Involved-Field Radiation Therapy for Patients With Unresectable Pancreatic Adenocarcinomas: Failure Pattern Analysis

Introduction Unresectable pancreatic tumors are frequently diagnosed. Initial treatment is carried out with chemotherapy. Eventually, in selected cases, radiotherapy may be used to improve local control rates and relieve the symptoms. The volume of radiotherapy treatment fields is the subject of controversy in the literature. The use of involved fields with the gross tumor volume encompassing the primary tumor and lymph nodes considered clinically positive is associated with a lower rate of side effects, but can lead to a higher rate of regional loco failures, especially in regional lymph nodes. The purpose of this article is to analyze the failure pattern of chemotherapy and involved-field radiation therapy (IFRT) for treating patients with unresectable pancreatic adenocarcinomas. Methods Clinical records of thirty consecutive patients treated from March 2016 to June 2020 for unresectable pancreatic adenocarcinoma were analyzed. The patients were treated with initial systemic chemotherapy (median: 6 cycles) with regimens based on gemcitabine or oxaliplatin-irinotecan (folfirinox/folfox) followed by radiotherapy (total dose of 50-54 Gy/with fractionation of 2 Gy/day). The patients were treated with IFRT. Local failure (LF) was defined as an increase in radiographic abnormality within the planning target volume (PTV). Elective nodal failure (ENF) was defined as recurrence in any lymph node region outside the PTV. Any other failure was defined as distant failure (DF). Results The median age of the patients was 68 years (range: 44-80 years); 20 patients (66.7%) were men, and 11 (36.6%) and 19 (63.4%) patients presented with tumors of stage II and III, respectively. Most patients (63.3%) had tumors in the pancreatic head. The median survival was 17.2 months. Tumor recurrences were classified as LF, DF, LF and DF in 7 (23.3%), 17 (56.7%), and 5 (16.7%) patients, respectively. Only one patient (3.3%) had both LF and ENF. No severe side effects related to radiotherapy were reported. Conclusion The use of IFRT did not cause a significant amount of ENF, besides presenting low morbidity, which is of special importance for patients with locally advanced tumors or low performance status. The predominant failure pattern was distant metastases.

Rationale and value of consolidative cranial local therapy in EGFR-mutant non-small cell lung cancer patients with baseline brain metastasis treated with first-line EGFR-TKIs

Objectives

To explore the rationale and value of consolidative cranial local therapy (CLT) in epidermal growth factor receptor (EGFR)-mutant non-small cell lung cancer (NSCLC) patients with brain metastases (BMs).

Methods

EGFR-mutant NSCLC patients with baseline BMs who received first-line EGFR-tyrosine kinase inhibitors (TKIs) at two academic centers from May 2015 to June 2020 were retrospectively enrolled. Patterns of tumor response and treatment failure were extensively analyzed in order to explore the rationale of CLT. Cranial lesions with number ⩽3 and largest tumor size ⩽3 cm at baseline and best response to EGFR-TKIs were defined as oligo-BMs and oligo-residual cranial disease (ORCD), respectively. To provide preliminary data supporting CLT, survival outcomes were compared in patients with ORCD, stratified by CLT status.

Results

Of the 216 patients enrolled, 57.1% had oligo-BMs and 24.5% received first-line osimertinib. At best response to the first-line EGFR-TKIs, intracranial complete response, partial response, and stable disease occurred in 18.5, 31.9, and 44.4% of the whole population, respectively. For patients without CLT (n = 193), ORCD was observed in 78.1% of the 105 patients with baseline oligo-BMs and 10.2% of the 88 patients with baseline multiple-BMs. With a median follow-up of 22.8 months, 107 patients had cranial first progressive disease (PD); more than 60% developed their first PD solely from the residual tumor sites at best response to EGFR-TKIs. Moreover, among patients with ORCD (n = 108), patients who received CLT (n = 17) achieved significantly longer progression-free survival (13.4 versus 8.5 months, p = 0.001) and overall survival (58.9 versus 28.8 months, p = 0.021) than those without CLT. Meanwhile, CLT remained as an independent prognostic factor associated with improved survival after Cox regression analyses.

