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Thor M, Shepherd AF, Apte A, Gelblum D, Wu AJ, Simone CB, Chaft J, Rimner A, Gomez DR, Deasy JO, Shaverdian N. A Novel FDG PET and Mean Lung Dose Model to Identify Stage III NSCLC Patients at High Risk of Developing Early Radiation Pneumonitis. Int J Radiat Oncol Biol Phys 2023; 117:S169. [PMID: 37784422 DOI: 10.1016/j.ijrobp.2023.06.271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Early radiation pneumonitis (RPEarly) is a primary reason for the premature discontinuation of durvalumab consolidation and can lead to poor survival in patients with stage III non-small cell lung cancer (NSCLC). Currently, there are no RP risk models specifically tested for RPEarly. Here, we tested the applicability of published RP models for predicting RPEarly and explored the value of integrating pretreatment FDG-PET parameters. MATERIALS/METHODS The cohort consisted of all 178 LA-NSCLC patients treated with concurrent chemoradiation (cCRT) and durvalumab between May 2017 and December 2021. RPEarly was defined as RP occurring within three months of cCRT completion; late RP (RPLate) was defined as any later occurring RP. The three published RP models analyzed included: 1) Mean lung dose (MLD), 2) MLD, age, pulmonary comorbidity, smoking status, and tumor location, and 3) MLD, age and pulmonary comorbidity. In addition, pretreatment FDG PET-CT scans were used to calculate SUV parameters from auto-segmented normal lung contours: 10th- and 90th percentile (SUVP10, SUVP90), maximum, mean (SUVmean), minimum, and standard deviation. The RP models were fit to RPEarly, RPLate, and RPEarly+Late in the 178 patients. To assess the association between FDG PET parameters and RP unbiasedly, the cohort was then randomly split, but enforcing similar RP rates, into a two-thirds derivation and a one-third validation subset. Model performance was assessed by AUC, p-values and the Hosmer-Lemeshow test (pHL; ideally ∼0.50). RESULTS The rates of RPEarly, RPLate, and RPEarly+Late were 12%, 11%, and 23%, respectively (corresponding to 21, 20, and 41 events). Only the MLD model significantly predicted RPEarly (AUC = 0.70; p = 0.04; pHL = 0.84); none of the three models predicted RPLate or RPEarly+Late. Among the FDG PET parameters, SUVP10, SUVP90 and SUVmean predicted RPEarly with similar performance (AUC = 0.69-0.73; p = 0.005-0.01; pHL = 0.68-0.72), and, therefore, bivariate models were built between MLD and each of SUVP10, SUVP90 and SUVmean. Only the MLD + SUVP90 model generalized in the validation subset (AUC = 0.63; p = 0.03; pHL = 0.89) and was thus deemed the final model for RPEarly. A final re-fitting of all model coefficients to the whole cohort indicated improvement over using the published MLD alone model (AUC = 0.75 vs. 0.70; p-value = 0.0006 vs. 0.04; pHL = 0.67 vs. 0.84). Risk of RPEarly is thus estimated as: RPEarly = 1/(1 = e-x); x = -5.79 + (1.57*MLD) + (0.14* SUVP90). CONCLUSION Patients at risk for RPEarly can be accurately identified prior to treatment by combining a re-fitted version of the published Mean Lung Dose model and pre-treatment FDG PET SUVP90 of the normal lung. This refined model can be used to identify patients with an exacerbated risk for premature durvalumab discontinuation due to RPEarly and could allow for interventions and/or the generation of "RPEarly sparing" treatment plans to improve overall treatment outcomes.
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Dee EC, Swami N, Li BT, Florez N, Gomez DR. Disparities in Stage at Presentation among Hispanic and Latinx Patients with Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2023; 117:e14. [PMID: 37784710 DOI: 10.1016/j.ijrobp.2023.06.677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Hispanic and Latinx people in the United States comprise 19% of the population and are the fastest-growing ethnic group. However, prior studies in non-small cell lung cancer (NSCLC) often analyze these diverse communities in aggregate. We aimed to identify differences in NSCLC stage at diagnosis in the US population, with a particular focus on disaggregated Hispanic populations. MATERIALS/METHODS Data from the National Cancer Database (NCDB) from 2004 to 2018 were used to identify patients with primary NSCLC. Individuals were disaggregated by racial and ethnic subgroup and Hispanic country of origin. Ordinal logistic regression adjusting for age, facility type, income, educational attainment, comorbidity index, insurance, and year of diagnosis was used to create adjusted odds ratios (aORs), with higher odds representing diagnosis at later-stage NSCLC. RESULTS Out of 1,773,177 patients with NSCLC, 50,512 were Hispanic/Latinx (2.8%). Hispanic patients were less likely to be insured (χ2 P<0.001) and were more likely to live in lower-income ZIP codes (χ2 P<0.001). Hispanic patients were more likely to be diagnosed with metastatic disease compared to non-Hispanic White (NHW) patients: 47% for Hispanic Black (HB), 46% Hispanic White (HW), and 44.3% of Hispanic other (HO) patients vs. 39.1% of NHW patients (aORs for later-stage disease with NHW as reference: HW 1.23, HB 1.26, HO 1.14, P<0.001 for all). Upon disaggregation by country of origin, 51.4% of Mexican, 41.7% of Puerto Rican, 44.6% of Cuban, 50.8% of South or Central American, 48.4% of Dominican, and 45.6% of Other Hispanic patients were diagnosed with metastatic disease, compared with 39.1% of NHW patients. Conversely, 20.2% of Mexican, 26.9% of Puerto Rican, 24.2% of Cuban, 22.5% of South or Central American, 23.7% of Dominican, and 24.5% of Other Hispanic patients were diagnosed with stage I disease, compared with 30.0% of NHW patients. On multivariable analysis, all Hispanic groups were more likely to present with later-stage NSCLC than NHW patients, with the greatest odds for Mexican patients (aOR 1.45, P<0.001). CONCLUSION Hispanic/Latinx patients with non-small cell lung cancer were more likely to be diagnosed with more advanced disease compared with non-Hispanic White patients. Disparities persisted upon disaggregation by both race and country of origin, with over half of Mexican patients with metastatic disease at diagnosis. Disparities amongst Hispanic groups by race and by country of origin highlight the shortcomings of treating these groups as a monolith and underscore the need for disaggregated research and targeted interventions. Further work should explore differences in exposures, behaviors, and access to care that may underlie these disparities.
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Lebow ES, Shaverdian N, Eichholz JE, Kratochvil LB, McCune M, Murciano-Goroff YR, Jee J, Eng J, Chaft JE, Kris MG, Kalashnikova E, Feeney J, Scalise CB, Sudhaman S, Palsuledesai CC, Malhotra M, Krainock M, Sethi H, Aleshin A, Liu MC, Shepherd AF, Wu AJ, Simone CB, Gelblum DY, Johnson KA, Rudin CM, Gomez DR, Razavi P, Reis-Filho JS, Isbell JM, Li BT, Rimner A. ctDNA-based detection of molecular residual disease in stage I-III non-small cell lung cancer patients treated with definitive radiotherapy. Front Oncol 2023; 13:1253629. [PMID: 37795442 PMCID: PMC10546425 DOI: 10.3389/fonc.2023.1253629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 08/24/2023] [Indexed: 10/06/2023] Open
Abstract
Background Sensitive and reliable biomarkers for early detection of recurrence are needed to improve post-definitive radiation risk stratification, disease management, and outcomes for patients with unresectable early-stage or locally advanced non-small cell lung cancer (NSCLC) who are treated with definitive radiation therapy (RT). This prospective, multistate single-center, cohort study investigated the association of circulating tumor DNA (ctDNA) status with recurrence in patients with unresectable stage I-III NSCLC who underwent definitive RT. Methods A total of 70 serial plasma samples from 17 NSCLC patients were collected before, during, and after treatment. A personalized, tumor-informed ctDNA assay was used to track a set of up to 16 somatic, single nucleotide variants in the associated patient's plasma samples. Results Pre-treatment ctDNA detection rate was 82% (14/17) and varied based on histology and stage. ctDNA was detected in 35% (6/17) of patients at the first post-RT timepoint (median of 1.66 months following the completion of RT), all of whom subsequently developed clinical progression. At this first post-RT time point, patients with ctDNA-positivity had significantly worse progression-free survival (PFS) [hazard ratio (HR): 24.2, p=0.004], and ctDNA-positivity was the only significant prognostic factor associated with PFS (HR: 13.4, p=0.02) in a multivariate analysis. All patients who developed clinical recurrence had detectable ctDNA with an average lead time over radiographic progression of 5.4 months, and post-RT ctDNA positivity was significantly associated with poor PFS (p<0.0001). Conclusion Personalized, longitudinal ctDNA monitoring can detect recurrence early in patients with unresectable NSCLC patients undergoing curative radiation and potentially risk-stratify patients who might benefit most from treatment intensification.
