryland School of Medicine, Baltimore, MD
| | - James W Snider
- University of Maryland Medical Center, and University of Maryland School of Medicine, Baltimore, MD
| | - Nancy Knight
- University of Maryland Medical Center, and University of Maryland School of Medicine, Baltimore, MD
| | - William F Regine
- University of Maryland Medical Center, and University of Maryland School of Medicine, Baltimore, MD
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Lin J, Lin MH, Hall A, Zhang B, Singh D, Regine WF. Comparison of bolus electron conformal therapy plans to traditional electron and proton therapy to treat melanoma in the medial canthus. Pract Radiat Oncol 2016; 6:105-9. [DOI: 10.1016/j.prro.2015.09.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 09/22/2015] [Accepted: 09/23/2015] [Indexed: 11/27/2022]
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Hanna A, Boggs DH, Kwok Y, Simard M, Regine WF, Mehta M. What predicts early volumetric edema increase following stereotactic radiosurgery for brain metastases? J Neurooncol 2015; 127:303-11. [DOI: 10.1007/s11060-015-2034-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 12/26/2015] [Indexed: 10/22/2022]
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Li D, Moughan J, Crane C, Hoffman JP, Regine WF, Abrams RA, Safran H, Liu C, Chang P, Freedman GM, Winter KA, Guha C, Abbruzzese JL. RECQ1 A159C Polymorphism Is Associated With Overall Survival of Patients With Resected Pancreatic Cancer: A Replication Study in NRG Oncology Radiation Therapy Oncology Group 9704. Int J Radiat Oncol Biol Phys 2015; 94:554-60. [PMID: 26725729 DOI: 10.1016/j.ijrobp.2015.10.062] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 09/29/2015] [Accepted: 10/29/2015] [Indexed: 11/18/2022]
Abstract
PURPOSE To confirm whether a previously observed association between RECQ1 A159C variant and clinical outcome of resectable pancreatic cancer patients treated with preoperative chemoradiation is reproducible in another patient population prospectively treated with postoperative chemoradiation. METHODS AND MATERIALS Patients were selected, according to tissue availability, from eligible patients with resected pancreatic cancer who were enrolled on the NRG Oncology Radiation Therapy Oncology Group 9704 trial of 5-fluorouacil (5-FU)-based chemoradiation preceded and followed by 5-FU or gemcitabine. Deoxyribonucleic acid was extracted from paraffin-embedded tissue sections, and genotype was determined using the Taqman method. The correlation between genotype and overall survival was analyzed using a Kaplan-Meier plot, log-rank test, and multivariate Cox proportional hazards models. RESULTS In the 154 of the study's 451 eligible patients with evaluable tissue, genotype distribution followed Hardy-Weinberg equilibrium (ie, 37% had genotype AA, 43% AC, and 20% CC). The RECQ1 variant AC/CC genotype carriers were associated with being node positive compared with the AA carrier (P=.03). The median survival times (95% confidence interval [CI]) for AA, AC, and CC carriers were 20.6 (16.3-26.1), 18.8 (14.2-21.6), and 14.2 (10.3-21.0) months, respectively. On multivariate analysis, patients with the AC/CC genotypes were associated with worse survival than patients with the AA genotype (hazard ratio [HR] 1.54, 95% CI 1.07-2.23, P=.022). This result seemed slightly stronger for patients on the 5-FU arm (n=82) (HR 1.64, 95% CI 0.99-2.70, P=.055) than for patients on the gemcitabine arm (n=72, HR 1.46, 95% CI 0.81-2.63, P=.21). CONCLUSIONS Results of this study suggest that the RECQ1 A159C genotype may be a prognostic or predictive factor for resectable pancreatic cancer patients who are treated with adjuvant 5-FU before and after 5-FU-based chemoradiation. Further study is needed in patients treated with gemcitabine to determine whether an association exists.
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Affiliation(s)
- Donghui Li
- Department of Gastrointestinal Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - Jennifer Moughan
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | - Christopher Crane
- Department of Gastrointestinal Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - John P Hoffman
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - William F Regine
- Department of Radiation Oncology, University of Maryland, Baltimore, Maryland
| | | | - Howard Safran
- Brown University Oncology Group, Providence, Rhode Island
| | - Chang Liu
- Department of Gastrointestinal Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ping Chang
- Department of Gastrointestinal Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Gary M Freedman
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kathryn A Winter
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | - Chandan Guha
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, New York
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Ben-Josef E, George A, Regine WF, Abrams R, Morgan M, Thomas D, Schaefer PL, DiPetrillo TA, Fromm M, Small W, Narayan S, Winter K, Griffith KA, Guha C, Williams TM. Glycogen Synthase Kinase 3 Beta Predicts Survival in Resected Adenocarcinoma of the Pancreas. Clin Cancer Res 2015; 21:5612-8. [PMID: 26240274 DOI: 10.1158/1078-0432.ccr-15-0789] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 07/21/2015] [Indexed: 01/06/2023]
Abstract
PURPOSE GSK3β is a protein kinase that can suppress a number of key oncoproteins. We have previously shown in preclinical models of pancreatic ductal adenocarcinoma (PDAC) that inhibition of GSK3β causes stabilization and nuclear translocation of β-catenin, poor differentiation, proliferation, and resistance to radiation. The objective of this study was to determine its utility as a biomarker of clinical outcomes. EXPERIMENTAL DESIGN Automated Quantitative Immunofluorescence Analysis (AQUA) of GSK3β was performed on a tissue microarray with samples from 163 patients treated on RTOG 9704. On the basis of findings in an exploratory cohort, GSK3β was analyzed as a categorical variable using its upper quartile (>Q3) as a cut point. Overall survival (OS) and disease-free survival (DFS) were estimated with the Kaplan-Meier method, and GSK3β groupings were compared using the log-rank test. Univariable and multivariable Cox proportional hazards models were used to determine associations between GSK3β and OS/DFS. RESULTS The 3-year OS rates for GSK3β≤Q3 versus GSK3β >Q3 were 16% (95% confidence intervals; CI, 10%-23%) and 30% (95% CI, 17%-44%), respectively, P = 0.0082. The 3-year DFS rates were 9% (95% CI, 5%-15%) and 20% (95% CI, 9%-33%) respectively, P value = 0.0081. On multivariable analysis, GSK3β was a significant predictor of OS. Patients with GSK3β >Q3 had a 46% reduced risk of dying of pancreatic cancer (HR, 0.54; 95% CI, 0.31-0.96, P value = 0.034). The HR for DFS was 0.65 (95% CI, 0.39-1.07; P value = 0.092). CONCLUSIONS GSK3β expression is a strong prognosticator in PDAC, independent of other known factors such as tumor (T) stage, nodal status, surgical margins and CA19-9. Clin Cancer Res; 21(24); 5612-8. ©2015 AACR.
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Affiliation(s)
| | - Asha George
- Radiation Therapy Oncology Group-Statistical Center, Philadelphia, Pennsylvania
| | | | - Ross Abrams
- Rush University Medical Center, Chicago, Illinois
| | | | - Dafydd Thomas
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Paul L Schaefer
- Toledo Community Hospital Oncology Program CCOP, Toledo, Ohio
| | | | | | | | - Samir Narayan
- Michigan Cancer Research Consortium CCOP, Ann Arbor, Michigan
| | - Kathryn Winter
- Radiation Therapy Oncology Group-Statistical Center, Philadelphia, Pennsylvania
| | | | - Chandan Guha
- Montefiore Medical Center, Moses Campus, Bronx, New York
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