Conclusions

Cranial progressive disease developed mostly at the residual cranial lesions in EGFR-mutant NSCLC patients with baseline BMs who received first-line EGFR-TKIs. Consolidative cranial local therapy targeting the oligo-residual cranial tumor lesions may provide survival benefit, which warrants future validation.

Survival Outcomes and Failure Patterns in Patients with Inoperable Non-Metastatic Pancreatic Cancer Treated with Definitive Radiotherapy

This study investigated the long-term results, failure patterns, and prognostic factors of patients with initially inoperable non-metastatic pancreatic cancer (PC) receiving definitive radiotherapy (RT). Between January 2016 and December 2020, a total of 168 non-metastatic PC patients, who were surgically unresectable or medically inoperable, were enrolled to receive definitive RT, with or without chemotherapy. Overall survival (OS) and progression-free survival (PFS) were evaluated using the Kaplan-Meier method with a log-rank test. The cumulative incidence of locoregional and distant progression was estimated using the competing risks model. The Cox proportional-hazards model was used to determine the influence of prognostic variables on OS. With a median follow-up of 20.2 months, the median OS (mOS) and median PFS (mPFS) from diagnosis were 18.0 months [95% confidence interval (CI), 16.5-21.7 months] and 12.3 months (95% CI, 10.2-14.3 months), respectively. The mOS and mPFS from RT were 14.3 months (95% CI, 12.7-18.3 months) and 7.7 months (95% CI, 5.5-12.0 months), respectively. The corresponding 1-year, 2-year, and 3-year OS from diagnosis and RT were 72.1%, 36.6%, and 21.5% as well as 59.0%, 28.8%, and 19.0%, respectively. In a multivariate analysis, stage I-II (p = 0.032), pre-RT CA19-9 ≤ 130 U/mL (p = 0.011), receiving chemotherapy (p = 0.003), and a biologically effective dose (BED₁₀) > 80 Gy (p = 0.014) showed a significant favorable influence on OS. Among the 59 available patients with definite progression sites, the recurrences of local, regional, and distant progression were 33.9% (20/59), 18.6% (11/59), and 59.3% (35/59), respectively. The 1-year and 2-year cumulative incidences of locoregional progression after RT were 19.5% (95% CI, 11.5-27.5%) and 32.8% (95% CI, 20.8-44.8%), respectively. Definitive RT was associated with long-term primary tumor control, resulting in superior survival in patients with inoperable non-metastatic PC. Further prospective randomized trials are warranted to validate our results in these patients.

Dentate line invasion as a predictive factor of poor distant relapse-free survival in locally advanced lower rectal cancer with anal sphincter involvement

Background

While an important surgical landmark of the dentate line has been established for locally advanced lower rectal cancer (LALRC), the prognostic significance of dentate line invasion (DLI) has not been well defined. This study aimed to explore the impact of DLI on prognosis in LALRC patients with anal sphincter involvement after neoadjuvant chemoradiotherapy followed by surgery.

Methods

We analyzed 210 LALRC patients and classified them into DLI group (n = 45) or non-DLI group (n = 165). The exact role of DLI in survival and failure patterns was assessed before and after propensity-score matching(PSM). Finally, 50 patients were matched.

Results

Before matching, patients in the DLI group had poorer 5-year distant relapse-free survival (DRFS) (P < 0.001), disease-free survival (DFS) (P < 0.001), and overall survival (OS) (P = 0.022) than those in the non-DLI group, with the exception of local recurrence-free survival (LRFS) (P = 0.114). After PSM, the 5-year DRFS, DFS, OS, and LRFS were 51.7% vs. 79.8%(P = 0.026), 51.7% vs. 79.8%(P = 0.029), 71.6% vs. 85.4%(P = 0.126), and 85.7% vs. 92.0%(P = 0.253), respectively, between the two groups. DLI was also an independent prognostic factor for poor DRFS with (Hazard ratio [HR] 3.843, P = 0.020) or without matching (HR 2.567, P = 0.001). The DLI group exhibited a higher rate of distant metastasis before (44.4% vs. 19.4%, P < 0.001) and after matching (48.0% vs. 20.0%, P = 0.037) and similar rates of locoregional recurrence before (13.3% vs.7.9%, P = 0.729) and after matching (16.0% vs.12.0%, P = 1.000).