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Iyengar P, All S, Berry MF, Boike TP, Bradfield L, Dingemans AMC, Feldman J, Gomez DR, Hesketh PJ, Jabbour SK, Jeter M, Josipovic M, Lievens Y, McDonald F, Perez BA, Ricardi U, Ruffini E, De Ruysscher D, Saeed H, Schneider BJ, Senan S, Widder J, Guckenberger M. Treatment of Oligometastatic Non-Small Cell Lung Cancer: An ASTRO/ESTRO Clinical Practice Guideline. Pract Radiat Oncol 2023; 13:393-412. [PMID: 37294262 DOI: 10.1016/j.prro.2023.04.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 04/07/2023] [Indexed: 06/10/2023]
Abstract
PURPOSE This joint guideline by American Society for Radiation Oncology (ASTRO) and the European Society for Radiotherapy and Oncology (ESTRO) was initiated to review evidence and provide recommendations regarding the use of local therapy in the management of extracranial oligometastatic non-small cell lung cancer (NSCLC). Local therapy is defined as the comprehensive treatment of all known cancer-primary tumor, regional nodal metastases, and metastases-with definitive intent. METHODS ASTRO and ESTRO convened a task force to address 5 key questions focused on the use of local (radiation, surgery, other ablative methods) and systemic therapy in the management of oligometastatic NSCLC. The questions address clinical scenarios for using local therapy, sequencing and timing when integrating local with systemic therapies, radiation techniques critical for oligometastatic disease targeting and treatment delivery, and the role of local therapy for oligoprogression or recurrent disease. Recommendations were based on a systematic literature review and created using ASTRO guidelines methodology. RESULTS Based on the lack of significant randomized phase 3 trials, a patient-centered, multidisciplinary approach was strongly recommended for all decision-making regarding potential treatment. Integration of definitive local therapy was only relevant if technically feasible and clinically safe to all disease sites, defined as 5 or fewer distinct sites. Conditional recommendations were given for definitive local therapies in synchronous, metachronous, oligopersistent, and oligoprogressive conditions for extracranial disease. Radiation and surgery were the only primary definitive local therapy modalities recommended for use in the management of patients with oligometastatic disease, with indications provided for choosing one over the other. Sequencing recommendations were provided for systemic and local therapy integration. Finally, multiple recommendations were provided for the optimal technical use of hypofractionated radiation or stereotactic body radiation therapy as definitive local therapy, including dose and fractionation. CONCLUSIONS Presently, data regarding clinical benefits of local therapy on overall and other survival outcomes is still sparse for oligometastatic NSCLC. However, with rapidly evolving data being generated supporting local therapy in oligometastatic NSCLC, this guideline attempted to frame recommendations as a function of the quality of data available to make decisions in a multidisciplinary approach incorporating patient goals and tolerances.
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Rimner A, Moore ZR, Lobaugh S, Geyer A, Gelblum DY, Abdulnour REE, Shepherd AF, Shaverdian N, Wu AJ, Cuaron J, Chaft JE, Zauderer MG, Eng J, Riely GJ, Rudin CM, Vander Els N, Chawla M, McCune M, Li H, Jones DR, Sopka DM, Simone CB, Mak R, Weinhouse GL, Liao Z, Gomez DR, Zhang Z, Paik PK. Randomized Phase 2 Placebo-Controlled Trial of Nintedanib for the Treatment of Radiation Pneumonitis. Int J Radiat Oncol Biol Phys 2023; 116:1091-1099. [PMID: 36889516 PMCID: PMC10751877 DOI: 10.1016/j.ijrobp.2023.02.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 01/08/2023] [Accepted: 02/15/2023] [Indexed: 03/09/2023]
Abstract
PURPOSE Radiation pneumonitis (RP) is the most common dose-limiting toxicity for thoracic radiation therapy. Nintedanib is used for the treatment of idiopathic pulmonary fibrosis, which shares pathophysiological pathways with the subacute phase of RP. Our goal was to investigate the efficacy and safety of nintedanib added to a prednisone taper compared with a prednisone taper alone in reducing pulmonary exacerbations in patients with grade 2 or higher (G2+) RP. METHODS AND MATERIALS In this phase 2, randomized, double-blinded, placebo-controlled trial, patients with newly diagnosed G2+ RP were randomized 1:1 to nintedanib or placebo in addition to a standard 8-week prednisone taper. The primary endpoint was freedom from pulmonary exacerbations at 1 year. Secondary endpoints included patient-reported outcomes and pulmonary function tests. Kaplan-Meier analysis was used to estimate the probability of freedom from pulmonary exacerbations. The study was closed early due to slow accrual. RESULTS Thirty-four patients were enrolled between October 2015 and February 2020. Of 30 evaluable patients, 18 were randomized to the experimental Arm A (nintedanib + prednisone taper) and 12 to the control Arm B (placebo + prednisone taper). Freedom from exacerbation at 1 year was 72% (confidence interval, 54%-96%) in Arm A and 40% (confidence interval, 20%-82%) in Arm B (1-sided, P = .037). In Arm A, there were 16 G2+ adverse events possibly or probably related to treatment compared with 5 in the placebo arm. There were 3 deaths during the study period in Arm A due to cardiac failure, progressive respiratory failure, and pulmonary embolism. CONCLUSIONS There was an improvement in pulmonary exacerbations by the addition of nintedanib to a prednisone taper. Further investigation is warranted for the use of nintedanib for the treatment of RP.
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Alessi JV, Ricciuti B, Wang X, Pecci F, Di Federico A, Lamberti G, Elkrief A, Rodig SJ, Lebow ES, Eicholz JE, Thor M, Rimner A, Schoenfeld AJ, Chaft JE, Johnson BE, Gomez DR, Awad MM, Shaverdian N. Impact of TMB/PD-L1 expression and pneumonitis on chemoradiation and durvalumab response in stage III NSCLC. Nat Commun 2023; 14:4238. [PMID: 37454214 PMCID: PMC10349822 DOI: 10.1038/s41467-023-39874-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 06/29/2023] [Indexed: 07/18/2023] Open
Abstract
Although concurrent chemoradiation (CRT) and durvalumab consolidation has become a standard treatment for stage III non-small cell lung cancer (NSCLC), clinicopathologic and genomic factors associated with its efficacy remain poorly characterized. Here, in a multi-institutional retrospective cohort study of 328 patients treated with CRT and durvalumab, we identify that very high PD-L1 tumor proportion score (TPS) expression ( ≥ 90%) and increased tumor mutational burden (TMB) are independently associated with prolonged disease control. Additionally, we identify the impact of pneumonitis and its timing on disease outcomes among patients who discontinue durvalumab: compared to patients who experienced early-onset pneumonitis ( < 3 months) leading to durvalumab discontinuation, patients with late-onset pneumonitis had a significantly longer PFS (12.7 months vs not reached; HR 0.24 [95% CI, 0.10 to 0.58]; P = 0.001) and overall survival (37.2 months vs not reached; HR 0.26 [95% CI, 0.09 to 0.79]; P = 0.017). These findings suggest that opportunities exist to improve outcomes in patients with lower PD-L1 and TMB levels, and those at highest risk for pneumonitis.
