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Tang C, Hara K, Sherry AD, Serrano AG, Kostousov LV, Hernandez SD, Lu W, Shen L, Shah AY, Jonasch E, Karam JA, Matin SF, Tannir N, Wang J, Msaouel P, Sircar K, Solis L. YIA24-001: Spatial Evolution of Immune Cell Dysfunction During Development of Oligometastatic Renal Cell Carcinoma: Secondary Analysis of a Prospective Trial. J Natl Compr Canc Netw 2024; 22:YIA24-001. [PMID: 38579843 DOI: 10.6004/jnccn.2023.7122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Affiliation(s)
- Chad Tang
- 1University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kieko Hara
- 1University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | | | - Wei Lu
- 1University of Texas MD Anderson Cancer Center, Houston, TX
| | - Li Shen
- 1University of Texas MD Anderson Cancer Center, Houston, TX
| | - Amishi Y Shah
- 1University of Texas MD Anderson Cancer Center, Houston, TX
| | - Eric Jonasch
- 1University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jose A Karam
- 1University of Texas MD Anderson Cancer Center, Houston, TX
| | - Surena F Matin
- 1University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nizar Tannir
- 1University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jing Wang
- 1University of Texas MD Anderson Cancer Center, Houston, TX
| | - Pavlos Msaouel
- 1University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Luisa Solis
- 1University of Texas MD Anderson Cancer Center, Houston, TX
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Balbach ML, Sherry AD, Rexer BN, Abramson VG, Niermann KJ, Johnson CR, Park BH, Mayer IA, Chakravarthy AB. Feasibility and Tolerability of Adjuvant Capecitabine-Based Chemoradiation in Patients With Breast Cancer and Residual Disease After Neoadjuvant Chemotherapy: A Prospective Clinical Trial. Int J Radiat Oncol Biol Phys 2024; 118:1262-1270. [PMID: 37433376 DOI: 10.1016/j.ijrobp.2023.06.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/13/2023] [Accepted: 06/20/2023] [Indexed: 07/13/2023]
Abstract
PURPOSE Addition of adjuvant capecitabine improves overall survival for patients with breast cancer lacking pathologic complete response to standard-of-care neoadjuvant chemotherapy. Combining radiosensitizing capecitabine concurrent with radiation may further improve disease control, although the feasibility and tolerability of chemoradiation in this setting is unknown. This study aimed to determine the feasibility of this combination. Secondary objectives included the effect of chemoradiation on physician-reported toxicity, patient-reported skin dermatitis, and patient-reported quality of life compared with patients with breast cancer treated with adjuvant radiation. METHODS AND MATERIALS Twenty patients with residual disease following standard neoadjuvant chemotherapy were enrolled in a prospective single-arm trial and treated with adjuvant capecitabine-based chemoradiation. Feasibility was defined as ≥75% of patients completing chemoradiation as planned. Toxicity was assessed using Common Terminology Criteria for Adverse Events version 5.0 and the patient-reported radiation-induced skin reaction scale. Quality of life was measured using the RAND Short-Form 36-Item Health Survey. RESULTS Eighteen patients (90%) completed chemoradiation without interruption or dose reduction. The incidence of grade ≥3 radiation dermatitis was 5% (1 of 20 patients). Patient-reported radiation dermatitis did not show a clinically meaningful difference following chemoradiation (mean increase, 55 points) compared with published reports of patients with breast cancer treated with adjuvant radiation alone (mean increase, 47 points). On the other hand, patient-reported quality of life demonstrated a clinically meaningful decline at the end of chemoradiation (mean, 46; SD, 7) compared with the reference population of patients treated with adjuvant radiation alone (mean, 50; SD, 6). CONCLUSIONS Adjuvant chemoradiation with capecitabine is feasible and tolerable in patients with breast cancer. Although current studies using adjuvant capecitabine for residual disease following neoadjuvant chemotherapy have specified sequential treatment of capecitabine and radiation, these results support the conduct of randomized trials in this setting to investigate the efficacy of concurrent radiation with capecitabine and provide patient-reported toxicity estimates for trial design.
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Affiliation(s)
- Meridith L Balbach
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alexander D Sherry
- Department of Radiation Oncology, Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Brent N Rexer
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Vandana G Abramson
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kenneth J Niermann
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Corbin R Johnson
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ben Ho Park
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ingrid A Mayer
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - A Bapsi Chakravarthy
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee.
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Sherry AD, Hahn AW, McCaw ZR, Abi Jaoude J, Kouzy R, Lin TA, Minsky B, Fuller CD, Meirson T, Msaouel P, Ludmir EB. Differential Treatment Effects of Subgroup Analyses in Phase 3 Oncology Trials From 2004 to 2020. JAMA Netw Open 2024; 7:e243379. [PMID: 38546648 PMCID: PMC10979321 DOI: 10.1001/jamanetworkopen.2024.3379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 01/04/2024] [Indexed: 04/01/2024] Open
Abstract
Importance Subgroup analyses are often performed in oncology to investigate differential treatment effects and may even constitute the basis for regulatory approvals. Current understanding of the features, results, and quality of subgroup analyses is limited. Objective To evaluate forest plot interpretability and credibility of differential treatment effect claims among oncology trials. Design, Setting, and Participants This cross-sectional study included randomized phase 3 clinical oncology trials published prior to 2021. Trials were screened from ClinicalTrials.gov. Main Outcomes and Measures Missing visual elements in forest plots were defined as a missing point estimate or use of a linear x-axis scale for hazard and odds ratios. Multiplicity of testing control was recorded. Differential treatment effect claims were rated using the Instrument for Assessing the Credibility of Effect Modification Analyses. Linear and logistic regressions evaluated associations with outcomes. Results Among 785 trials, 379 studies (48%) enrolling 331 653 patients reported a subgroup analysis. The forest plots of 43% of trials (156 of 363) were missing visual elements impeding interpretability. While 4148 subgroup effects were evaluated, only 1 trial (0.3%) controlled for multiple testing. On average, trials that did not meet the primary end point conducted 2 more subgroup effect tests compared with trials meeting the primary end point (95% CI, 0.59-3.43 tests; P = .006). A total of 101 differential treatment effects were claimed across 15% of trials (55 of 379). Interaction testing was missing in 53% of trials (29 of 55) claiming differential treatment effects. Trials not meeting the primary end point were associated with greater odds of no interaction testing (odds ratio, 4.47; 95% CI, 1.42-15.55, P = .01). The credibility of differential treatment effect claims was rated as low or very low in 93% of cases (94 of 101). Conclusions and Relevance In this cross-sectional study of phase 3 oncology trials, nearly half of trials presented a subgroup analysis in their primary publication. However, forest plots of these subgroup analyses largely lacked essential features for interpretation, and most differential treatment effect claims were not supported. Oncology subgroup analyses should be interpreted with caution, and improvements to the quality of subgroup analyses are needed.
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Affiliation(s)
- Alexander D. Sherry
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Andrew W. Hahn
- Department of Genitourinary Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Zachary R. McCaw
- Insitro, South San Francisco, San Francisco, California
- Department of Biostatistics, University of North Carolina at Chapel Hill
| | - Joseph Abi Jaoude
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Ramez Kouzy
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Timothy A. Lin
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bruce Minsky
- Department of Gastrointestinal Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - C. David Fuller
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Tomer Meirson
- Davidoff Cancer Center, Rabin Medical Center, Petach Tikva, Israel
| | - Pavlos Msaouel
- Department of Genitourinary Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston
- Department of Translational Molecular Pathology, Division of Pathology/Lab Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Ethan B. Ludmir
- Department of Gastrointestinal Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston
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Hsu EJ, Lin TA, Dabush DR, McCaw Z, Koong A, Lin C, Abi Jaoude J, Patel R, Kouzy R, El Alam MB, Noticewala S, Yang Y, Sherry AD, Fuller CD, Thomas CR, Tang C, Msaouel P, Das P, Huang B, Tian L, Sun R, Lee JJ, Meirson T, Ludmir EB. Association of differential censoring with survival and suboptimal control arms among oncology clinical trials. J Natl Cancer Inst 2024:djae028. [PMID: 38331394 DOI: 10.1093/jnci/djae028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 01/14/2024] [Accepted: 02/01/2024] [Indexed: 02/10/2024] Open
Abstract
Differential censoring (DC), referring to censoring imbalance between treatment arms, may bias the interpretation of survival outcomes in clinical trials. In 146 phase 3 oncology trials with statistically significant time-to-event surrogate primary endpoints (PEPs), we evaluated the association between DC in the surrogate PEP, control arm adequacy, and the subsequent statistical significance of OS results. Twenty-four (16%) trials exhibited DC favoring the control arm (ConDC), while 15 (10%) exhibited experimental arm DC (ExpDC). Positive OS was more common in ConDC trials (63%) than trials without DC (37%) or with ExpDC (47%; odds ratio [OR] 2.64, 95% CI 1.10-7.20; P=.04). ConDC trials more frequently used suboptimal control arms (46%) compared to 20% without DC and 13% with ExpDC (OR 3.60, 95% CI 1.29-10.0; P=.007). The presence of ConDC in trials with surrogate PEPs, especially in those with OS conversion, may indicate an inadequate control arm and should be examined and explained.
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Affiliation(s)
- Eric J Hsu
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Timothy A Lin
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dor R Dabush
- Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel
| | - Zachary McCaw
- Department of Biostatistics, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Alex Koong
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christine Lin
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph Abi Jaoude
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Roshal Patel
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ramez Kouzy
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Molly B El Alam
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sonal Noticewala
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yumeng Yang
- School of Bioinformatics, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Alexander D Sherry
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Clifton D Fuller
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Charles R Thomas
- Radiation Oncology, Dartmouth Cancer Center, Geisel School of Medicine, Lebanon, NH, USA
| | - Chad Tang
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pavlos Msaouel
- Department of Genitourinary Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Lu Tian
- Department of Health Research and Policy, Stanford University, Stanford, CA, USA
| | - Ryan Sun
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - J Jack Lee
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tomer Meirson
- Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ethan B Ludmir
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Sherry AD, Corn PG, Tang C. Metastases-Targeting Radiotherapy and ADT-Reply. JAMA Oncol 2023; 9:1587-1588. [PMID: 37707804 DOI: 10.1001/jamaoncol.2023.3631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Affiliation(s)
- Alexander D Sherry
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Paul G Corn
- Department of Genitourinary Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Chad Tang
- Department of Genitourinary Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston
- Department of Investigational Cancer Therapeutics, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston
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Sherry AD, Corrigan KL, Kouzy R, Jaoude JA, Yang Y, Patel RR, Totten DJ, Newman NB, Das P, Taniguchi C, Minsky B, Snyder RA, Fuller CD, Ludmir E. Prevalence, trends, and characteristics of trials investigating local therapy in contemporary phase 3 clinical cancer research. Cancer 2023; 129:3430-3438. [PMID: 37382235 DOI: 10.1002/cncr.34929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/11/2023] [Accepted: 05/05/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Although most patients with cancer are treated with local therapy (LT), the proportion of late-phase clinical trials investigating local therapeutic interventions is unknown. The purpose of this study was to determine the proportion, characteristics, and trends of phase 3 cancer clinical trials assessing the therapeutic value of LT over time. METHODS This was a cross-sectional analysis of interventional randomized controlled trials in oncology published from 2002 through 2020 and registered on ClinicalTrials.gov. Trends and characteristics of LT trials were compared to all other trials. RESULTS Of 1877 trials screened, 794 trials enrolling 584,347 patients met inclusion criteria. A total of 27 trials (3%) included a primary randomization assessing LT compared with 767 trials (97%) investigating systemic therapy or supportive care. Annual increase in the number of LT trials (slope [m] = 0.28; 95% confidence interval [CI], 0.15-0.39; p < .001) was outpaced by the increase of trials testing systemic therapy or supportive care (m = 7.57; 95% CI, 6.03-9.11; p < .001). LT trials were more often sponsored by cooperative groups (22 of 27 [81%] vs. 211 of 767 [28%]; p < .001) and less often sponsored by industry (5 of 27 [19%] vs. 609 of 767 [79%]; p < .001). LT trials were more likely to use overall survival as primary end point compared to other trials (13 of 27 [48%] vs. 199 of 767 [26%]; p = .01). CONCLUSIONS In contemporary late-phase oncology research, LT trials are increasingly under-represented, under-funded, and evaluate more challenging end points compared to other modalities. These findings strongly argue for greater resource allocation and funding mechanisms for LT clinical trials. PLAIN LANGUAGE SUMMARY Most people who have cancer receive treatments directed at the site of their cancer, such as surgery or radiation. We do not know, however, how many trials test surgery or radiation compared to drug treatments (that go all over the body). We reviewed trials testing the most researched strategies (phase 3) completed between 2002 and 2020. Only 27 trials tested local treatments like surgery or radiation compared to 767 trials testing other treatments. Our study has important implications for funding research and understanding cancer research priorities.