Conclusions

DLI may portend worse DRFS and distant metastasis in LALRC patients with anal sphincter involvement, and this may be an important variable to guide clinicians.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-10299-8.

The Failure Patterns of Nasopharygeal Carcinoma After Intensity-Modulated Radiotherapy and Implications for Surveillance

Objective

To investigate the treatment outcomes, failure patterns and surveillance strategy in patients with nasopharyngeal carcinoma (NPC) after intensity-modulated radiotherapy (IMRT).

Methods

A cohort of patients with NPC who had received the full course of IMRT between 2008 and 2012 were retrospectively analyzed. The failure patterns, time to recurrence, and detection methods were recorded. The survival was calculated using the Kaplan–Meier method. Multivariate proportional hazard regression models were used to test the prognostic factors.

Results

In total, 2607 patients with NPC treated with IMRT were recruited. After the median follow-up of 112 months, 402 (15.4%) patients experienced distant metastasis, 225 (8.6%) patients had local recurrence, and 77 (3.0%) patients had regional recurrences. The 10-year overall survival (OS), local recurrence-free survival (LRFS), and distant metastasis-free survival (DMFS) rates were 74.5%, 90.1%, and 79.3%, respectively. The factors of male sex, age >50 years, lactate dehydrogenase >245 IU/L, advanced T classification, and advanced N classification were associated with poor OS. The N disease classification was the most important factor in predicting distant metastasis, and advanced T disease classification for high risk of local recurrence. For patients with T1 disease, the incidence of local recurrence was less than 2%, and the incidence of distant metastasis was less than 5% for patients with N0 disease. About 83% of the recurrence occurred in the first 5 years, and 20% of the recurrences showed no symptoms.

Conclusion

High rate of local-regional control can be achieved for patients with NPC after IMRT, while distant metastasis remains as the major cause of failures. Patients with advanced N classification has high risk to develop distant metastasis, and most occurred within 5 years. Developing rational and individualized surveillance strategies based on the high risk factors of recurrence is helpful to balance the survival benefit and medical cost.

Patterns of Failure in Patients With Advanced Non-Small Cell Lung Cancer Treated With Immune Checkpoint Inhibitors

Objective

The advent of immune checkpoint inhibitors (ICIs) has rapidly transformed the treatment paradigm of non-small cell lung cancer (NSCLC). Despite the durability of response to ICIs, the vast majority of patients will later develop progression. However, the failure patterns of ICI treatment are unknown. Here, our study explored the failure patterns in advanced NSCLC patients treated with ICIs.

Methods

A cohort of 156 IIIB or IV NSCLC patients treated with first-/second-line ICIs were retrospectively analyzed. Patients who experienced clinical benefit and then developed progression were identified. The disease progression patterns were divided into three categories: progression in new sites, progression in existing sites, and combined progression. The number of progression sites was also recorded.

Results

Before the cutoff date, 91 (77.1%) patients had experienced disease progression; 34% of patients had progressed in the last 9 months of the first year. Fifty-three (58.2%) patients had developed progression at existing lesions, and 56 (61.5%) patients had shown ≤2 progression sites (oligo-progression). In patients with oligo-progression, the median time of disease progression was 8.23 months and the counterpart (systemic progression) was 5.97 months. The oligo-progression patients showed prolonged median overall survival (27.23 months) compared with patients with systemic progression (18.87 months).

Conclusions

Failure patterns of ICI therapy were predominantly “existing” sites, and the most common lesions of progression were the lung and lymph nodes. Most patients experienced oligo-progression which occurred later than systemic progression and showed prolonged overall survival. The control of the local lesions might be beneficial to improve ICI treatment efficacy.

Assessing failure patterns of radical intent radiation strategies in patients with locally advanced carcinoma of the esophagus

BACKGROUND

Patterns of failure following definitive CRT (dCRT) are different as compared to neoadjuvant chemoradiotherapy (NACRT) with increased locoregional failures documented with dCRT.

AIM

To document failure patterns in patients with esophageal carcinoma treated with neoadjuvant and definitive intent radiation strategies.