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Ricciuti B, Elkrief A, Alessi J, Wang X, Li Y, Gupta H, Muldoon DM, Bertram AA, Pecci F, Lamberti G, Federico AD, Barrichello A, Vaz VR, Gandhi M, Lee E, Shapiro GI, Park H, Nishino M, Lindsay J, Felt KD, Sharma B, Cherniack AD, Rodig S, Gomez DR, Shaverdian N, Rakaee M, Bandlamudi C, Ladanyi M, Janne PA, Schoenfeld AJ, Sholl LM, Awad MM, Cheng ML. Clinicopathologic, Genomic, and Immunophenotypic Landscape of ATM Mutations in Non-Small Cell Lung Cancer. Clin Cancer Res 2023; 29:2540-2550. [PMID: 37097610 PMCID: PMC11031845 DOI: 10.1158/1078-0432.ccr-22-3413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 03/09/2023] [Accepted: 04/20/2023] [Indexed: 04/26/2023]
Abstract
PURPOSE ATM is the most commonly mutated DNA damage and repair gene in non-small cell lung cancer (NSCLC); however, limited characterization has been pursued. EXPERIMENTAL DESIGN Clinicopathologic, genomic, and treatment data were collected for 5,172 patients with NSCLC tumors which underwent genomic profiling. ATM IHC was performed on 182 NSCLCs with ATM mutations. Multiplexed immunofluorescence was performed on a subset of 535 samples to examine tumor-infiltrating immune cell subsets. RESULTS A total of 562 deleterious ATM mutations were identified in 9.7% of NSCLC samples. ATM-mutant (ATMMUT) NSCLC was significantly associated with female sex (P = 0.02), ever smoking status (P < 0.001), non-squamous histology (P = 0.004), and higher tumor mutational burden (DFCI, P < 0.0001; MSK, P < 0.0001) compared with ATM-wild-type (ATMWT) cases. Among 3,687 NSCLCs with comprehensive genomic profiling, co-occurring KRAS, STK11, and ARID2 oncogenic mutations were significantly enriched among ATMMUT NSCLCs (Q < 0.05), while TP53 and EGFR mutations were enriched in ATMWT NSCLCs. Among 182 ATMMUT samples with ATM IHC, tumors with nonsense, insertions/deletions, or splice site mutations were significantly more likely to display ATM loss by IHC (71.4% vs. 28.6%; P < 0.0001) compared with tumors with only predicted pathogenic missense mutations. Clinical outcomes to PD-(L)1 monotherapy (N = 1,522) and chemo-immunotherapy (N = 951) were similar between ATMMUT and ATMWT NSCLCs. Patients with concurrent ATM/TP53 mutations had significantly improved response rate and progression-free survival with PD-(L)1 monotherapy. CONCLUSIONS Deleterious ATM mutations defined a subset of NSCLC with unique clinicopathologic, genomic, and immunophenotypic features. Our data may serve as resource to guide interpretation of specific ATM mutations in NSCLC.
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Lengel HB, Mastrogiacomo B, Connolly JG, Tan KS, Liu Y, Fick CN, Dunne EG, He D, Lankadasari MB, Satravada BA, Sun Y, Kundra R, Fong C, Smith S, Riely GJ, Rudin CM, Gomez DR, Solit DB, Berger MF, Li BT, Mayo MW, Matei I, Lyden DC, Adusumilli PS, Schultz N, Sanchez-Vega F, Jones DR. Genomic mapping of metastatic organotropism in lung adenocarcinoma. Cancer Cell 2023; 41:970-985.e3. [PMID: 37084736 PMCID: PMC10391526 DOI: 10.1016/j.ccell.2023.03.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 02/02/2023] [Accepted: 03/22/2023] [Indexed: 04/23/2023]
Abstract
We analyzed 2,532 lung adenocarcinomas (LUAD) to identify the clinicopathological and genomic features associated with metastasis, metastatic burden, organotropism, and metastasis-free survival. Patients who develop metastasis are younger and male, with primary tumors enriched in micropapillary or solid histological subtypes and with a higher mutational burden, chromosomal instability, and fraction of genome doublings. Inactivation of TP53, SMARCA4, and CDKN2A are correlated with a site-specific shorter time to metastasis. The APOBEC mutational signature is more prevalent among metastases, particularly liver lesions. Analyses of matched specimens show that oncogenic and actionable alterations are frequently shared between primary tumors and metastases, whereas copy number alterations of unknown significance are more often private to metastases. Only 4% of metastases harbor therapeutically actionable alterations undetected in their matched primaries. Key clinicopathological and genomic alterations in our cohort were externally validated. In summary, our analysis highlights the complexity of clinicopathological features and tumor genomics in LUAD organotropism.
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Walch H, Skakodub A, Tringale KR, Vasudevan HN, Eichholz J, Kelly DW, Lebow E, Moss NS, Yu KKH, Li BT, Mueller B, Khan A, Yu Y, Powell S, Reis-Filho JS, Imber BS, Razavi P, Gomez DR, Schultz N, Pike LR. Abstract 6063: Genomic characterization of non-small cell lung cancer (NSCLC) brain metastasis (BM) patients identifies novel alterations associated with tropisms and disease progression. Cancer Res 2023. [DOI: 10.1158/1538-7445.am2023-6063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
Abstract
Intro: Half of all patients with NSCLC develop BM during their clinical course. While modern NSCLC-directed agents yield excellent systemic response, most patients require focal BM treatment. Prior reports of BM genomics have been limited by low numbers and a lack of matched specimens. Here, we report the largest cohort to date of molecularly-profiled NSCLC BM samples with comprehensive clinical follow-up.
Methods: Clinical data and outcomes for 244 patients with NSCLC and resected BM were identified. Samples were assessed using MSK-IMPACT, a custom tumor-normal next generation sequencing assay. 51 (20.9%) patients had matched primary site tissue, and 44 (18%) patients had matched tissue from another metastatic site or CSF. Genomic alterations were filtered for driver variants using OncoKB. Publicly available genomic data for NSCLC primary samples was used for comparison against the primary samples from our BM cohort.
Results: The most frequently altered genes in BM tumors were TP53 (72%), CDKN2A (34%), KRAS (31%), KEAP1 (26%), and EGFR (21%). CDKN2A was more frequently altered in BM samples compared to NSCLC primary lesions (34% vs 14%, p = 0.003). Additionally, cell cycle pathway alterations were enriched in BM (56% vs 31%, p = 0.002). BM samples also had a significantly higher fraction of genome altered (FGA) relative to primary samples (p < 0.0001). We then compared primary samples from BM patients against primary samples from metastatic NSCLC patients without BM and primary samples from non-metastatic NSCLC patients. We found an enrichment of alterations in TP53 (68.6% vs 27.7%, p < 0.0001), NKX2-1 (11.4% vs 1.7%, p = 0.006), SMARCA4 (11.4% vs 2.1%, p = 0.01), RB1 (11.4% vs 1.7%, p = 0.006), and FOXA1 (11.4% vs 0.9%, p = 0.001) in the primary samples from BM patients compared to non-metastatic patients. Next, we grouped patients based on CNS progression patterns and found that EGFR alterations were enriched in patients with leptomeningeal progression when compared to patients without progression (42% vs 18%, p = 0.03).
Conclusions: In our cohort of molecularly-profiled NSCLC BM, we found an enrichment of cell cycle pathway alterations and a higher FGA in BMs compared to their primary tumor controls. Additionally, several genes were enriched in the primary tissue of patients that developed BM compared to primary tissue from non-metastatic patients. EGFR alterations were enriched in patients who develop leptomeningeal disease (LMD). Our work herein characterizes the genomic profiles of NSCLC patients with BM and identifies specific genes enriched in the primary tissue of BM patients compared to primary tissue from both non-BM metastatic patients and non-metastatic patients. Finally, our finding that EGFR alterations were enriched in patients with LMD suggests specific biologic underpinnings driving patterns of CNS progression.