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Affiliation(s)
- Alexander D Sherry
- Division of Radiation Oncology, Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kelsey L Corrigan
- Division of Radiation Oncology, Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ramez Kouzy
- Division of Radiation Oncology, Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Joseph Abi Jaoude
- Division of Radiation Oncology, Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Yumeng Yang
- Department of Biomedical Informatics, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Roshal R Patel
- Division of Radiation Oncology, Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Douglas J Totten
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Neil B Newman
- Department of Radiation Oncology, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Prajnan Das
- Division of Radiation Oncology, Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Cullen Taniguchi
- Division of Radiation Oncology, Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Division of Radiation Oncology, Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Bruce Minsky
- Division of Radiation Oncology, Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Rebecca A Snyder
- Division of Surgery, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - C David Fuller
- Division of Radiation Oncology, Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ethan Ludmir
- Division of Radiation Oncology, Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Sherry AD, Msaouel P, McCaw ZR, Abi Jaoude J, Hsu EJ, Kouzy R, Patel R, Yang Y, Lin TA, Taniguchi CM, Rödel C, Fokas E, Tang C, Fuller CD, Minsky B, Meirson T, Sun R, Ludmir EB. Prevalence and implications of significance testing for baseline covariate imbalance in randomised cancer clinical trials: The Table 1 Fallacy. Eur J Cancer 2023; 194:113357. [PMID: 37827064 DOI: 10.1016/j.ejca.2023.113357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND The 'Table 1 Fallacy' refers to the unsound use of significance testing for comparing the distributions of baseline variables between randomised groups to draw erroneous conclusions about balance or imbalance. We performed a cross-sectional study of the Table 1 Fallacy in phase III oncology trials. METHODS From ClinicalTrials.gov, 1877 randomised trials were screened. Multivariable logistic regressions evaluated predictors of the Table 1 Fallacy. RESULTS A total of 765 randomised controlled trials involving 553,405 patients were analysed. The Table 1 Fallacy was observed in 25% of trials (188 of 765), with 3% of comparisons deemed significant (59 of 2353), approximating the typical 5% type I error assertion probability. Application of trial-level multiplicity corrections reduced the rate of significant findings to 0.3% (six of 2345 tests). Factors associated with lower odds of the Table 1 Fallacy included industry sponsorship (adjusted odds ratio [aOR] 0.29, 95% confidence interval [CI] 0.18-0.47; multiplicity-corrected P < 0.0001), larger trial size (≥795 versus <280 patients; aOR 0.32, 95% CI 0.19-0.53; multiplicity-corrected P = 0.0008), and publication in a European versus American journal (aOR 0.06, 95% CI 0.03-0.13; multiplicity-corrected P < 0.0001). CONCLUSIONS This study highlights the persistence of the Table 1 Fallacy in contemporary oncology randomised controlled trials, with one of every four trials testing for baseline differences after randomisation. Significance testing is a suboptimal method for identifying unsound randomisation procedures and may encourage misleading inferences. Journal-level enforcement is a possible strategy to help mitigate this fallacy.
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Affiliation(s)
- Alexander D Sherry
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pavlos Msaouel
- Department of Genitourinary Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Translational Molecular Pathology, Division of Pathology/Lab Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zachary R McCaw
- Insitro, South San Francisco, CA, USA; Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Joseph Abi Jaoude
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Radiation Oncology, Stanford University, Stanford, CA, USA
| | - Eric J Hsu
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ramez Kouzy
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Roshal Patel
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Yumeng Yang
- Department of Biomedical Informatics, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Timothy A Lin
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Cullen M Taniguchi
- Department of Gastrointestinal Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Experimental Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Claus Rödel
- Department of Radiotherapy and Oncology, University of Frankfurt, Frankfurt, Germany; Frankfurt Cancer Institute, Frankfurt, Germany; German Cancer Research Center (DKFZ), Heidelberg, German Cancer Consortium (DKTK), Partner Site Frankfurt am Main, Frankfurt, Germany
| | - Emmanouil Fokas
- Department of Radiotherapy and Oncology, University of Frankfurt, Frankfurt, Germany; Frankfurt Cancer Institute, Frankfurt, Germany; German Cancer Research Center (DKFZ), Heidelberg, German Cancer Consortium (DKTK), Partner Site Frankfurt am Main, Frankfurt, Germany
| | - Chad Tang
- Department of Translational Molecular Pathology, Division of Pathology/Lab Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Genitourinary Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Clifton David Fuller
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bruce Minsky
- Department of Gastrointestinal Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tomer Meirson
- Davidoff Cancer Center, Rabin Medical Center, Petach Tikva, Israel
| | - Ryan Sun
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ethan B Ludmir
- Department of Gastrointestinal Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Sherry AD, Haymaker C, Bathala T, Lu X, Medina-Rosales M, Marmonti E, Pradeep H, Liu S, Fellman B, Mok H, Choi S, Chun SG, Aparicio A, Kovitz C, Zurita-Saavedra A, Gomez DR, Reuben A, Wistuba I, Corn PG, Tang C. Peripheral T-Cell Priming and Micrometastatic Disease Control with Metastasis-Directed Therapy: Multidimensional Immunogenomic Profiling of Oligometastatic Prostate Cancer in the EXTEND Trial. Int J Radiat Oncol Biol Phys 2023; 117:S33-S34. [PMID: 37784479 DOI: 10.1016/j.ijrobp.2023.06.299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Comprehensive metastasis-directed therapy (MDT) for oligometastatic prostate cancer extended progression-free survival (PFS) and time to new lesion formation in the intermittent hormone therapy (HT) basket of EXTEND. To better understand the mechanism of MDT benefit, we pooled the intermittent and continuous HT baskets of EXTEND and tested the hypothesis that adding MDT to HT would program systemic T-cells to control micrometastatic disease. MATERIALS/METHODS A total of 174 men were randomized to HT with or without MDT to up to 5 sites of metastases. HT was given for 6 months (intermittent basket, n = 87) or indefinitely (continuous basket, n = 87). Peripheral blood samples were drawn at enrollment, at the end of MDT, at 3 months follow-up (3 mo F/U), and at progression and then analyzed by flow cytometry, T-cell receptor (TCR)-β CDR3 variable region sequencing, multiplex cytokine profiling, and next-generation circulating tumor DNA (ctDNA) sequencing. TCR clonal expansion was determined using a published betabinomial model. Repertoire changes were assessed by Morisita's index, and dominant TCR repertoire motifs were characterized with ImmunoMap. Associations between blood markers and PFS were evaluated with Cox regression adjusted hazard ratios (aHR) accounting for randomization arm and stratifying for intermittent vs continuous HT. RESULTS Randomization to MDT+HT was associated with T-cell activation, proliferation, and clonal expansion. This response was first observed at end-MDT as upregulated expression of T-cell activation and inhibition markers (i.e., ICOS, Tim-3, and LAG-3) and increases in highly proliferative CD4+ and CD8+ Ki67hi T-cells (all P<0.05). TCR sequencing of 7,678,911 T-cells revealed that MDT+HT was associated with TCR clonal expansion, remodeling of the TCR repertoire, and changes in dominant TCR motifs at end-MDT and 3 mo F/U (all P<0.05). Observed T-cell priming could be driven by signaling networks of canonical T-cell stimulatory cytokines (IL-2, IL-12, and IL-15), which were upregulated at end-MDT and persisted at 3 mo F/U (all P<0.05). This modulation of T-cell phenotype, clonotype, and cytokine concentrations was not observed in the HT-monotherapy arm. At end-MDT, systemic T-cell responses were associated with improved PFS, most notably CD8+ T-cell expression of LAG-3 (aHR 0.22, 95% CI 0.03-0.91) and high TCR clonal expansion (aHR 0.13, 95% CI 0.02-0.52). High ctDNA burden at end-MDT correlated with worse PFS (aHR 1.41, 95% CI 1.04-2.54), as did CD8+ T-cell expression of inhibitory receptor TIGIT at 3 mo F/U (aHR 1.03, 95% CI 1.01-1.06). CONCLUSION The addition of MDT to HT induced systemic T-cell activation and expansion, which was not observed in the HT-only arm. This systemic immune response was independently associated with improved PFS. In addition to cytoreduction of macroscopic disease, MDT-induced immune education may be an important complementary mechanism of micrometastatic control in oligometastatic prostate cancer.
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Affiliation(s)
- A D Sherry
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - C Haymaker
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - T Bathala
- Department of Abdominal Imaging, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - X Lu
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - M Medina-Rosales
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - E Marmonti
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - H Pradeep
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - S Liu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - B Fellman
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - H Mok
- Department of Genitourinary Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - S Choi
- Department of Genitourinary Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - S G Chun
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - A Aparicio
- Department of Genitourinary Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - C Kovitz
- Department of General Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - A Zurita-Saavedra
- Department of Genitourinary Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - D R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - A Reuben
- Department of Thoracic-Head & Neck Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - I Wistuba
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - P G Corn
- Department of Genitourinary Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - C Tang
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX; Department of Genitourinary Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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Lin TA, Sherry AD, Ludmir EB. Challenges, Complexities, and Considerations in the Design and Interpretation of Late-Phase Oncology Trials. Semin Radiat Oncol 2023; 33:429-437. [PMID: 37684072 PMCID: PMC10917127 DOI: 10.1016/j.semradonc.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Abstract
Optimal management of cancer patients relies heavily on late-phase oncology randomized controlled trials. A comprehensive understanding of the key considerations in designing and interpreting late-phase trials is crucial for improving subsequent trial design, execution, and clinical decision-making. In this review, we explore important aspects of late-phase oncology trial design. We begin by examining the selection of primary endpoints, including the advantages and disadvantages of using surrogate endpoints. We address the challenges involved in assessing tumor progression and discuss strategies to mitigate bias. We define informative censoring bias and its impact on trial results, including illustrative examples of scenarios that may lead to informative censoring. We highlight the traditional roles of the log-rank test and hazard ratio in survival analyses, along with their limitations in the presence of nonproportional hazards as well as an introduction to alternative survival estimands, such as restricted mean survival time or MaxCombo. We emphasize the distinctions between the design and interpretation of superiority and noninferiority trials, and compare Bayesian and frequentist statistical approaches. Finally, we discuss appropriate utilization of phase II and phase III trial results in shaping clinical management recommendations and evaluate the inherent risks and benefits associated with relying on phase II data for treatment decisions.