METHODS

Subjects were 123 patients treated with two chemoradiotherapy strategies. Group 1 (n = 99) underwent dose escalated definitive chemoradiotherapy (dCRT), Group 2 (n = 24) received neoadjuvant chemoradiotherapy (NACRT) followed by surgery. Cumulative incidence of locoregional failure (LRF), local failure (LF), regional lymph node failure (RLNF), and distant metastasis (DM) were computed; differences between the groups was evaluated using log rank test. Univariable and multivariable predictors of failure were identified using Cox regression analysis.

RESULTS

Cumulative LRF: 64% in Group 1 vs 35% in Group 2 (P = .050). Cumulative LF: 59% in Group 1 vs 12% in Group 2 (P = .000). Cumulative RLNF: 30% in Group 1 vs 24% in Group 2 (P = .592). Most common RLNF: mediastinum for both groups (6% vs 12.5%, respectively). Distant metastasis: 40.4% Group 1 vs 17% Group 2 (P = .129), predominantly lung (Group 1, 5%), and nonregional nodes (Group 2, 8.3%). Univariate analysis identified age ≤50, absence of concurrent chemotherapy, dose ≤50 Gy, and incomplete radiotherapy to predict higher odds of LRF and DM for Group 1; absence of comorbidities predicted for lower odds of LRF for Group 2. Age ≤50 predicted for higher odds of RNLR for Group 1, while absence of comorbidities predicted for lower odds of RNLR in Group 2. Multivariate analysis identified age ≤50, incomplete radiotherapy, and absence of concurrent chemotherapy to predict higher odds of LRF for Group 1. Age ≤50, absence of concurrent chemotherapy predicted higher odds of DM for Group 1. Absence of comorbidity predicted lower odds of LRF in Group 2.

CONCLUSION

LRF is common in both groups, with LF being predominant in dCRT as opposed to RNLF in NACRT. Age ≤50, absence of concurrent chemotherapy is a predictor of LRF and DM in dCRT.

Learning from Failure: Big Data Analysis for Detecting the Patterns of Failure in Innovative Startups

This article aims at identifying appropriate models for analyzing large datasets to serve a twofold goal: first, to better understand the dynamics impacting innovative startups' performance and their managerial practice and, second, to detect their patterns of failure. Therefore, we investigate the interaction of economic-financial, context, and governance dimensions of 4185 Italian innovative startups created from 2012 to 2015. Once startups have been grouped, we focus only on those that are unsuccessful. Then, failure patterns have been uncovered, integrating the use of factor and cluster analysis, where factor scores for each firm are used to identify a set of homogeneous groups based on clustering methods. The integrated use of those large-dimensional data techniques permits to classify items in rigorous ways and to unfold structures of the data, which are not apparent in the beginning. The analysis suggests that each pattern of failure is a multidimensional construct and, as a consequence can generate different managerial implications. Therefore, an effective handling of failure requires management to use appropriate interventions targeted at the challenges faced by that particular pattern of failure in the age of different firms.

Experimental Study on Dynamic Splitting Characteristics of Carbon Fiber Reinforced Concrete

Due to the non-uniform tension and compression strength of concrete, carbon fiber can be added to concrete to improve its static tensile behavior and increase the tension–compression ratio. In view of the destructive consequences of impacts and explosions, it is necessary to study the dynamic responses of carbon fiber reinforced concrete (CFRC) structures. Therefore, the effects of the stress rates and carbon fiber contents on the dynamic tension behavior of CFRC were investigated in this paper. The dynamic splitting tests of concrete with the fiber contents of 0, 0.1, 0.2, and 0.3% were carried out by using a split Hopkinson pressure bar (SHPB) device with a diameter of 74 mm. We found that with the increase of fiber content, the static tensile strength of CFRC increases obviously, but the increased amplitude tends to decrease. The dynamic tensile strength and dynamic increase factor (DIF) both increase with the increase of stress rate, but the growth rate slows down, showing an obvious rate effect. The rate sensitivity of ordinary concrete is higher than CFRC. There are significant differences in the influence of carbon fiber on the dynamic and static strength of concrete. In the design of concrete mixing proportion, the content of carbon fiber should be appropriately selected to meet the requirements of dynamic and static mechanical properties.

Risk factors and patterns of lymph node involvement in primary gastric large B-cell lymphoma: implications for target definition

Background

The aim of this study was to identify the appropriate radiation volume for primary gastric diffuse large B-cell lymphoma (PG-DLBCL).