Citation Format: Henry Walch, Anna Skakodub, Kathryn R. Tringale, Harish N. Vasudevan, Jordan Eichholz, Daniel W. Kelly, Emily Lebow, Nelson S. Moss, Kenny Kwok Hei Yu, Bob T. Li, Boris Mueller, Atif Khan, Yao Yu, Simon Powell, Jorge S. Reis-Filho, Brandon S. Imber, Pedram Razavi, Daniel R. Gomez, Nikolaus Schultz, Luke R. Pike. Genomic characterization of non-small cell lung cancer (NSCLC) brain metastasis (BM) patients identifies novel alterations associated with tropisms and disease progression [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 6063.
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Miao E, Eichholz JE, Lebow ES, Flynn J, Zhang Z, Walch H, Hubbeling H, Beal K, Moss NS, Yu KK, Meng A, Kelly DW, Gomez DR, Li BT, Rimner A, Schultz N, Drilon A, Imber BS, Pike LRG. Characterization of Central Nervous System Clinico-Genomic Outcomes in ALK-Positive Non-Small Cell Lung Cancer Patients with Brain Metastases Treated with Alectinib. Lung Cancer 2023; 178:57-65. [PMID: 36780766 PMCID: PMC10065905 DOI: 10.1016/j.lungcan.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 01/11/2023] [Accepted: 02/04/2023] [Indexed: 02/11/2023]
Abstract
INTRODUCTION Highly effective brain-penetrant ALK-targeted tyrosine kinase inhibitors (TKIs) have been developed for the management of NSCLC patients with brain metastases (BM). Local therapy (LT) such as SRS or therapeutic craniotomy is increasingly being deferred for such patients. Herein we report detailed patient- and lesion-level intracranial outcomes and co-mutational genomic profiles from a cohort of NSCLC patients with BM treated with alectinib, with or without LT. METHODS We retrospectively reviewed ALK fusion-positive NSCLC patients with BMs who received alectinib at the diagnosis of BM from 1/2012 and 5/2021. Outcome variables included intracranial progression-free survival (iPFS), overall survival (OS), duration of TKI therapy, and CNS response rates. Genomic characteristics from tumor specimens were assessed with MSK-IMPACT, a next-generation sequencing (NGS)-based genomic profiling assay. RESULTS A total of 38 patients with 114 CNS lesions were included. Twelve of these patients also received contemporaneous LT (SRS, WBRT, or surgical resection). Maximal BM diameter in the TKI + LT group was greater (p < 0.003) but despite this difference, iPFS (TKI only, HR 1.21, 95 % CI 0.51-2.89; p = 0.66) and OS (TKI only, HR 5.99, 95 % CI 0.77-46.6; p = 0.052) were similar between groups and trended towards more favorable outcomes with the addition of LT. SMARCA4 co-alterations were associated with inferior OS (HR 8.76, 1.74-44.2; p = 0.009). CONCLUSIONS Our study demonstrated that patients with ALK fusion-positive NSCLC treated with TKI + LT had larger BM and higher likelihood of pre-treatment neurologic symptoms. Despite these differences, iPFS was similar between groups. Results should be interpreted with caution as our study was limited by an underpowered sample size. SMARCA4 co-alterations were associated with inferior OS and these findings warrant further investigation.
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Lebow ES, Shepherd A, Eichholz JE, Offin M, Gelblum DY, Wu AJ, Simone CB, Schoenfeld AJ, Jones DR, Rimner A, Chaft JE, Riaz N, Gomez DR, Shaverdian N. Analysis of Tumor Mutational Burden, Progression-Free Survival, and Local-Regional Control in Patents with Locally Advanced Non-Small Cell Lung Cancer Treated With Chemoradiation and Durvalumab. JAMA Netw Open 2023; 6:e2249591. [PMID: 36602799 PMCID: PMC9856786 DOI: 10.1001/jamanetworkopen.2022.49591] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
IMPORTANCE The addition of consolidative durvalumab to chemoradiation has improved disease control and survival in locally advanced non-small cell lung cancer (NSCLC). However, there remains a need to identify biomarkers for response to this therapy to allow for risk adaptation and personalization. OBJECTIVES To evaluate whether TMB or other variants associated with radiation response are also associated with outcomes following definitive chemoradiation and adjuvant durvalumab among patients with locally advanced unresectable NSCLC. DESIGN, SETTING, AND PARTICIPANTS This cohort study included consecutive patients with unresectable locally advanced NSCLC treated with chemoradiation and adjuvant durvalumab between November 2013 and March 2020 who had prospective comprehensive genomic profiling. This study was completed at a multisite tertiary cancer center. The median (IQR) follow-up time was 26 (21-36) months. Statistical analysis was conducted from April to October 2022. EXPOSURES Patients were grouped into TMB-high (≥10 mutations/megabase [mt/Mb]) and TMB-low (<10 mt/Mb) groups and were additionally evaluated by the presence of somatic alterations associated with radiation resistance (KEAP1/NFE2L2) or radiation sensitivity (DNA damage repair pathway). MAIN OUTCOMES AND MEASURES The primary outcomes were 24-month local-regional failure (LRF) and progression-free survival (PFS). RESULTS In this cohort study of 81 patients (46 [57%] male patients; median [range] age, 67 [45-85] years), 36 patients (44%) had TMB-high tumors (≥10 mt/Mb). Patients with TMB-high vs TMB-low tumors had markedly lower 24-month LRF (9% [95% CI, 0%-46%] vs 51% [95% CI, 36%-71%]; P = .001) and improved 24-month PFS (66% [95% CI, 54%-84%] vs 27% [95% CI, 13%-40%]; P = .003). The 24-month LRF was 52% (95% CI, 25%-84%) among patients with KEAP1/NFE2L2-altered tumors compared with 27% (95% CI, 17%-42%) among patients with KEAP1/NFE2L2-wildtype tumors (P = .05). On Cox analysis, only TMB status was associated with LRF (hazard ratio [HR], 0.17; 95% CI, 0.03-0.64; P = .02) and PFS (HR, 0.45; 95% CI, 0.21-0.90; P = .03). Histology, disease stage, Eastern Cooperative Oncology Group status, programmed cell death ligand 1 expression, and pathogenic KEAP1/NFE2L2, KRAS, and DNA damage repair pathway alterations were not significantly associated with LRF or PFS. CONCLUSIONS AND RELEVANCE In this cohort study, TMB-high status was associated with improved local-regional control and PFS after definitive chemoradiation and adjuvant durvalumab. TMB status may facilitate risk-adaptive radiation strategies in unresectable locally advanced NSCLC.