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Affiliation(s)
- Timothy A Lin
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alexander D Sherry
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ethan B Ludmir
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX.; Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX..
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10
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Sherry AD, Maroongroge S, De B, Amini B, Conley AP, Bishop AJ, Wang C, Beckham T, Tom M, Briere T, Li J, Yeboa DN, McAleer MF, North R, Tatsui CE, Rhines LD, Ghia AJ. Management of chordoma and chondrosarcoma with definitive dose-escalated single-fraction spine stereotactic radiosurgery. J Neurooncol 2023; 164:377-386. [PMID: 37667065 DOI: 10.1007/s11060-023-04432-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 08/19/2023] [Indexed: 09/06/2023]
Abstract
PURPOSE The management of chordoma or chondrosarcoma involving the spine is often challenging due to adjacent critical structures and tumor radioresistance. Spine stereotactic radiosurgery (SSRS) has radiobiologic advantages compared with conventional radiotherapy, though there is limited evidence on SSRS in this population. We sought to characterize the long-term local control (LC) of patients treated with SSRS. METHODS We retrospectively reviewed patients with chordoma or chondrosarcoma treated with dose-escalated SSRS, defined as 24 Gy in 1 fraction to the gross tumor volume. Overall survival (OS) was calculated by Kaplan-Meier functions. Competing risk analysis using the cause-specific hazard function estimated LC time. RESULTS Fifteen patients, including 12 with chordoma and 3 with chondrosarcoma, with 22 lesions were included. SSRS intent was definitive, single-modality in 95% of cases (N = 21) and post-operative in 1 case (5%). After a median censored follow-up time of 5 years (IQR 4 to 8 years), median LC time was not reached (IQR 8 years to not reached), with LC rates of 100%, 100%, and 90% at 1 year, 2 years, and 5 years. The median OS was 8 years (IQR 3 years to not reached). Late grade 3 toxicity occurred after 23% of treatments (N = 5, fracture), all of which were managed successfully with stabilization. CONCLUSION Definitive dose-escalated SSRS to 24 Gy in 1 fraction appears to be a safe and effective treatment for achieving durable local control in chordoma or chondrosarcoma involving the spine, and may hold particular importance as a low-morbidity alternative to surgery in selected cases.
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Affiliation(s)
- Alexander D Sherry
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Sean Maroongroge
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Brian De
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Behrang Amini
- Department of Musculoskeletal Imaging, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anthony P Conley
- Department of Sarcoma Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew J Bishop
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Chenyang Wang
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Thomas Beckham
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Martin Tom
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Tina Briere
- Department of Radiation Physics, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jing Li
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Debra N Yeboa
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Mary Frances McAleer
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Robert North
- Department of Neurosurgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Claudio E Tatsui
- Department of Neurosurgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laurence D Rhines
- Department of Neurosurgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amol J Ghia
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA.
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11
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Tang C, Sherry AD, Haymaker C, Bathala T, Liu S, Fellman B, Cohen L, Aparicio A, Zurita AJ, Reuben A, Marmonti E, Chun SG, Reddy JP, Ghia A, McGuire S, Efstathiou E, Wang J, Wang J, Pilie P, Kovitz C, Du W, Simiele SJ, Kumar R, Borghero Y, Shi Z, Chapin B, Gomez D, Wistuba I, Corn PG. Addition of Metastasis-Directed Therapy to Intermittent Hormone Therapy for Oligometastatic Prostate Cancer: The EXTEND Phase 2 Randomized Clinical Trial. JAMA Oncol 2023; 9:825-834. [PMID: 37022702 PMCID: PMC10080407 DOI: 10.1001/jamaoncol.2023.0161] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 12/20/2022] [Indexed: 04/07/2023]
Abstract
Importance Despite evidence demonstrating an overall survival benefit with up-front hormone therapy in addition to established synergy between hormone therapy and radiation, the addition of metastasis-directed therapy (MDT) to hormone therapy for oligometastatic prostate cancer, to date, has not been evaluated in a randomized clinical trial. Objective To determine in men with oligometastatic prostate cancer whether the addition of MDT to intermittent hormone therapy improves oncologic outcomes and preserves time with eugonadal testosterone compared with intermittent hormone therapy alone. Design, Setting, Participants The External Beam Radiation to Eliminate Nominal Metastatic Disease (EXTEND) trial is a phase 2, basket randomized clinical trial for multiple solid tumors testing the addition of MDT to standard-of-care systemic therapy. Men aged 18 years or older with oligometastatic prostate cancer who had 5 or fewer metastases and were treated with hormone therapy for 2 or more months were enrolled to the prostate intermittent hormone therapy basket at multicenter tertiary cancer centers from September 2018 to November 2020. The cutoff date for the primary analysis was January 7, 2022. Interventions Patients were randomized 1:1 to MDT, consisting of definitive radiation therapy to all sites of disease and intermittent hormone therapy (combined therapy arm; n = 43) or to hormone therapy only (n = 44). A planned break in hormone therapy occurred 6 months after enrollment, after which hormone therapy was withheld until progression. Main Outcomes and Measures The primary end point was disease progression, defined as death or radiographic, clinical, or biochemical progression. A key predefined secondary end point was eugonadal progression-free survival (PFS), defined as the time from achieving a eugonadal testosterone level (≥150 ng/dL; to convert to nanomoles per liter, multiply by 0.0347) until progression. Exploratory measures included quality of life and systemic immune evaluation using flow cytometry and T-cell receptor sequencing. Results The study included 87 men (median age, 67 years [IQR, 63-72 years]). Median follow-up was 22.0 months (range, 11.6-39.2 months). Progression-free survival was improved in the combined therapy arm (median not reached) compared with the hormone therapy only arm (median, 15.8 months; 95% CI, 13.6-21.2 months) (hazard ratio, 0.25; 95% CI, 0.12-0.55; P < .001). Eugonadal PFS was also improved with MDT (median not reached) compared with the hormone therapy only (6.1 months; 95% CI, 3.7 months to not estimable) (hazard ratio, 0.32; 95% CI, 0.11-0.91; P = .03). Flow cytometry and T-cell receptor sequencing demonstrated increased markers of T-cell activation, proliferation, and clonal expansion limited to the combined therapy arm. Conclusions and Relevance In this randomized clinical trial, PFS and eugonadal PFS were significantly improved with combination treatment compared with hormone treatment only in men with oligometastatic prostate cancer. Combination of MDT with intermittent hormone therapy may allow for excellent disease control while facilitating prolonged eugonadal testosterone intervals. Trial Registration ClinicalTrials.gov Identifier: NCT03599765.
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Affiliation(s)
- Chad Tang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston
| | - Alexander D. Sherry
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Cara Haymaker
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston
| | - Tharakeswara Bathala
- Department of Abdominal Imaging, The University of Texas MD Anderson Cancer Center, Houston
| | - Suyu Liu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston
| | - Bryan Fellman
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston
| | - Lorenzo Cohen
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Ana Aparicio
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Amado J. Zurita
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Alexandre Reuben
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Enrica Marmonti
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston
| | - Stephen G. Chun
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Jay P. Reddy
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Amol Ghia
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Sean McGuire
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Eleni Efstathiou
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Jennifer Wang
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Jianbo Wang
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Patrick Pilie
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Craig Kovitz
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Weiliang Du
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston
| | - Samantha J. Simiele
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston
| | - Rachit Kumar
- Department of Radiation Oncology, Banner MD Anderson Cancer Center, Gilbert, Arizona
| | - Yerko Borghero
- Department of Radiation Oncology, Banner MD Anderson Cancer Center, Gilbert, Arizona
| | - Zheng Shi
- Department of Radiation Oncology, The University of Texas Health Science Center at San Antonio
| | - Brian Chapin
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston
| | - Daniel Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ignacio Wistuba
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston
| | - Paul G. Corn
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
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Dao E, Clavijo Jordan MV, Geraki K, Martins AF, Chirayil S, Sherry AD, Farquharson MJ. Using micro-synchrotron radiation x-ray fluorescence (µ-SRXRF) for trace metal imaging in the development of MRI contrast agents for prostate cancer imaging. J Trace Elem Med Biol 2022; 74:127054. [PMID: 35939923 PMCID: PMC9940726 DOI: 10.1016/j.jtemb.2022.127054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 05/13/2022] [Accepted: 08/02/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Contrast agents (CA) are administered in magnetic resonance imaging (MRI) clinical exams to measure tissue perfusion, enhance image contrast between adjacent tissues, or provide additional biochemical information in molecular MRI. The efficacy of a CA is determined by the tissue distribution of the agent and its concentration in the extracellular space of all tissues. METHODS In this work, micro-synchrotron radiation x-ray fluorescence (µ-SRXRF) was used to examine and characterize a gadolinium-based zinc-sensitive agent (GdL2) currently under development for detection of prostate cancer (PCa) by MRI. Prostate tissue samples were collected from control mice and mice with known PCa after an MRI exam that included injection of GdL2. The samples were raster scanned to investigate trends in Zn, Gd, Cu, Fe, S, P, and Ca. RESULTS Significant Zn and Gd co-localization was observed in both healthy and malignant tissues. In addition, a marked decrease in Zn was found in the lateral lobe of the prostate obtained from mice with PCa. CONCLUSION We demonstrate here that µ-SRXRF is a useful tool for monitoring the distribution of several elements including Zn and Gd in animal models of cancer. The optimized procedures for tissue preparation, processing, data collection, and analysis are described.