Methods

We retrospectively analyzed the clinical and pathological findings of 68 patients treated with total gastrectomy and D2 lymphadenectomy.

Results

There were 23, 14, and 29 patients with stage I, stage II, and stage IIE disease, respectively, and 30 patients had lymph node involvement. Primary tumor location, as well as the depth of invasion, was significantly associated with lymph node involvement. When the tumor was limited to the muscularis, the involved lymph nodes were found to be perigastric nodes. For tumors invading beyond the muscularis, regional lymph nodes were involved.

Conclusion

The optimal radiation volume for patients with PG-DLBCL is largely dependent on the primary location and depth of invasion. Larger series and longer follow-up are needed to further delineate the radiation volumes for PG-DLBCL.

Details of out-field regional recurrence after involved-field irradiation with concurrent chemotherapy for locally advanced esophageal squamous cell carcinoma

Background

The purpose of this study was to describe the patterns of out-field regional recurrence after involved-field irradiation (IFI) in definitive concurrent chemoradiotherapy (CCRT) for locally advanced esophageal squamous cell carcinoma (LA-ESCC) and identify the possible risk factors.

Patients and methods

Eighty patients with LA-ESCC who received CCRT with IFI between January 2003 and January 2009 at the Shandong Cancer Hospital were recruited and analyzed. Imaging scans demonstrating first sites of failure were compared with original computed tomography-based radiation treatment plans, and failure patterns were defined as in-field, outfield regional (failures in initially uninvolved regional nodes), and distant failures.

Results

After a median follow-up time of 52.6 months, 24 patients had evidence of out-field regional failure, 43 patients had evidence of in-field failure, and 33 patients had the evidence of distant failure. Multivariate analysis revealed that out-field regional failure was associated with clinical tumor status (T4 vs T1–3, odds ratio [OR] =6.547, P=0.002), tumor length (>8 cm vs ≤8 cm, OR =4.130, P=0.036), response to CCRT (complete response vs no complete response, OR =2.646, P=0.035), and in-field failure (no in-field failure vs in-field failure, OR =1.32, P=0.016). Survival analyses indicated that, compared to in-field failure or distant failure alone group, out-field regional failure alone group tended to have longer overall (P=0.006) and progression-free survival (P=0.164).

Conclusion

Our data suggested that the predominant failure pattern after IFI was not out-field regional failure, which also did not influence survival significantly, and that out-field regional failure did not shorten the time to disease recurrence, which also did not influence survival significantly. In addition, out-field regional failure was likely to appear later than in-field and distant failures. The relatively advanced local disease followed by poor local control and distant metastases contributed more to the poor outcome of LA-ESCC. Further prospective studies are needed to verify the findings of this study.

Failure patterns in patients with esophageal cancer treated with definitive chemoradiation

BACKGROUND

Local failure after definitive chemoradiation therapy for unresectable esophageal cancer remains problematic. Little is known about the failure pattern based on modern-day radiation treatment volumes. We hypothesized that most local failures would be within the gross tumor volume (GTV), where the bulk of the tumor burden resides.

METHODS

We reviewed treatment volumes for 239 patients who underwent definitive chemoradiation therapy and compared this information with failure patterns on follow-up positron emission tomography (PET). Failures were categorized as within the GTV, the larger clinical target volume (CTV, which encompasses microscopic disease), or the still larger planning target volume (PTV, which encompasses setup variability) or outside the radiation field.

RESULTS

At a median follow-up time of 52.6 months (95% confidence interval, 46.1-56.7 months), 119 patients (50%) had experienced local failure, 114 (48%) had distant failure, and 74 (31%) had no evidence of failure. Of all local failures, 107 (90%) were within the GTV, 27 (23%) were within the CTV, and 14 (12%) were within in the PTV. On multivariate analysis, GTV failure was associated with tumor status (T3/T4 vs T1/T2; odds ratio, 6.35; P = .002), change in standardized uptake value on PET before and after treatment (decrease >52%: odds ratio, 0.368; P = .003), and tumor size (>8 cm, 4.08; P = .009).

CONCLUSIONS

Most local failures after definitive chemoradiation for unresectable esophageal cancer occur in the GTV. Future therapeutic strategies should focus on enhancing local control.