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De B, Farooqi AS, Mitchell KG, Ludmir EB, Lewis J, Rinsurongkawong W, Rinsurongkawong V, Lee JJ, Swisher SG, Gibbons DL, Zhang J, Le X, Elamin YY, Gomez DR, Ning MS, Lin SH, Liao Z, Chang JY, Vaporciyan AA, Heymach JV, Antonoff MB, Gandhi SJ. Benchmarking Outcomes for Molecularly Characterized Synchronous Oligometastatic Non-Small-Cell Lung Cancer Reveals EGFR Mutations to Be Associated With Longer Overall Survival. JCO Precis Oncol 2023; 7:e2200540. [PMID: 36716413 PMCID: PMC9928880 DOI: 10.1200/po.22.00540] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/03/2022] [Accepted: 12/12/2022] [Indexed: 02/01/2023] Open
Abstract
PURPOSE Local consolidative therapy (LCT) for patients with synchronous oligometastatic non-small-cell lung cancer is an evolving treatment strategy, but outcomes following LCT stratified by genetic mutations have not been reported. We sought to identify genomic associations with overall survival (OS) and progression-free survival (PFS) for these patients. METHODS We identified all patients presenting between 2000 and 2017 with stage IV non-small-cell lung cancer and ≤ 3 synchronous metastatic sites. Patients were grouped according to mutational statuses. Primary outcomes included OS and PFS following initial diagnosis. RESULTS Of 194 included patients, 121 received comprehensive LCT to all sites of disease with either surgery or radiation. TP53 mutations were identified in 40 of 78 (55%), KRAS in 32 of 95 (34%), EGFR in 24 of 109 (22%), and STK11 in nine of 77 (12%). At median follow-up of 96 months, median OS and PFS were 26 (95% CI, 23 to 31) months and 11 (95% CI, 9 to 13) months, respectively. On multivariable analysis, patients with EGFR mutations had lower mortality risk (hazard ratio [HR], 0.53; 95% CI, 0.29 to 0.98; P = .044) compared with wild-type patients, and patients with STK11 mutations had higher risk of progression or mortality (HR, 2.32; 95% CI, 1.12 to 4.79; P = .023) compared with wild-type patients. TP53 and KRAS mutations were not associated with OS or PFS. Among 71 patients with known EGFR mutational status who received comprehensive LCT, EGFR mutations were associated with lower mortality compared with wild-type (HR, 0.45; 95% CI, 0.22 to 0.94; P = .032). CONCLUSION When compared with wild-type patients, those with EGFR and STK11 mutations had longer OS and shorter PFS, respectively. EGFR mutations were associated with longer OS among oligometastatic patients treated with comprehensive LCT in addition to systemic therapy.
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McMillan MT, Shepherd AF, Kang M, Lin L, Shaverdian N, Wu AJ, Gelblum DY, Ohri N, Lazarev S, Xu L, Chhabra AM, Hasan S, Choi JI, Gomez DR, Rimner A, Lin H, Simone CB. Safety and efficacy of stereotactic body proton therapy for high-risk lung tumors. JOURNAL OF RADIOSURGERY AND SBRT 2023; 9:63-74. [PMID: 38029007 PMCID: PMC10681142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 07/11/2023] [Indexed: 12/01/2023]
Abstract
Purpose Stereotactic body proton therapy (SBPT) is an emerging treatment strategy for lung tumors that aims to combine the excellent local control benefits of ultra-hypofractionation with the physical advantages of protons, which reduce the integral dose to organs at risk (OARs) compared to photons. To date, however, very little data delivering SBPT in 5 or fewer fractions to lung tumors have been reported. Given that photon stereotactic body radiation therapy can struggle to deliver ablative doses to high-risk tumors (i.e., central/ultra-central location, prior in-field radiation, tumor size >5 cm, or the presence of severe pulmonary comorbidities) while adhering to OAR dose constraints, we hypothesized that SBPT would be an effective alternative for patients with high-risk tumors. Methods and Materials Twenty-seven high-risk patients with 29 lung tumors treated with SBPT at the New York Proton Center between December 2019 and November 2022 were retrospectively identified. Patients were divided into three major subgroups: early-stage non-small cell lung cancer (NSCLC), locally recurrent NSCLC, and metastatic cancer from lung cancer or other histologies. Patient characteristics were reported using descriptive statistics, actuarial methods were used to quantify disease control rates, and toxicities were scored using CTCAE v 5.0. Results The most common high-risk indications for SBPT were central/ultra-central tumor location (69.0%), severe COPD (48.1%), reirradiation (44.4%), significant pulmonary fibrosis (22.2%), and large tumor size > 5 cm (18.5%). In total, 96.6% of tumors were fully covered by the prescription dose without compromising target coverage. Three-year actuarial rates of local control for early-stage NSCLC, locally recurrent NSCLC, and metastatic patients were 89%, 100%, and 43%, respectively. Three-year actuarial rates of regional control were 89%, 67%, and 86%. Three-year actuarial rates of distant metastasis-free survival were 79%, 100%, and 0%. Two patients (7.4%), both of whom had clinically significant baseline interstitial lung disease and pre-treatment continuous oxygen demand, experienced grade ≥2 pulmonary toxicity (1 grade 3, 1 grade 5). There were no acute or late grade ≥2 toxicities related to esophagitis, cardiac injury, airway injury, pulmonary fibrosis, bronchopulmonary hemorrhage or brachial plexopathy. Conclusions In the largest study of proton SBRT reported to date, SBPT has a favorable toxicity profile while being an effective approach for treating most high-risk tumors without requiring dose de-escalation or compromising tumor coverage and warrants further investigation.
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Haseltine JM, Apte A, Jackson A, Yorke E, Yu AF, Plodkowski A, Wu A, Peleg A, Al-Sadawi M, Iocolano M, Gelblum D, Shaverdian N, Simone CB, Rimner A, Gomez DR, Shepherd AF, Thor M. Association of cardiac calcium burden with overall survival after radiotherapy for non-small cell lung cancer. Phys Imaging Radiat Oncol 2023; 25:100410. [PMID: 36687507 PMCID: PMC9852638 DOI: 10.1016/j.phro.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 12/05/2022] [Accepted: 01/03/2023] [Indexed: 01/07/2023] Open
Abstract
Background and purpose Coronary calcifications are associated with coronary artery disease in patients undergoing radiotherapy (RT) for non-small cell lung cancer (NSCLC). We quantified calcifications in the coronary arteries and aorta and investigated their relationship with overall survival (OS) in patients treated with definitive RT (Def-RT) or post-operative RT (PORT). Materials and methods We analyzed 263 NSCLC patients treated from 2004 to 2017. Calcium burden was ascertained with a Hounsfield unit (HU) cutoff of > 130 in addition to a deep learning (DL) plaque estimator. The HU cutoff volumes were defined for coronary arteries (PlaqueCoro) and coronary arteries and aorta combined (PlaqueCoro+Ao), while the DL estimator ranged from 0 (no plaque) to 3 (high plaque). Patient and treatment characteristics were explored for association with OS. Results The median PlaqueCoro and PlaqueCoro+Ao was 0.75 cm3 and 0.87 cm3 in the Def-RT group and 0.03 cm3 and 0.52 cm3 in the PORT group. The median DL estimator was 2 in both cohorts. In Def-RT, large PlaqueCoro (HR:1.11 (95%CI:1.04-1.19); p = 0.008), and PlaqueCoro+Ao (HR:1.06 (95%CI:1.02-1.11); p = 0.03), and poor Karnofsky Performance Status (HR: 0.97 (95%CI: 0.94-0.99); p = 0.03) were associated with worse OS. No relationship was identified between the plaque volumes and OS in PORT, or between the DL plaque estimator and OS in either Def-RT or PORT. Conclusions Coronary artery calcification assessed from RT planning CT scans was significantly associated with OS in patients who underwent Def-RT for NSCLC. This HU thresholding method can be straightforwardly implemented such that the role of calcifications can be further explored.