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Affiliation(s)
- E Dao
- Department of Physics & Astronomy, McMaster University, 1280 Main St. W., Hamilton, ON L8S 4K1, Canada; Cluster of Excellence iFIT (EXC 2180) "Image-Guided and Functionally Instructed Tumor Therapies", University of Tuebingen, 72076, Germany.
| | - M V Clavijo Jordan
- Advanced Imaging Research Center, University of Texas Southwestern Medical Center, Dallas, TX 75390, United States; Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX 75390, United States; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA 02129, United States; Cluster of Excellence iFIT (EXC 2180) "Image-Guided and Functionally Instructed Tumor Therapies", University of Tuebingen, 72076, Germany
| | - K Geraki
- Diamond Light Source, Harwell, Didcot OX11 0DE, United Kingdom; Cluster of Excellence iFIT (EXC 2180) "Image-Guided and Functionally Instructed Tumor Therapies", University of Tuebingen, 72076, Germany
| | - A F Martins
- Advanced Imaging Research Center, University of Texas Southwestern Medical Center, Dallas, TX 75390, United States; Werner Siemens Imaging Center, Eberhard Karls University Tuebingen, Tuebingen 72076, Germany; Cluster of Excellence iFIT (EXC 2180) "Image-Guided and Functionally Instructed Tumor Therapies", University of Tuebingen, 72076, Germany
| | - S Chirayil
- Advanced Imaging Research Center, University of Texas Southwestern Medical Center, Dallas, TX 75390, United States; Cluster of Excellence iFIT (EXC 2180) "Image-Guided and Functionally Instructed Tumor Therapies", University of Tuebingen, 72076, Germany
| | - A D Sherry
- Advanced Imaging Research Center, University of Texas Southwestern Medical Center, Dallas, TX 75390, United States; Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX 75390, United States; Cluster of Excellence iFIT (EXC 2180) "Image-Guided and Functionally Instructed Tumor Therapies", University of Tuebingen, 72076, Germany; Department of Chemistry, University of Texas at Dallas, Richardson, TX 75080, United States
| | - M J Farquharson
- Cluster of Excellence iFIT (EXC 2180) "Image-Guided and Functionally Instructed Tumor Therapies", University of Tuebingen, 72076, Germany; School of Interdisciplinary Science, McMaster University, Hamilton, ON L8S 4K1, Canada
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13
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Affiliation(s)
- Alexander D Sherry
- Department of Radiation Oncology, Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Tharakeswara K Bathala
- Department of Abdominal Imaging, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Suyu Liu
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Bryan M Fellman
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Stephen G Chun
- Department of Radiation Oncology, Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Nikesh Jasani
- Department of General Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - B Ashleigh Guadagnolo
- Department of Radiation Oncology, Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Anuja Jhingran
- Department of Radiation Oncology, Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jay P Reddy
- Department of Radiation Oncology, Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Paul G Corn
- Department of Genitourinary Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amishi Y Shah
- Department of Genitourinary Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kelsey W Kaiser
- Department of Radiation Oncology, Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amol J Ghia
- Department of Radiation Oncology, Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Daniel R Gomez
- Department of Radiation Oncology, Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Chad Tang
- Department of Radiation Oncology, Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Investigational Cancer Therapeutics, University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Translational Molecular Pathology, University of Texas MD Anderson Cancer Center, Houston, Texas.
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Khattab MH, Sherry AD, Devan SP, Luo G, Chaballout BH, Jean-Baptiste S, Xu J, Bick S, Petrie WM, Cmelak AJ. Noninvasive Capsulotomy for Refractory Depression by Frameless Stereotactic Radiosurgery. Int J Radiat Oncol Biol Phys 2022; 113:960-966. [PMID: 35595157 DOI: 10.1016/j.ijrobp.2022.04.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 04/16/2022] [Accepted: 04/28/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Effective treatment options for refractory depression are needed. Recent advancements permit both precise ablative radiation and functional neurologic connectome analysis using standard MRI. We combined these innovations to perform stereotactic radiosurgical capsulotomy for the treatment of medically refractory major depressive disorder and study connectome response using a novel tractography-based approach. METHODS AND MATERIALS Patients with medically refractory depression were enrolled on a prospective pilot single-arm observational trial from 2020 to 2021 at a single academic tertiary referral center. Bilateral ablation of the anterior limb of the internal capsule was accomplished by mask-based linear accelerator stereotactic radiosurgery. Beck's Depression Inventory measured efficacy. Montreal Cognitive Assessment evaluated cognition. RESULTS Three patients were enrolled. Depression burden was improved by 88% at 12 month follow-up and by 55% at 18 month follow-up for patient 1 and 2, respectively. Patient 1 discontinued ketamine therapy, and patient 2 discontinued electroconvulsive therapy. Patient 3 reported global improvement in symptoms and function at 3 months. All 3 patients had reduction or resolution of suicidal ideation. No patient experienced cognitive decline or neurologic toxicity, and MoCA score, as well as subjective patient-reported evaluations of concentration and attention, were superior after treatment. Tractography confirmed intended disruption of the cortico-striatal-thalamo-cortical loop with structural reorganization in the connectome. Connectome change was consistent between patients. Observed increases in caudate and putamen connectivity and decreases in thalamic connectivity may explain improved concentration, attention, and depression. The diversity and magnitude of connectome change may correlate with degree of clinical response. CONCLUSIONS In three patients with refractory depression, radiosurgical capsulotomy significantly reduced the burden of depression. Functional connectome reorganization offers neurobiological evidence to support further investigations of the role of radiosurgery in depression.
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Affiliation(s)
- Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN; Minneapolis Radiation Oncology, Edina, MN.
| | - Alexander D Sherry
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN; Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sean P Devan
- Department of Radiology and Radiological Sciences, Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN
| | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Basil H Chaballout
- University of South Carolina School of Medicine Greenville, Greenville, SC
| | - Samuel Jean-Baptiste
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Junzhong Xu
- Department of Radiology and Radiological Sciences, Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN
| | - Sarah Bick
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - William M Petrie
- Department of Psychiatry, Vanderbilt University Medical Center, Nashville, TN
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN
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15
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Anderson JL, Khattab MH, Sherry AD, Luo G, Chitale RV, Froehler MT, Fusco MR, Cmelak AJ, Attia A. Improved Cerebral Arteriovenous Malformation Obliteration With 3-Dimensional Rotational Digital Subtraction Angiography for Radiosurgical Planning: A Retrospective Cohort Study. Neurosurgery 2021. [DOI: 10.1093/neuros/nyaa321_s066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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16
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Perkins EL, Manzoor NF, Totten DJ, Sherry AD, Cass N, Thompson R, Tawfik K, O'Malley M, Bennett M, Haynes DS. The Influence of Extent of Resection and Tumor Morphology on Facial Nerve Outcomes Following Vestibular Schwannoma Surgery. Otol Neurotol 2021; 42:e1346-e1352. [PMID: 34238899 DOI: 10.1097/mao.0000000000003253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the influence extent of resection and tumor characteristics on facial nerve (FN) outcomes following microsurgical resection of vestibular schwannoma (VS). STUDY DESIGN Retrospective chart review. SETTING Tertiary referral center. PATIENTS Three hundred eighty-five patients who underwent VS microsurgical resection. INTERVENTIONS Microsurgical VS resection. MAIN OUTCOME MEASURES House-Brackmann (HB) scores postoperatively. Good FN function was defined as HB grade I and II and poor FN function was defined as HB grade III and VI. Gross total resection (GTR) versus subtotal resection (STR). Propensity-score matching was used in subset analysis to balance tumor volume between the surgical cohorts, followed by multivariable analysis. RESULTS Seventy-one patients (18%) underwent STR and 314 patients (82%) underwent GTR. Two hundred fourteen patients (63%) had good FN function at 2 to 3 weeks postoperatively, and 80% had good FN function at 1 year. In single predictor analysis, STR did not influence FN function at 2 to 3 weeks (p = 0.65). In propensity-score matched subset analysis (N = 178), patients with STR were less likely to have poor FN function at 2 to 3 weeks (p = 0.02) independent of tumor volume (p = 0.004), but there was no correlation between STR and FN function at 1 year (p = 0.09). Ventral extension of tumor relative to the internal auditory canal plane was associated with poor FN outcomes at 2 to 3 weeks (p = 0.0001) and 1-year postop (p = 0.002). CONCLUSIONS When accounting for tumor volume, STR is protective in immediate postoperative FN function compared to GTR. Ventral extension of the tumor is a clinical predictor of long-term FN outcomes.
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Affiliation(s)
- Elizabeth L Perkins
- Department of Otolaryngology/Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nauman F Manzoor
- Department of Otolaryngology/Head and Neck Surgery, Case Western Reserve University School of Medicine, University Hospitals ENT Institute, Cleveland, Ohio
| | - Douglas J Totten
- Vanderbilt University School of Medicine, Vanderbilt University Medical Center
| | - Alexander D Sherry
- Vanderbilt University School of Medicine, Vanderbilt University Medical Center
| | - Nathan Cass
- Department of Otolaryngology/Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Reid Thompson
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kareem Tawfik
- Department of Otolaryngology/Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew O'Malley
- Department of Otolaryngology/Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Marc Bennett
- Department of Otolaryngology/Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David S Haynes
- Department of Otolaryngology/Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Patro A, Totten DJ, Sherry AD, Manzoor NF, Cass ND, Tawfik K, Bennett ML, O'Malley MR, Haynes DS, Perkins EL. Outcomes of Initial Observation Versus Upfront Microsurgical Resection for Small to Medium-sized Vestibular Schwannomas. Otol Neurotol 2021; 42:1408-1413. [PMID: 34149031 DOI: 10.1097/mao.0000000000003243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess postoperative outcomes and predictive factors of patients observed prior to microsurgery and those undergoing upfront resection for small and medium-sized VS. STUDY DESIGN Retrospective cohort. SETTING Tertiary referral center. PATIENTS VS patients who had microsurgery from 2003 to 2018 for tumors up to 2.5 cm. MAIN OUTCOME MEASURES Postoperative outcomes including facial nerve function and interventions, complications, extent of resection, and salvage therapy. RESULTS Of 220 patients, 120 were initially observed, and 100 pursued upfront microsurgery. There was no significant association between initial observation and upfront microsurgery for postoperative facial nerve function at 2 to 3 weeks (p = 0.18) or 12 months (p = 0.5), facial nerve intervention (p = 0.5), major/minor complications (p = 0.48/0.63), recurrence (p = 0.8), subtotal resection (p = 0.6), or salvage therapy (p = 0.9). Time from initial consultation to surgery did not significantly impact outcomes. Intrameatal tumors were more likely to be observed (odds ratios [OR] 2.93; 95% CI 1.53-5.63; p = 0.001). Patients with larger tumor volume (OR 0.52; 95% CI 0.37-0.72; p < 0.0001), brainstem compression (OR 0.28; 95% CI 0.09-0.91; p = 0.03), or higher PTA were less likely to undergo observation (OR 0.99; 95% CI 0.97-0.997; p = 0.02). On multivariable analysis, predictive factors for observation were smaller tumor volume (OR 0.53; 95% CI 0.38-0.75; p < 0.001), lower PTA (OR 0.99; 95% CI 0.98-0.999; p = 0.04), and diabetes (OR 2.54; 95% CI 0.95-6.83; p = 0.06). CONCLUSIONS Patients with worse hearing, larger tumor volume, and brainstem compression were more likely to pursue upfront microsurgery. A watchful waiting period does not appear to worsen outcomes and can be considered for patients with better hearing and smaller tumors without brainstem compression.
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Affiliation(s)
- Ankita Patro
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center
| | | | | | - Nauman F Manzoor
- Department of Otolaryngology - Head and Neck Surgery, University Hospitals, ENT Institute, Case Western Reserve University, Cleveland, Ohio
| | - Nathan D Cass
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center
| | - Kareem Tawfik
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center
| | - Marc L Bennett
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center
| | - Matthew R O'Malley
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center
| | - David S Haynes
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center
| | - Elizabeth L Perkins
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center
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Totten DJ, Sherry AD, Manzoor NF, Perkins EL, Cass ND, Khattab MH, Cmelak AJ, Haynes DS, Aulino JM. Diameter-Based Volumetric Models May Inadequately Calculate Jugular Paraganglioma Volume Following Sub-Total Resection. Otol Neurotol 2021; 42:e1339-e1345. [PMID: 34149025 DOI: 10.1097/mao.0000000000003226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND As gross total resection of jugular paragangliomas (JPs) may result in cranial nerve deficits, JPs are increasingly managed with subtotal resection (STR) with postoperative radiological monitoring. However, the validity of commonly used diameter-based models that calculate postoperative volume to determine residual tumor growth is dubious. The purpose of this study was to assess the accuracy of these models compared to manual volumetric slice-by-slice segmentation. METHODS A senior neuroradiologist measured volumes via slice-by-slice segmentation of JPs pre- and postoperatively from patients who underwent STR from 2007 to 2019. Volumes from three linear-based models were calculated. Models with absolute percent error (APE) > 20% were considered unsatisfactory based on a common volumetric definition for residual growth. Bland-Altman plots were used to evaluate reproducibility, and Wilcoxon matched-pairs signed rank test evaluated model bias. RESULTS Twenty-one patients were included. Median postoperative APE exceeded the established 20% threshold for each of the volumetric models as cuboidal, ellipsoidal, and spherical model APE were 63%, 28%, and 27%, respectively. The postoperative cuboidal model had significant systematic bias overestimating volume (p = 0.002) whereas the postoperative ellipsoidal and spherical models lacked systematic bias (p = 0.11 and p = 0.82). CONCLUSION Cuboidal, ellipsoidal, and spherical models do not provide accurate assessments of postoperative JP tumor volume and may result in salvage therapies that are unnecessary or inappropriately withheld due to inaccurate assessment of residual tumor growth. While more time-consuming, slice-by-slice segmentation by an experienced neuroradiologist provides a substantially more accurate and precise measurement of tumor volume that may optimize clinical management.
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Affiliation(s)
| | | | - Nauman F Manzoor
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center
| | - Elizabeth L Perkins
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center
| | - Nathan D Cass
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center
| | - Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt University Medical Center
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center
| | - David S Haynes
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center
| | - Joseph M Aulino
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
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Khattab MH, Cmelak AJ, Sherry AD, Luo G, Wang L, Yu H, Hedera P, Phibbs FT, Lindsell CJ, Neimat J, Kirschner AN. Noninvasive Thalamotomy for Refractory Tremor by Frameless Radiosurgery. Int J Radiat Oncol Biol Phys 2021; 112:121-130. [PMID: 34454047 DOI: 10.1016/j.ijrobp.2021.08.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 07/27/2021] [Accepted: 08/12/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE We sought to determine whether a more widely accessible, non-invasive frameless approach to radiosurgical thalamotomy would improve objective measures of refractory essential or parkinsonian tremor without added toxicity compared to reports of frame-based radiosurgery. METHODS We conducted a single-arm pilot observational prospective trial of adult patients with essential or parkinsonian tremor from 2013 to 2019 and report results at one-year follow-up. Patients were treated with frameless unilateral radiosurgical ablation of the thalamic ventral intermediate nucleus to a maximum dose of 160 Gy. Treatment response was measured by the Fahn-Tolosa-Marin (FTM) tremor rating scale and the Quality of Life in Essential Tremor or Parkinson's Disease Questionnaire obtained prior to treatment and at 3, 6, 9, and 12 months. RESULTS Thirty-three patients, including 23 with essential tremor and 10 with Parkinson's disease, were enrolled. Overall treatment response rate per FTM was 83% (n=15/18) at 6 months. There was a marked improvement in tremor, with average total FTM reduction of 21% at 3 months (from 46 to 30 points, p=0.003) and 41% at 6 months (from 46 to 24 points, p=0.001). At 6 months, functional decline had regressed by 54% (from 15 to 7 points, p=0.001). Quality of life improved by 57% (p=0.001) at 6 months in patients with essential tremor, and patients with Parkinson's Disease had unchanged quality of life. At one-year follow-up, grade 2 neurologic adverse events were observed in 6% (n=2/33) of patients without any grade ≥ 3 events. CONCLUSION Noninvasive, frameless radiosurgical thalamotomy may be a feasible treatment for patients with refractory tremor and demonstrates short-term safety at one-year follow-up. This pilot study provides promising preliminary descriptions of efficacy, and definitive estimates of long-term safety and benefit require further study with longer follow-up.
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Affiliation(s)
- Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN.
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Alexander D Sherry
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Hong Yu
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Peter Hedera
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN; Department of Neurology, University of Louisville School of Medicine, Louisville, KY
| | - Fenna T Phibbs
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN
| | | | - Joseph Neimat
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN; Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, KY
| | - Austin N Kirschner
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN
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20
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Sherry AD, Pasalic D, Gunn GB, Fuller CD, Phan J, Rosenthal DI, Morrison WH, Sturgis EM, Gross ND, Gillison ML, Ferrarotto R, El-Naggar AK, Garden AS, Frank SJ. Proton Beam Therapy for Head and Neck Carcinoma of Unknown Primary: Toxicity and Quality of Life. Int J Part Ther 2021; 8:234-247. [PMID: 34285950 PMCID: PMC8270080 DOI: 10.14338/ijpt-20-00034.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/21/2020] [Indexed: 12/26/2022] Open
Abstract
Purpose Proton radiation therapy (PRT) may offer dosimetric and clinical benefit in the treatment of head and neck carcinoma of unknown primary (HNCUP). We sought to describe toxicity and quality of life (QOL) in patients with HNCUP treated with PRT. Patients and Methods Toxicity and QOL were prospectively tracked in patients with HNCUP from 2011 to 2019 after institutional review board approval. Patients received PRT to the mucosa of the nasopharynx, oropharynx, and bilateral cervical lymph nodes with sparing of the larynx and hypopharynx. Patient-reported outcomes were tracked with the MD Anderson Symptom Inventory–Head and Neck Module, the Functional Assessment of Cancer Therapy–Head and Neck, the MD Anderson Dysphagia Inventory, and the Xerostomia-Related QOL Scale. Primary study endpoints were the incidence of grade ≥ 3 (G3) toxicity and QOL patterns. Results Fourteen patients (median follow-up, 2 years) were evaluated. Most patients presented with human papillomavirus–positive disease (n = 12, 86%). Rates of G3 oral mucositis, xerostomia, and dermatitis were 7% (n = 1), 21% (n = 3), and 36% (n = 5), respectively. None required a gastrostomy. During PRT, QOL was reduced relative to baseline and recovered shortly after PRT. At 2 years after PRT, the local regional control, disease-free survival, and overall survival were 100% (among 7 patients at risk), 79% (among 6 patients at risk), and 90% (among 7 patients at risk), respectively. Conclusion Therefore, PRT for HNCUP was associated with highly favorable dosimetric and clinical outcomes, including minimal oral mucositis, xerostomia, and dysphagia. Toxicity and QOL may be superior with PRT compared with conventional radiation therapy and PRT maintains equivalent oncologic control. Further prospective studies are needed to evaluate late effects and cost-effectiveness.
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Affiliation(s)
| | - Dario Pasalic
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G Brandon Gunn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - C David Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jack Phan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David I Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William H Morrison
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Erich M Sturgis
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Neil D Gross
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maura L Gillison
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Renata Ferrarotto
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Adel K El-Naggar
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Adam S Garden
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Khattab MH, Sherry AD, Aulino JM, Becker JE, Petrie WM, Cmelak AJ. Chronic Electroconvulsive Therapy May Induce Calvarial Hyperemia and Marrow Replacement. J ECT 2021; 37:e13-e16. [PMID: 33122499 DOI: 10.1097/yct.0000000000000728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Electroconvulsive therapy (ECT) is a treatment option for a number of psychiatric disorders, including refractory major depression and obsessive compulsive disorder. There are no known structural sequelae of ECT. Here we present a patient with severe refractory obsessive compulsive disorder and major depression treated over 2 years with ECT every 2 weeks. Planning magnetic resonance imaging intended for a potential procedural intervention for her psychiatric disease incidentally demonstrated a new area of increased enhancement and loss of marrow signal within the right frontal bone. Imaging findings were suggestive of underlying bone marrow or bone changes, although there was no evidence of bone destruction on bone-windowed computed tomography (CT) and there was no uptake on nuclear bone scan. The CT chest/abdomen/pelvis were also reassuring that this did not represent metastatic disease, and findings were unchanged on repeat magnetic resonance imaging 4 months later. Thus, this area corresponded to the site directly underlying the unilateral ECT electrode placement, suggestive of never-before described ECT-induced hyperemia. We report for the first time that frequent, chronic ECT may induce asymptomatic skull bone marrow hyperemia with radiologic findings. This appears to be a direct consequence of electrical current leading to chronic inflammatory and edematous marrow replacement. Electroconvulsive therapy should be added to the neuroradiological differential diagnosis of calvarial enhancement and loss of marrow signal. Psychiatrists should counsel patients on the possibility of this rare radiological finding, which may be confused for other processes.
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Affiliation(s)
- Mohamed H Khattab
- From the Department of Radiation Oncology, Vanderbilt University Medical Center
| | | | | | - Jonathan E Becker
- Department of Psychiatry, Vanderbilt University Medical Center, Nashville, TN
| | - William M Petrie
- Department of Psychiatry, Vanderbilt University Medical Center, Nashville, TN
| | - Anthony J Cmelak
- From the Department of Radiation Oncology, Vanderbilt University Medical Center
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22
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Xu MC, Khattab MH, Luo G, Sherry AD, Morales-Paliza M, Chaballout BH, Anderson JL, Attia A, Cmelak AJ. Effects of cone versus multi-leaf collimation on dosimetry and neurotoxicity in patients with small arteriovenous malformations treated by stereotactic radiosurgery. J Radiosurg SBRT 2021; 7:287-294. [PMID: 34631230 PMCID: PMC8492055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 02/15/2021] [Indexed: 06/13/2023]
Abstract
PURPOSE/OBJECTIVE Linear accelerator (LINAC) based stereotactic radiosurgery (SRS) for arteriovenous malformations (AVMs) is delivered with cone or multileaf collimators (MLCs), and favorable dosimetry is associated with reduced radionecrosis in normal brain tissue. This study aims to determine whether cones or MLCs has better dosimetric characteristics, to predict differences in toxicity. METHODS All patients treated for AVMs using LINAC SRS from 2003-2017 were examined retrospectively. Demographic data, volumes of normal tissue exposed to 12Gy (V12Gy[cc]) and 4Gy (V4Gy[cc]), maximal dose, and dose gradient were analyzed. Univariate and multivariate analyses were used to evaluate relationships between collimator type, dosimetric parameters, and toxicity. Propensity score matching was used to adjust for AVM size. RESULTS Compared to MLC, cones were independently associated with reduced V12Gy[cc] after propensity score matching (p=0.008) and reduced neurotoxicity (p=0.016). Higher V12Gy[cc] (p=0.0008) and V4Gy[cc] (p=0.002) were associated with increased neurotoxicity. CONCLUSIONS Treating AVMs with cone-based SRS over MLC-based SRS may improve dosimetry and reduce toxicities.