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Katipally RR, Spurr LF, Gutiontov SI, Turchan WT, Connell P, Juloori A, Malik R, Binkley MS, Jiang AL, Rouhani SJ, Chervin CS, Wanjari P, Segal JP, Ng V, Loo BW, Gomez DR, Bestvina CM, Vokes EE, Ferguson MK, Donington JS, Diehn M, Pitroda SP. STK11 Inactivation Predicts Rapid Recurrence in Inoperable Early-Stage Non-Small-Cell Lung Cancer. JCO Precis Oncol 2023; 7:e2200273. [PMID: 36603171 PMCID: PMC10530422 DOI: 10.1200/po.22.00273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 10/04/2022] [Accepted: 11/14/2022] [Indexed: 01/06/2023] Open
Abstract
PURPOSE Molecular factors predicting relapse in early-stage non-small-cell lung cancer (ES-NSCLC) are poorly understood, especially in inoperable patients receiving radiotherapy (RT). In this study, we compared the genomic profiles of inoperable and operable ES-NSCLC. MATERIALS AND METHODS This retrospective study included 53 patients with nonsquamous ES-NSCLC (stage I-II) treated at a single institution (University of Chicago) with surgery (ie, operable; n = 30) or RT (ie, inoperable; n = 23) who underwent tumor genomic profiling. A second cohort of ES-NSCLC treated with RT (Stanford, n = 39) was included to power clinical analyses. Prognostic gene alterations were identified and correlated with clinical variables. The primary clinical end point was the correlation of prognostic genes with the cumulative incidence of relapse, disease-free survival, and overall survival (OS) in a pooled RT cohort from the two institutions (N = 62). RESULTS Although the surgery cohort exhibited lower rates of relapse, the RT cohort was highly enriched for somatic STK11 mutations (43% v 6.7%). Receiving supplemental oxygen (odds ratio [OR] = 5.5), 20+ pack-years of tobacco smoking (OR = 6.1), and Black race (OR = 4.3) were associated with increased frequency of STK11 mutations. In the pooled RT cohort (N = 62), STK11 mutation was strongly associated with inferior oncologic outcomes: 2-year incidence of relapse was 62% versus 20% and 2-year OS was 52% versus 85%, remaining independently prognostic on multivariable analyses (relapse: subdistribution hazard ratio = 4.0, P = .0041; disease-free survival: hazard ratio, 6.8, P = .0002; OS: hazard ratio, 6.0, P = .022). STK11 mutations were predominantly associated with distant failure, rather than local. CONCLUSION In this cohort of ES-NSCLC, STK11 inactivation was associated with poor oncologic outcomes after RT and demonstrated a novel association with clinical hypoxia, which may underlie its correlation with medical inoperability. Further validation in larger cohorts and investigation of effective adjuvant systemic therapies may be warranted.
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Liu Y, Yao L, Kalhor N, Carter BW, Altan M, Blumenschein G, Byers LA, Fossella F, Gibbons DL, Kurie JM, Lu C, Skoulidis F, Chang JY, Liao Z, Gomez DR, O'Reilly M, Heymach JV, Tsao AS, Lin SH. Final efficacy outcomes of atezolizumab with chemoradiation for unresectable NSCLC: The phase II DETERRED trial. Lung Cancer 2022; 174:112-117. [PMID: 36371941 DOI: 10.1016/j.lungcan.2022.10.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/13/2022] [Accepted: 10/21/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION The phase II DETERRED trial assessed the safety and efficacy of consolidation and concurrent immunotherapy with chemoradiation in unresectable locally advanced non-small cell lung cancer. We present updated efficacy analysis of this trial. METHODS The trial was conducted in 2 parts with patients in part 1 (n = 10) receiving chemoradiation with consolidation atezolizumab, while patients in part 2 (n = 30) received concurrent and consolidation atezolizumab. Progression-free survival (PFS), time to second progression (PFS2), and overall survival (OS) were assessed using Kaplan-Meier analysis. Subset analyses were performed by programmed cell death ligand-1 (PD-L1) status and targetable driver oncogene mutation status. RESULTS At a median follow-up of 39.2 months, the median PFS for part 1 was 18.9 months and 15.1 months for part 2. Median OS for part 1 was 26.5 months and was not reached for part 2. For the cohort, 3-year OS was 53.8%, while 4-year OS was 47.4%. Patients with targetable driver oncogene mutations had a median PFS of 9.4 months and OS of not reached compared to 16.6 months (HR: 3.49, p = 0.02) and 26.9 months (HR: 0.40, p = 0.12) respectively compared to those without targetable driver oncogene mutations. Patients with PD-L1 < 1% had median PFS of 11.0 months and OS of 26.5 months compared to 27.4 months (HR: 2.01, p = 0.10) and not reached (HR: 1.49, p = 0.41) respectively for those with PD-L1 ≥ 1%. CONCLUSIONS In the DETERRED trial, chemoradiation with concurrent and/or consolidative atezolizumab led to comparable efficacy as consolidative durvalumab in the PACIFIC trial. The presence of targetable driver oncogene mutations led to worse PFS, while PD-L1 < 1% trended to worse PFS.
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Sherry AD, Bathala TK, Liu S, Fellman BM, Chun SG, Jasani N, Guadagnolo BA, Jhingran A, Reddy JP, Corn PG, Shah AY, Kaiser KW, Ghia AJ, Gomez DR, Tang C. Definitive Local Consolidative Therapy for Oligometastatic Solid Tumors: Results From the Lead-in Phase of the Randomized Basket Trial EXTEND. Int J Radiat Oncol Biol Phys 2022; 114:910-918. [PMID: 35691448 PMCID: PMC11041161 DOI: 10.1016/j.ijrobp.2022.05.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/01/2022] [Accepted: 05/07/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE The benefit of local consolidative therapy (LCT) for oligometastasis across histologies remains uncertain. EXTernal beam radiation to Eliminate Nominal metastatic Disease (EXTEND; NCT03599765) is a randomized phase 2 basket trial evaluating the effectiveness of LCT for oligometastatic solid tumors. We report here the prospective results of the single-arm "lead-in" phase intended to identify histologies most likely to accrue to histology-specific endpoints in the randomized phase. METHODS AND MATERIALS Eligible histologies included colorectal, sarcoma, lung, head and neck, ovarian, renal, melanoma, pancreatic, prostate, cervix/uterine, breast, and hepatobiliary. Patients received LCT to all sites of active metastatic disease and primary/regional disease (as applicable) plus standard-of-care systemic therapy or observation. The primary endpoint in EXTEND was progression-free survival (PFS), and the primary endpoint of the lead-phase was histology-specific accrual feasibility. Adverse events were graded by Common Terminology Criteria for Adverse Events version 4.0. RESULTS From August 2018 through January 2019, 50 patients were enrolled and 49 received definitive LCT. Prostate, breast, and kidney were the highest enrolling histologies and identified for independent accrual in the randomization phase. Most patients (73%) had 1 or 2 metastases, most often in lung or bone (79%), and received ablative radiation (62%). Median follow-up for censored patients was 38 months (range, 16-42 months). Median PFS was 13 months (95% confidence interval, 9-24), 3-year overall survival rate was 73% (95% confidence interval, 57%-83%), and local control rate was 98% (93 of 95 tumors). Two patients (4%) had Common Terminology Criteria for Adverse Events grade 3 toxic effects related to LCT; no patient had grade 4 or 5 toxic effects. CONCLUSIONS The prospective lead-in phase of the EXTEND basket trial demonstrated feasible accrual, encouraging PFS, and low rates of severe toxic effects at mature follow-up. The randomized phase is ongoing with histology-based baskets that will provide histology-specific evidence for LCT in oligometastatic disease.
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Hubbeling H, Choudhury N, Flynn J, Zhang Z, Falcon C, Rusch VW, Park BJ, Ziv E, Shaverdian N, Gelblum DY, Shepherd AF, Simone CB, Wu AJ, Gomez DR, Drilon A, Rimner A. Outcomes With Local Therapy and Tyrosine Kinase Inhibition in Patients With ALK/ ROS1/ RET-Rearranged Lung Cancers. JCO Precis Oncol 2022; 6:e2200024. [PMID: 36201714 PMCID: PMC9848570 DOI: 10.1200/po.22.00024] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 05/08/2022] [Accepted: 08/08/2022] [Indexed: 11/06/2022] Open
Abstract
PURPOSE Local therapy prolongs progression-free survival in patients with oligometastatic non-small-cell lung cancers treated with chemotherapy. We previously reported that local therapy also prolongs survival and time to next therapy in patients on tyrosine kinase inhibitors (TKIs) for EGFR-mutant lung adenocarcinomas. Here, we investigate the role of local therapy in patients progressing on TKIs for ALK/ROS1/RET-rearranged lung adenocarcinomas. MATERIALS AND METHODS Patients with advanced ALK/ROS/RET-rearranged lung adenocarcinomas who underwent radiation, surgery, or percutaneous thermal ablation from 2012 to 2020 for progression on an ALK/ROS1/RET TKI were included. Progression patterns were identified. Times from local therapy to progression, next therapy, and death were measured. RESULTS Sixty-one patients with ALK (n = 37), ROS1 (n = 12), and RET (n = 12) fusions were identified. Patients received radiotherapy (92%), surgery (13%), and percutaneous thermal ablation (8%). Local therapy was administered for solitary/oligoprogressive (94%) or polyprogressive (6%) disease. For most patients (85%), local therapy addressed all progressing sites. The median times from any local therapy to subsequent progression and next systemic therapy were 6.8 months (95% CI, 5.1 to 8.1) and 10 months (95% CI, 8.4 to 15.3), respectively. Third or greater local therapy was associated with shorter time to progression and next therapy than first/second local therapies (hazard ratio, 4.97; P < .001 and hazard ratio, 2.48; P < .001). The median overall survival from first local therapy was 34 months (95% CI, 26 to not reached). CONCLUSION Local therapy for progression on ALK, ROS1, or RET TKIs is associated with clinically meaningful time on continued TKI therapy beyond progression, especially earlier in the course of disease.