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Affiliation(s)
- Mark C Xu
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Manuel Morales-Paliza
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Basil H. Chaballout
- University of South Carolina School of Medicine Greenville, Greenville, SC, USA
| | | | - Albert Attia
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
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Anderson JL, Khattab MH, Sherry AD, Luo G, Chitale RV, Froehler MT, Fusco MR, Cmelak AJ, Attia A. Improved Cerebral Arteriovenous Malformation Obliteration With 3-Dimensional Rotational Digital Subtraction Angiography for Radiosurgical Planning: A Retrospective Cohort Study. Neurosurgery 2020; 88:122-130. [PMID: 32717053 DOI: 10.1093/neuros/nyaa321] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 05/24/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Stereotactic radiosurgery (SRS) for cerebral arteriovenous malformations (AVMs) is well-established. Radiographic advantages exist for 3-dimensional rotational digital subtraction angiography (3DRA) over 2-dimensional digital subtraction angiography (2D DSA) in delineating AVM nidus structure for SRS treatment planning. However, currently there is limited to no data directly comparing 2D DSA versus 3DRA in terms of patient outcomes. OBJECTIVE To investigate whether the use of 3DRA over 2D DSA in radiosurgical treatment planning for AVMs associates with improved clinical outcomes. METHODS All AVM patients treated with SRS at our institution between the years 2000 and 2018 were identified. Primary outcomes were obliteration rates and time to obliteration (TTO); secondary outcomes included rates of post-SRS hemorrhage, salvage therapy, and symptomatic radionecrosis. A minimum of 12 mo of follow-up imaging/angiogram post-SRS was required, or alternatively evidence of obliteration on angiogram prior to 12 mo post-SRS. Single predictor and multivariable Cox regression and logistic regression models were constructed to test for association between radiographic, clinical, and treatment factors with outcomes. RESULTS A total of 75 patients were included. Total 17 patients received 3DRA and 58 patients received 2D DSA, with a median follow-up of 3.29 yr. The 3DRA is significantly associated with improved TTO on single predictor (HR 2.87, 1.29-6.12; P = .0109) and multivariable analysis (HR 2.448, 1.076-5.750; P = .0330) and increased odds of achieving obliteration by 3 yr post-SRS on single predictor analysis (OR 6.044, 1.405-26.009; P = .0157). CONCLUSION The 3DRA over 2D DSA in SRS treatment planning for AVMs may result in improved TTO and 3-yr obliteration rates. Further investigation and prospective study are warranted.
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Affiliation(s)
| | - Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rohan V Chitale
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael T Froehler
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew R Fusco
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Khattab MH, Sherry AD, Jessop AC, Ciombor KK, Chakravarthy B. Early detection of SARS-CoV-2 from staging PET-CT. ACTA ACUST UNITED AC 2020; 9:93-95. [PMID: 33014283 PMCID: PMC7524033 DOI: 10.1007/s13566-020-00436-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 09/24/2020] [Indexed: 10/29/2022]
Abstract
Objective SARS-CoV-2 infection may manifest with minimal or no clinical symptoms. However, signs of infection may appear on routine imaging obtained in the care of patients with cancer. The management of patients planned for chemoradiation with asymptomatic or mildly symptomatic SARS-CoV-2 infection is uncertain. Methods Here, we present a case study of a mildly symptomatic patient with anal cancer diagnosed with SARS-CoV-2 from a staging PET-CT scan. Results PET-CT scan for anal cancer staging demonstrated pulmonary avidity suspicious for an infectious, rather than malignant, process. In the setting of these imaging findings and new-onset anosmia, viral polymerase chain reaction was ordered and found to be positive for SARS-CoV-2. To avoid myelosuppression in the setting of active infection, planned chemoradiation was delayed until cessation of viral shedding. Conclusion In the COVID-19 era, oncologists obtaining routine staging imaging should have high diagnostic suspicion for subclinical SARS-CoV-2 infection. To avoid precipitating severe pneumonia and hospitalization, multidisciplinary discussion with risk-benefit analysis is recommended before initiating immunosuppressive therapies such as chemoradiation.
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Affiliation(s)
- Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, 2220 Pierce Avenue, Preston Research Building, Rm B-1003, Nashville, TN 37232-5671 USA
| | | | - Aaron C Jessop
- Division of Nuclear Medicine, Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN USA
| | - Kristen K Ciombor
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN USA
| | - Bapsi Chakravarthy
- Department of Radiation Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, 2220 Pierce Avenue, Preston Research Building, Rm B-1003, Nashville, TN 37232-5671 USA
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Sherry AD, von Eyben R, Newman NB, Gutkin P, Mayer I, Horst K, Chakravarthy AB, Rafat M. Systemic Inflammation After Radiation Predicts Locoregional Recurrence, Progression, and Mortality in Stage II-III Triple-Negative Breast Cancer. Int J Radiat Oncol Biol Phys 2020; 108:268-276. [PMID: 31809877 PMCID: PMC7473500 DOI: 10.1016/j.ijrobp.2019.11.398] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 11/24/2019] [Accepted: 11/26/2019] [Indexed: 01/10/2023]
Abstract
PURPOSE Patients with triple-negative breast cancer experience high rates of recurrence after radiation, which may be facilitated by the recruitment of circulating tumor cells to proinflammatory microenvironments in the absence of lymphocytes. We hypothesized that patients with lymphopenia and elevated inflammatory hematologic markers after radiation therapy would have an increased risk of locoregional failure. METHODS AND MATERIALS With approval, we retrospectively studied a cohort of women treated with adjuvant radiation therapy for stage II-III triple-negative breast cancer. We analyzed the relationship between post-radiation therapy neutrophil:lymphocyte ratio (NLR) and locoregional recurrence by using Cox regression. RESULTS One-hundred thirty patients met inclusion criteria, and median follow-up time was 7.6 years. Patients with an NLR ≥3 had a higher rate of locoregional failure (P = .04) and lower overall survival (P = .04). After adjusting for stage (hazard ratio [HR], 5.5; P < .0001) and neoadjuvant chemotherapy (HR, 2.5; P = .0162), NLR was highly predictive of locoregional failure (HR, 1.4; P = .0009). NLR was also highly predictive of overall survival (HR, 1.3; P = .0007) after adjustment for stage and neoadjuvant chemotherapy. CONCLUSIONS Innate peripheral inflammation after radiation therapy for triple-negative breast cancer in an immunocompromised setting may be a novel prognostic biomarker for locoregional recurrence, progression, and survival. This finding supports preclinical studies of post-radiation therapy inflammation-mediated tumor progression. Further studies are needed to confirm this finding and develop treatment strategies.
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Affiliation(s)
| | - Rie von Eyben
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Neil B Newman
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Paulina Gutkin
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Ingrid Mayer
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kathleen Horst
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - A Bapsi Chakravarthy
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Marjan Rafat
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Chemical and Biomolecular Engineering, Vanderbilt University School of Engineering, Nashville, Tennessee; Department of Biomedical Engineering, Vanderbilt University School of Engineering, Nashville, Tennessee.
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Manzoor NF, Yancey KL, Aulino JM, Sherry AD, Khattab MH, Cmelak A, Morrel WG, Haynes DS, Bennett ML, O'Malley MR, Netterville J, Wanna G, Rivas A. Contemporary Management of Jugular Paragangliomas With Neural Preservation. Otolaryngol Head Neck Surg 2020; 164:391-398. [PMID: 32660391 DOI: 10.1177/0194599820938660] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Management of jugular paragangliomas (PGL) has evolved toward subtotal resection (STR). The purpose of this study is to analyze neural preservation and adjuvant treatment for long-term local control. STUDY DESIGN Retrospective chart review. SETTINGS Tertiary neurotology practice. SUBJECTS AND METHODS Adults undergoing surgical treatment of jugular PGL between 2006 and 2019. Patients, disease, and treatment variables were collected retrospectively. Single predictor logistic regression was used to ascertain predictors of regrowth or need for salvage radiation. RESULTS A total of 41 patients (median age, 47 years; 76% female) were identified. Most patients presented with advanced-stage disease (Glasscock-Jackson stage III-IV = 76%). Subtotal resection (STR) was performed in 32 (78%) patients. Extended STR (type 1) was the most commonly performed conservative procedure (n = 19, 59%). Postoperative new low cranial neuropathy (LCN) involving CN X and XII was rare (n = 3 and n = 1, respectively). Seventeen patients (41%) underwent postsurgical therapy for tumor regrowth or recurrence, including 15 patients who underwent adjuvant (n = 4) or salvage (n = 11) radiation. Overall tumor control of 94.7% was achieved at a mean follow-up of 35 months. All patients treated with combined modality treatment had local control at last follow-up. Logistic regression identified no single predictor for postsurgical radiation treatment or salvage-free survival. CONCLUSION Management of jugular PGL with a conservative approach is safe and effective with a low rate of new LCN deficit. Active surveillance of residual tumor with salvage radiation for growth results in excellent long-term tumor control.
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Affiliation(s)
- Nauman F Manzoor
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kristen L Yancey
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Joseph M Aulino
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Alexander D Sherry
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anthony Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - William G Morrel
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - David S Haynes
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Marc L Bennett
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew R O'Malley
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - James Netterville
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - George Wanna
- Department of Otolaryngology, New York Eye and Ear Infirmary, New York, New York, USA
| | - Alejandro Rivas
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Khattab MH, Sherry AD, Manzoor N, Totten DJ, Luo G, Chambless LB, Rivas A, Haynes DS, Cmelak AJ, Attia A. Progressive Vestibular Schwannoma following Subtotal or Near-Total Resection: Dose-Escalated versus Standard-Dose Salvage Stereotactic Radiosurgery. J Neurol Surg B Skull Base 2020; 82:e9-e14. [PMID: 34306912 DOI: 10.1055/s-0040-1712462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 03/19/2020] [Indexed: 10/24/2022] Open
Abstract
Objective Local failure of incompletely resected vestibular schwannoma (VS) following salvage stereotactic radiosurgery (SRS) using standard doses of 12 to 13 Gy is common. We hypothesized that dose-escalated SRS, corrected for biologically effective dose, would have superior local control of high-grade VS progressing after subtotal or near-total resection compared with standard-dose SRS. Design Retrospective cohort study. Setting Tertiary academic referral center. Participants Adult patients treated with linear accelerator-based SRS for progressive VS following subtotal or near-total resection. Main Outcome Measures Dose-escalated SRS was defined by a biologically effective dose exceeding a single-fraction 13-Gy regimen. Study outcomes were local control and neurologic sequelae of SRS. Binary logistic regression was used to evaluate predictors of study outcomes. Results A total of 18 patients with progressive disease following subtotal (71%) and near-total (39%) resection of Koos grade IV disease (94%) were enrolled. Of the 18 patients, 7 were treated with dose-escalated SRS and 11 with standard-dose SRS. Over a median follow-up of 32 months after SRS, local control was 100% in the dose-escalated cohort and 91% in the standard-dose cohort ( p = 0.95). Neurologic sequelae occurred in 28% of patients, including 60% of dose-escalated cohort and 40% of the standard-dose cohort ( p = 0.12), although permanent neurologic sequelae were low at 6%. Conclusions Dose-escalated SRS has similar local control of recurrent VS following progression after subtotal or near-total resection and does not appear to have higher neurologic sequalae. Larger studies are needed.
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Affiliation(s)
- Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Alexander D Sherry
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Nauman Manzoor
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Douglas J Totten
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Lola B Chambless
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Alejandro Rivas
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - David S Haynes
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States.,Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
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Khattab MH, Sherry AD, Xu MC, Kelly P, Anderson JL, Luo G, Chambless LB, Cmelak AJ, Attia A. Stereotactic Radiosurgery and Hypofractionated Stereotactic Radiotherapy for Nonfunctioning Pituitary Adenoma. J Neurol Surg B Skull Base 2020; 82:e51-e58. [PMID: 34306917 DOI: 10.1055/s-0040-1710518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 03/14/2020] [Indexed: 10/24/2022] Open
Abstract
Objectives Hypofractionated stereotactic radiotherapy (HSRT) in two to five fractions may offer patients with large nonfunctioning pituitary adenomas (NFPAs) with chiasm involvement a safe and effective treatment over a single week. However, little has been reported regarding this novel approach. Design We compared the feasibility, outcomes, and toxicity of single-fraction stereotactic radiosurgery and HSRT. Setting This study was conducted at a tertiary academic referral center. Participants After approval by the institutional review board, we performed a retrospective cohort study of patients treated at our institution with stereotactic radiosurgery (SRS) and HSRT for NFPA. Selection for SRS or HSRT was based on clinicopathologic factors including tumor size and cavernous sinus invasion at the discretion of the treating physician. Main Outcome Measures Local control, endocrinopathy, and radiation-associated toxicity were evaluated by binary logistic regression and Cox's proportional hazards regression. Results A total of 45 patients with mean follow-up of 5 years were enrolled including 26 patients treated by HSRT with mean follow-up of 3 years and 19 patients treated by SRS with median follow-up of 6 years. Clinicopathologic characteristics were balanced between cohorts. Local failure at last follow-up was 5% in the SRS cohort and 8% in the HSRT cohort, and rates of post-SRS endocrinopathy were similar between each cohort. Late complications including radionecrosis, visual deficit, and secondary malignancy were minimal in either cohort. Conclusions HSRT is an appropriate treatment strategy for patients with NFPAs, particularly for optic pathway preservation in the setting of large tumors with chiasm involvement. Further studies are needed to optimize fractionated approaches and patient selection.
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Affiliation(s)
- Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Alexander D Sherry
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Mark C Xu
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Patrick Kelly
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Joshua L Anderson
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Lola B Chambless
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, United States.,Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
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Abstract
Background Lymphopenia during chemoradiation (CRT) for esophageal cancer (EC) can adversely affect clinical outcomes. We sought to explore an association between lymphopenia and dosimetric parameters during CRT for EC. Methods After IRB approval, we retrospectively reviewed 54 patients treated with either definitive or neoadjuvant CRT for EC. Absolute lymphocyte count was recorded weekly during CRT up and graded according to the common terminology of adverse events (CTCAE) version 4.0. Dose volume histograms (DVH) parameters were collected based on vertebral body, body dose, dose to peripheral lymphocytes, and spleen. Logistic regression correlated Grade 4 toxicity with DVH parameters and linear regression analysis correlated absolute lymphocyte nadir counts with DVH parameters. Receiver operator curves (ROC) were constructed to define dosimetric thresholds. Results There were a total of 21 Grade 4 events (38.8%) of lymphopenia. Increasing vertebral volume receiving ≥10 Gy (OR 1.1, P=0.04), ≥20 Gy (OR 1.1, P=0.03), ≥30 Gy (OR 1.1, P=0.012), or mean body dose (OR 1.04, P=0.032) were correlated with Grade 4 lymphopenia on multivariable logistic regression. The dosimetric parameters most predictive of Grade 4 toxicity via a ROC analysis included absolute vertebral volume receiving 10 Gy >289 cc, 20 Gy ≥270 cc, and vertebral volumes receiving 30 Gy ≥197 cc. On multivariable linear regression increasing volume receiving 20 Gy (Beta -0.004, P=0.001), 30 Gy (Beta -0.005, P=0.0046), and mean body dose (Beta -0.002, P=0.001) all correlated with absolute lymphocyte nadir. Conclusions Lymphopenia, a known negative prognostic factor in EC, is closely correlated with the volume of vertebral bodies receiving radiation during CRT for EC. Dosimetric sparing of the vertebral bodies may result in better outcomes.
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Affiliation(s)
- Neil B Newman
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | | | - Evan C Osmundson
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
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30
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Khattab MH, Sherry AD, Whitaker R, Wharton DM, Weaver KD, Chambless LB, Cmelak AJ, Attia A. A Retrospective Cohort Study of Longitudinal Audiologic Assessment in Single and Fractionated Stereotactic Radiosurgery for Vestibular Schwannoma. Neurosurgery 2020; 85:E1078-E1083. [PMID: 31215628 DOI: 10.1093/neuros/nyz219] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 03/18/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Fractionated stereotactic radiosurgery (SRS) for vestibular schwannomas (VS) has been theorized to allow for tumor control with higher rates of hearing preservation in selected patients with useful hearing. However, there is a paucity of literature with formal audiologic measures of hearing preservation to support the standard use of fractionated SRS in VS. We hypothesized that fractionation would diminish the amount of hearing damage. OBJECTIVE To evaluate the relationship between audiologic performance and SRS fractionation scheme. METHODS We performed an IRB-approved retrospective review of patients treated with 1, 3, or 5 fraction SRS for VS at our institution from 1998 to 2016. Pre- and post-SRS audiograms with speech awareness threshold (SAT) in treated and contralateral ears were obtained. Contralateral ear measurements were used for hearing normalization to account for presbycusis. RESULTS Fifty-six patients with median audiologic follow-up 2.0 yr (mean 2.66 yr, min-max 0.50-9.45 yr) were included. Patients treated with single fractionation had a significantly worsened SAT (dB) compared to patients treated with 5 fractions (P = .008) and compared to all multifraction patients (P = .009) at 12 to 24 mo follow-up. CONCLUSION This retrospective analysis supports the use of fractionated SRS to preserve hearing in patients with VS. SAT can be used as an objective metric of hearing response to radiosurgery.
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Affiliation(s)
- Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Ryan Whitaker
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David M Wharton
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Kyle D Weaver
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lola B Chambless
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
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Anderson JL, Newman NB, Anderson C, Sherry AD, Yock AD, Osmundson EC. Mean cardiopulmonary dose and vertebral marrow dose differentially predict lineage-specific leukopenia kinetics during radiotherapy for esophageal cancer. Radiother Oncol 2020; 152:169-176. [PMID: 32291110 DOI: 10.1016/j.radonc.2019.12.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 12/12/2019] [Accepted: 12/13/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE Lymphopenia is associated with poor outcomes in esophageal cancer (EC) patients undergoing chemoradiotherapy (CRT). We hypothesized that radiation dose to marrow (central) vs. circulating (peripheral) leukocytes (WBCs) may have unique effects on WBC counts and clinical outcomes in EC. MATERIALS AND METHODS Weekly and 90-day post-CRT blood cell counts were evaluated for 46 patients with stage II-III EC treated with CRT. Thoracic vertebral volume spared (TVS) radiation was extracted from dose volume histograms (DVH). Mean cardiopulmonary dose (mCPD) was calculated as mean dose to the volumetric sum of heart, lungs, and great vessels as a surrogate for circulating blood pool. Linear and logistic regression identified associations between dosimetric variables and hematologic toxicities (HT). Repeated measures ANOVA tested associations between cell count trends and clinical predictors. RESULTS WBCs and platelets reached nadir at week 6 of CRT. On multivariate analysis, mCPD was associated with lower WBC and neutrophil nadirs (p < 0.05). TVS5-40 Gy were associated with higher lymphocyte nadirs (all p < 0.05). Repeated measures ANOVA revealed an interaction effect of sex on absolute lymphocyte trend as well as age (<67 vs. >67) and diabetes on normalized lymphocyte trend (all p < 0.015). CONCLUSIONS mCPD and volume of thoracic marrow spared radiation differentially predict lineage-specific leukopenias during CRT for EC. mCPD is significantly associated with lower total WBC and neutrophil nadirs. In contrast, greater thoracic marrow spared radiation is associated with mitigation of lymphopenia during CRT. Clinical factors such as sex, age, and diabetes may be associated with a more rapid decline in hematologic counts during treatment.
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Affiliation(s)
| | - Neil B Newman
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, United States
| | | | | | - Adam D Yock
- Vanderbilt University School of Medicine, Nashville, United States
| | - Evan C Osmundson
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, United States.
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Sherry AD, Newman NB, Anderson JL, Osmundson EC. Systemic inflammatory dynamics during chemoradiotherapy predict response, relapse, metastasis, and survival in esophageal carcinoma. J Surg Oncol 2020; 121:303-312. [PMID: 31799692 DOI: 10.1002/jso.25793] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 11/25/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND AND OBJECTIVES Lymphopenia associated with chemoradiotherapy predicts prognosis in esophageal carcinoma. The purpose of our study was to evaluate alterations in hematologic measures of inflammation during chemoradiation. METHODS We performed an observational study evaluating adults treated with chemoradiation in the neoadjuvant or definitive setting for stage II-III esophageal carcinoma. Multivariable logistic regression evaluated predictors of pathologic response. Survival was analyzed by time-varying multivariable Cox proportional hazards regressions. RESULTS A total of 94 patients were included with median follow-up of 1.6 years. Elevated neutrophil:lymphocyte ratio (NLR) was predictive of incomplete pathologic response to neoadjuvant chemoradiation (OR, 1.07; P = .0030) as well as shorter distant metastasis-free survival (HR, 1.01; P = .0369) and reduced overall survival (HR, 1.01; P = .0448). An NLR > 5.55 in week two of chemoradiation predicted shorter overall survival (P = .0070). Upon adjusted analysis, NLR was independently associated with reduced probability of complete pathologic response (OR, 0.80; P = .0291), as well as poor histologic response to neoadjuvant chemoradiation (OR, 1.05; P = .0303), shorter disease-free survival (HR, 1.02; P = .0077), and reduced overall survival (HR, 1.02; P = .0070). CONCLUSIONS Dynamic time-dependent changes in NLR during chemoradiation predict response, relapse, metastasis, and survival in esophageal carcinoma. Prospective validation is warranted.