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Lin D, Gomez DR, Zhang YH, Gennarelli R, Efstathiou JA, Barker CA, Gelblum DY, Shah MK, Liberman L, Hirsch AE, Cahlon O, Gillespie EF. Radiation Oncology AcaDemic Mentorship Program (ROADMAP) for Junior Faculty: One-Year Results of a Prospective Single Institution Initiative. Int J Radiat Oncol Biol Phys 2022; 114:21-29. [PMID: 35644504 PMCID: PMC9396442 DOI: 10.1016/j.ijrobp.2022.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/21/2022] [Accepted: 05/07/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Although mentorship has been associated with promotion, job satisfaction, and retention, data are limited on the mentorship experience of clinical- versus research-track physicians as well as feasibility and relative priority of formal program components. METHODS AND MATERIALS Within a single-institution, multi-site, academic network, we implemented a Radiation Oncology AcaDemic Mentorship Program (ROADMAP) for junior faculty. Validated surveys assessing mentee satisfaction were distributed at baseline and 1 year. The statistical analysis included Wilcoxon rank sum and signed tests. Mentees assessed the likelihood to recommend each program component (10-point Likert-type scale), and means with standard error (SE) are reported. RESULTS Among 42 eligible junior faculty, 36 (86%) opted into the program. The median time since residency was 2.5 years (interquartile range, 1.75-5.25) on the clinical track (n = 12) and 3 years (interquartile range, 2.75-5.00) on the research track (n = 24). At baseline, research-track physicians reported higher satisfaction with mentoring than physicians on the clinical track (2.92 vs 2.16; P = .02). Among 32 physicians completing 1 year, overall satisfaction with mentoring increased compared with baseline (2.72 vs 3.87; P < .001), which persisted on subset analysis for both clinical- (2.16 vs 4.03; P < .001) and research-track physicians (2.99 vs 3.77; P = .005). At 1 year, 28 mentees (88%) opted to continue the program. Program components were rated 8.25 (SE, 0.37) for mentor-mentee pairings, 7.22 (SE, 0.39) for goal setting, 6.84 (SE, 0.47) for administrative support, 6.69 (SE, 0.44) for peer mentoring, and 6.53 (SE, 0.45) for steering committee oversight. Ratings of peer mentoring were not associated with track (P = .59) or years in practice (P = .29). CONCLUSIONS Clinical-track physicians may be less satisfied with mentorship than research-track faculty. However, all junior faculty, regardless of track, appeared to benefit from formalizing dyadic mentor-mentee relationships, goal setting, and peer mentoring. Further work is needed to determine the role of mentorship in addressing physician burnout.
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Schoenfeld AJ, Rizvi HA, Memon D, Shaverdian N, Bott MJ, Sauter JL, Tsai CJ, Lihm J, Hoyos D, Plodkowski AJ, Perez-Johnston R, Sawan P, Egger JV, Greenbaum BD, Rimner A, Riely GJ, Rudin CM, Rusch VW, Gomez DR, Hellmann MD. Systemic and Oligo-Acquired Resistance to PD-(L)1 Blockade in Lung Cancer. Clin Cancer Res 2022; 28:3797-3803. [PMID: 35767426 PMCID: PMC10448606 DOI: 10.1158/1078-0432.ccr-22-0657] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/04/2022] [Accepted: 06/27/2022] [Indexed: 11/16/2022]
Abstract
PURPOSE Clinical patterns and the associated optimal management of acquired resistance to PD-(L)1 blockade are poorly understood. EXPERIMENTAL DESIGN All cases of metastatic lung cancer treated with PD-(L)1 blockade at Memorial Sloan Kettering were reviewed. In acquired resistance (complete/partial response per RECIST, followed by progression), clinical patterns were distinguished as oligo (OligoAR ≤ 3 lesions of disease progression) or systemic (sAR). We analyzed the relationships between patient characteristics, burden/location of disease, outcomes, and efficacy of therapeutic interventions. RESULTS Of 1,536 patients, 312 (20%) had an initial response and 143 developed AR (9% overall, 46% of responders). OligoAR was the most common pattern (80/143, 56%). Baseline tumor mutational burden, depth of response, and duration of response were significantly increased in oligoAR compared with sAR (P < 0.001, P = 0.03, P = 0.04, respectively), whereas baseline PD-L1 and tumor burden were similar. Post-progression, oligoAR was associated with improved overall survival (median 28 months vs. 10 months, P < 0.001) compared with sAR. Within oligoAR, post-progression survival was greater among patients treated with locally-directed therapy (e.g., radiation, surgery; HR, 0.41; P = 0.039). Fifty-eight percent of patients with oligoAR treated with locally-directed therapy alone are progression-free at last follow-up (median 16 months), including 13 patients who are progression-free more than 2 years after local therapy. CONCLUSIONS OligoAR is a common and distinct pattern of acquired resistance to PD-(L)1 blockade compared with sAR. OligoAR is associated with improved post-progression survival and some cases can be effectively managed with local therapies with durable benefit.
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Santos PMG, Li X, Gomez DR. Local Consolidative Therapy for Oligometastatic Non-Small Cell Lung Cancer. Cancers (Basel) 2022; 14:3977. [PMID: 36010969 PMCID: PMC9406686 DOI: 10.3390/cancers14163977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 07/21/2022] [Accepted: 07/22/2022] [Indexed: 11/30/2022] Open
Abstract
In the last 20 years, significant strides have been made in our understanding of the biological mechanisms driving disease pathogenesis in metastatic non-small cell lung cancer (NSCLC). Notably, the development and application of predictive biomarkers as well as refined treatment regimens in the form of chemoimmunotherapy and novel targeted agents have led to substantial improvements in survival. Parallel to these remarkable advancements in modern systemic therapy has been a growing recognition of "oligometastatic disease" as a distinct clinical entity-defined by the presence of a controlled primary tumor and ≤5 sites of metastatic disease amenable to local consolidative therapy (LAT), with surgery or stereotactic ablative body radiotherapy (SABR). To date, three randomized studies have provided clinical evidence supporting the use of LAT/SABR in the treatment of oligometastatic NSCLC. In this review, we summarize clinical evidence from these landmark studies and highlight ongoing trials evaluating the use of LAT/SABR in a variety of clinical contexts along the oligometastatic disease spectrum. We discuss important implications and caveats of the available data, including considerations surrounding patient selection and application in routine clinical practice. We conclude by offering potential avenues for further investigation in the oligometastatic disease space.
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Haseltine JM, Offin M, Flynn JR, Zhang Z, Lebow ES, Aziz K, Makhnin A, Eichholz J, Lim LP, Li M, Isbell JM, Gomez DR, Li BT, Rimner A. Tumor volume as a predictor of cell free DNA mutation detection in advanced non-small cell lung cancer. Transl Lung Cancer Res 2022; 11:1578-1590. [PMID: 36090640 PMCID: PMC9459617 DOI: 10.21037/tlcr-22-164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 06/14/2022] [Indexed: 01/13/2023]
Abstract
Background Cell free DNA (cfDNA) is an exciting biomarker with applications across the cancer care continuum. Determinants of cfDNA shedding dynamics remain an active research area. We performed a detailed analysis of tumor volume and factors associated with detection of cfDNA mutations. Methods Patients with advanced non-small cell lung cancers (NSCLCs) were prospectively enrolled on a plasma biomarker protocol. Next generation sequencing (NGS) was performed using a validated, bias-corrected, hybrid-capture panel assay of lung cancer-associated genes. Volume of tumor in different subsites and total tumor volume were determined through manual volume delineation using PET/CT and brain magnetic resonance imaging (MRI) imaging. The primary endpoint was detection of cfDNA mutation; secondary endpoints were overall survival (OS) and variant allele frequency (VAF). Results There were 110 patients included, 78 of whom had at least one mutation detected. Median total tumor volume for the entire cohort, patients with mutation detected, and patients with no mutation detected were 66 mL (range, 2-1,383 mL), 76 mL (range, 5-1,383 mL), and 45 mL (range, 2-460 mL), respectively (P=0.002; mutation detected vs. not). The optimal total tumor volume threshold to predict increased probability of mutation detection was 65 mL (P=0.006). Total tumor volume greater than 65 mL was a significant predictor of mutation detection on multivariate analysis (OR: 4.30, P=0.003). Significant predictors of OS were age (HR: 1.04, P=0.002), detection of cfDNA mutation (HR: 2.11, P=0.024), and presence of bone metastases (HR: 1.66, P=0.047). Conclusions Total tumor volume greater than 65 mL was associated with cfDNA mutation detection in patients with advanced NSCLC.
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Zhang H, Onochie I, Hilal L, Wijetunga NA, Hipp E, Guttmann DM, Cahlon O, Washington C, Gomez DR, Gillespie EF. Prospective clinical evaluation of integrating a radiation anatomist for contouring in routine radiation treatment planning. Adv Radiat Oncol 2022; 7:101009. [PMID: 36092987 PMCID: PMC9449753 DOI: 10.1016/j.adro.2022.101009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 05/22/2022] [Indexed: 11/18/2022] Open
Abstract
Purpose A radiation anatomist was trained and integrated into clinical practice at a multi-site academic center. The primary objective of this quality improvement study was to determine whether a radiation anatomist improves the quality of organ-at-risk (OAR) contours, and secondarily to determine the impact on efficiency in the treatment planning process. Methods and Materials From March to August 2020, all patients undergoing computed tomography–based radiation planning at 2 clinics at Memorial Sloan Kettering Cancer Center were assigned using an “every other” process to either (1) OAR contouring by a radiation anatomist (intervention) or (2) contouring by the treating physician (standard of care). Blinded dosimetrists reported OAR contour quality using a 3-point scoring system based on a common clinical trial protocol deviation scale (1, acceptable; 2, minor deviation; and 3, major deviation). Physicians reported time spent contouring for all cases. Analyses included the Fisher exact test and multivariable ordinal logistic regression. Results There were 249 cases with data available for the primary endpoint (66% response rate). The mean OAR quality rating was 1.1 ± 0.4 for the intervention group and 1.4 ± 0.7 for the standard of care group (P < .001), with subset analysis showing a significant difference for gastrointestinal cases (n = 49; P <.001). Time from simulation to contour approval was reduced from 3 days (interquartile range [IQR], 1-6 days) in the control group to 2 days (IQR, 1-5 days) in the intervention group (P = .007). Both physicians and dosimetrists self-reported decreased time spent contouring in the intervention group compared with the control group, with a decreases of 8 minutes (17%; P < .001) and 5 minutes (50%; P = .002), respectively. Qualitative comments most often indicated edits required to bowel contours (n = 14). Conclusions These findings support improvements in both OAR contour quality and workflow efficiency with implementation of a radiation anatomist in routine practice. Findings could also inform development of autosegmentation by identifying disease sites and specific OARs contributing to low clinical efficiency. Future research is needed to determine the potential effect of reduced physician time spent contouring OARs on burnout.
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Ledesma Vicioso N, Lin D, Gomez DR, Yang JT, Lee NY, Rimner A, Yamada Y, Zelefsky MJ, Kalman NS, Rutter CE, Kotecha RR, Mehta MP, Panoff JE, Chuong MD, Salner AL, Ostroff JS, Diamond LC, Mathis NJ, Cahlon O, Pfister DG, Zhang Z, Chino F, Tsai J, Gillespie EF. Implementation Strategies to Increase Clinical Trial Enrollment in a Community-Academic Partnership and Impact on Hispanic Representation: An Interrupted Time Series Analysis. JCO Oncol Pract 2022; 18:e780-e785. [PMID: 35544650 PMCID: PMC10166438 DOI: 10.1200/op.22.00037] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Community-academic partnerships have the potential to improve access to clinical trials for under-represented minority patients who more often receive cancer treatment in community settings. In 2017, the Memorial Sloan Kettering (MSK) Cancer Center began opening investigator-initiated clinical trials in radiation oncology in targeted community-based partner sites with a high potential to improve diverse population accrual. This study evaluates the effectiveness of a set of implementation strategies for increasing overall community-based enrollment and the resulting proportional enrollment of Hispanic patients on trials on the basis of availability in community-based partner sites. METHODS An interrupted time series analysis evaluating implementation strategies was conducted from April 2018 to September 2021. Descriptive analysis ofHispanic enrollment on investigator-initiated randomized therapeutic radiation trials open at community-based sites was compared with those open only at themain academic center. RESULTS Overall, 84 patients were enrolled in clinical trials in the MSK Alliance, of which 48 (56%) identified as Hispanic. The quarterly patient enrollment pre- vs postimplementation increased from 1.39 (95% CI, -3.67 to 6.46) to 9.42 (95% CI, 2.05 to 16.78; P5 .017). In the investigator-initiated randomized therapeutic radiation trials open in the MSK Alliance, Hispanic representation was 11.5% and 35.9% in twometastatic trials and 14.2% in a proton versus photon trial. Inmatched trials open only at the main academic center, Hispanic representation was 5.6%, 6.0%, and 4.0%, respectively. CONCLUSION A combination of practice-level and physician-level strategies implemented at community-based partner sites was associated with increased clinical trial enrollment, which translated to improved Hispanic representation. This supports the role Q:2 of strategic community-academic partnerships in addressing disparities in clinical trial enrollment.
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Diplas BH, Santos PMG, Shahrokni A, Warner A, Iyengar P, Yang JT, Gomez DR, Palma DA, Tsai CJ. The Role of Ablative Radiotherapy in Older Adults With Limited Metastatic Disease. Semin Radiat Oncol 2022; 32:135-141. [PMID: 35307115 PMCID: PMC10898514 DOI: 10.1016/j.semradonc.2021.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
For patients with oligometastatic cancer, radiotherapy presents a promising avenue for achieving meaningful symptom relief and durable disease control. Data from recently published and ongoing randomized studies are helping to define the appropriate contexts for effective intervention with stereotactic ablative body radiotherapy (SABR) in the oligometastatic setting. Importantly, older adults represent a significant portion of patients with oligometastatic disease, yet often comprise a minority of patients in clinical trials. Moreover, older adults of the same chronologic age may have variable degrees of fitness and frailty. In this review, we highlight the specific challenges and considerations for the use of radiotherapy for older adults with oligometastatic disease-noting the importance of geriatric assessments in clinical decision-making about the appropriateness of SABR and other metastasis-directed therapies in this population. We then review data from existing trials, including a subset analysis of adverse events and survival estimates among older adults enrolled in the landmark SABR-COMET trial. Finally, we discuss future directions for research, including the need for focused clinical trials in older adult cohorts. Ultimately, a multidisciplinary approach is critical when carefully balancing the potential risks and benefits of this emerging treatment paradigm in the older adult population.
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