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Affiliation(s)
| | - Neil B Newman
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Evan C Osmundson
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
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Sherry AD, Bezzerides M, Khattab MH, Luo G, Ancell KK, Kirschner AN. An autoimmune-based, paraneoplastic neurologic syndrome following checkpoint inhibition and concurrent radiotherapy for merkel cell carcinoma: case report. Strahlenther Onkol 2020; 196:664-670. [PMID: 32006066 DOI: 10.1007/s00066-020-01582-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 01/11/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE Merkel cell carcinoma is highly sensitive to both radiation and immunotherapy. Moreover, concurrent radioimmunotherapy may capitalize on anti-tumor immune activity and improve Merkel cell treatment response, although an enhanced immune system may cross-react with native tissues and lead to significant sequelae. METHODS Here we present a case study of a patient with metastatic Merkel cell carcinoma treated with radiotherapy concurrent with pembrolizumab. RESULTS After radioimmunotherapy, the patient developed sensory neuropathy, visual hallucinations, and mixed motor neuron findings. Neurologic dysfunction progressed to profound gastrointestinal dysmotility necessitating parenteral nutrition and intubation with eventual expiration. CONCLUSION This case represents a unique autoimmune paraneoplastic neurologic syndrome, likely specific to neuroendocrine tumors and motivated by concurrent radioimmunotherapy. Recognition of the potential role of radioimmunotherapy may provide an advantage in anticipating these severe sequelae.
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MESH Headings
- Aged
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antineoplastic Agents, Immunological/adverse effects
- Antineoplastic Agents, Immunological/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Autoimmune Diseases of the Nervous System/etiology
- Autoimmune Diseases of the Nervous System/immunology
- Axilla
- Carboplatin/administration & dosage
- Carcinoma, Merkel Cell/drug therapy
- Carcinoma, Merkel Cell/radiotherapy
- Carcinoma, Merkel Cell/secondary
- Combined Modality Therapy
- Deglutition Disorders/etiology
- Etoposide/administration & dosage
- Fatal Outcome
- Fingers
- Hallucinations/etiology
- Humans
- Lymphatic Metastasis/diagnostic imaging
- Lymphatic Metastasis/radiotherapy
- Male
- Neuralgia/drug therapy
- Neuralgia/etiology
- Palliative Care
- Paraneoplastic Syndromes, Nervous System/etiology
- Paraneoplastic Syndromes, Nervous System/immunology
- Parenteral Nutrition, Total
- Pneumonia, Aspiration/etiology
- Positron Emission Tomography Computed Tomography
- Radioimmunotherapy/adverse effects
- Radiotherapy, High-Energy
- Radiotherapy, Intensity-Modulated/adverse effects
- Skin Neoplasms/drug therapy
- Skin Neoplasms/radiotherapy
- Skin Neoplasms/secondary
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Affiliation(s)
| | | | - Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt University Medical Center, 2220 Pierce Avenue, PRB-B1003, Nashville, TN, USA
| | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt University Medical Center, 2220 Pierce Avenue, PRB-B1003, Nashville, TN, USA
| | - Kristin K Ancell
- Department of Medicine, Division of Hematology Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Austin N Kirschner
- Department of Radiation Oncology, Vanderbilt University Medical Center, 2220 Pierce Avenue, PRB-B1003, Nashville, TN, USA.
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Khattab MH, Sherry AD, Kim E, Anderson J, Luo G, Yu H, Englot DJ, Chambless LB, Cmelak AJ, Attia A. Body mass index and response to stereotactic radiosurgery in the treatment of refractory trigeminal neuralgia: A retrospective cohort study. J Radiosurg SBRT 2020; 6:253-261. [PMID: 32185084 PMCID: PMC7065898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 07/11/2019] [Indexed: 06/10/2023]
Abstract
Stereotactic radiosurgery (SRS) is used as a noninvasive treatment option for patients with trigeminal neuralgia (TN), but the effect of obesity on pain relief post SRS, if any, is unknown. The primary goal of our study was to evaluate the association between obesity and response to SRS in patients with TN. We conducted an IRB-approved retrospective review of patients treated with SRS for TN between 2010 and 2017. Barrow Neurologic Institute (BNI) Score was assigned pre-and post-SRS to quantify pain level. Thirty-two patients (65% female) between the ages of 24 and 96 were studied with a median follow-up time of 11 months. Patients with BMI >25 were significantly less likely to have improvement in their symptoms with SRS (p = 0.005). Elevated BMI may be associated with worsened response to SRS in the treatment of TN.
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Affiliation(s)
- Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt University Medical Center, 2220 Pierce Avenue, PRB-B1003, Nashville, TN 37232, USA
| | | | - Ellen Kim
- Department of Radiation Oncology, Vanderbilt University Medical Center, 2220 Pierce Avenue, PRB-B1003, Nashville, TN 37232, USA
| | - Joshua Anderson
- Vanderbilt University School of Medicine, Nashville, TN 37232, USA
| | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt University Medical Center, 2220 Pierce Avenue, PRB-B1003, Nashville, TN 37232, USA
| | - Hong Yu
- Department of Radiation Oncology, Vanderbilt University Medical Center, 2220 Pierce Avenue, PRB-B1003, Nashville, TN 37232, USA
- Vanderbilt University School of Medicine, Nashville, TN 37232, USA
- Department of Biomedical Engineering, School of Engineering, Vanderbilt University, Nashville, TN 37232, USA
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Dario J Englot
- Department of Biomedical Engineering, School of Engineering, Vanderbilt University, Nashville, TN 37232, USA
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Lola B Chambless
- Department of Radiation Oncology, Vanderbilt University Medical Center, 2220 Pierce Avenue, PRB-B1003, Nashville, TN 37232, USA
- Vanderbilt University School of Medicine, Nashville, TN 37232, USA
- Department of Biomedical Engineering, School of Engineering, Vanderbilt University, Nashville, TN 37232, USA
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Vanderbilt University Institute of Imaging Science, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center, 2220 Pierce Avenue, PRB-B1003, Nashville, TN 37232, USA
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt University Medical Center, 2220 Pierce Avenue, PRB-B1003, Nashville, TN 37232, USA
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Sherry AD, Bingham B, Kim E, Monsour M, Luo G, Attia A, Chambless LB, Cmelak AJ. Secondary malignancy following stereotactic radiosurgery for benign neurologic disease: A cohort study and review of the literature. J Radiosurg SBRT 2020; 6:287-294. [PMID: 32185088 PMCID: PMC7065897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 12/17/2019] [Indexed: 06/10/2023]
Abstract
Radiation-associated malignancy and malignant transformation are risks associated with stereotactic radiosurgery (SRS); however, incidence is uncertain. The purpose of our study is to present the rate of radiation-associated malignancy and malignant transformation at our institution. After IRB approval, we undertook a retrospective cohort study evaluating patients treated with Gamma Knife® or linac-based SRS between 1990 and 2014 for benign CNS pathology with at least 5 years of clinical follow-up. Risk of transformation was calculated using the Kaplan-Meier method. A total of 273 patients met selection criteria. Median clinical follow-up after SRS was 11 years (range 5-27). Over 3,216 patient-years following SRS, we found zero cases of radiation-associated malignancy and two cases of radiation-associated malignant transformation for a crude rate of 0.73% or case rate of 0.62 per 1,000 patient-years. The Kaplan-Meier risk of malignant transformation at 5, 10, and 15 years was 0.4% (95% CI 0.05% 2.6%). These data support the continued use of SRS for benign intracranial pathology without significant concern for secondary malignancy.
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Affiliation(s)
| | - Brian Bingham
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ellen Kim
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lola B. Chambless
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Anthony J. Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
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Sherry AD, Stewart A, Luo G, Kirschner AN. Intensity-Modulated Radiotherapy is Superior to Three-Dimensional Conformal Radiotherapy in the Trimodality Management of Muscle-Invasive Bladder Cancer with Daily Cone Beam Computed Tomography Optimization. ACTA ACUST UNITED AC 2019; 8:395-403. [PMID: 33343830 DOI: 10.1007/s13566-019-00411-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Objective Intensity modulated radiation therapy (IMRT) using a volumetric-modulated arc therapy technique may offer dosimetric and clinical benefits compared to the historical standard of care 3D-conformal radiotherapy (3D-CRT) in definitive treatment of bladder cancer. We hypothesized that IMRT with CBCT would reduce dose to the rectum, bowel, and bladder compared to 3D-CRT. Methods We reviewed nineteen patients treated with maximal transurethral resection of bladder tumor followed by concurrent chemotherapy with IMRT. All patients received 45 Gy to the entire empty bladder followed by 19.8 Gy tumor boost treated with full bladder. 3D-CRT treatment plans were created for the same prescription. Paired t-test or Wilcoxon matched-pairs signed rank test analyzed dosimetry and bladder volumes. Results The rectum and bowel V40, V45, V50, V55, and V60 were reduced by over 50% in the IMRT plans compared to 3D-CRT (p<0.0001). IMRT also reduced volume of bladder irradiated compared to 3D-CRT (p<0.01). After CBCT, patients were likely to undergo clinically significant shifts ≥ 0.5 cm before boost delivery (p=0.001). Bladder volumes were significantly lower during boost treatments compared to pre-treatment simulation (p=0.002). There were 4 (21%) grade 3 genitourinary toxicities and 1 (5%) grade 3 gastrointestinal toxicity. Conclusion IMRT is superior to 3D-CRT for bladder cancer and spares dose to bowel, rectum, and bladder with improved acute toxicity compared to published clinical literature. For boost treatment, daily full bladder volume and positioning are not always reproducible, supporting the need for CBCT for optimal localization of the primary bladder tumor.
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Affiliation(s)
| | | | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN USA
| | - Austin N Kirschner
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN USA
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Sherry AD, Khattab MH, Xu MC, Kelly P, Anderson JL, Luo G, Utz AL, Chambless LB, Cmelak AJ, Attia A. Outcomes of stereotactic radiosurgery and hypofractionated stereotactic radiotherapy for refractory Cushing's disease. Pituitary 2019; 22:607-613. [PMID: 31552580 DOI: 10.1007/s11102-019-00992-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE Hypofractionated stereotactic radiotherapy (HSRT) for refractory Cushing's disease may offer a condensed treatment schedule for patients with large tumors abutting the optic chiasm unsuitable for stereotactic radiosurgery (SRS). To-date only four patients have been treated by HSRT in the published literature. We investigated the feasibility, toxicity, and efficacy of HSRT compared to SRS. METHODS After approval, we retrospectively evaluated patients treated at our institution for refractory Cushing's disease with SRS or HSRT. Study outcomes included biochemical control, time to biochemical control, local control, and late complications. Binary logistic regression and Cox proportional hazards regression evaluated predictors of outcomes. RESULTS Patients treated with SRS (n = 9) and HSRT (n = 9) were enrolled with median follow-up of 3.4 years. Clinicopathologic details were balanced between the cohorts. Local control was 100% in both cohorts. Time to biochemical control was 6.6. and 9.5 months in the SRS and HSRT cohorts, respectively (p = 0.6258). Two patients in each cohort required salvage bilateral adrenalectomy. Late complications including secondary malignancy, radionecrosis, cranial nerve neuropathy, and optic pathway injury were minimal for either cohort. CONCLUSIONS HSRT is an appropriate treatment approach for refractory Cushing's disease, particularly for patients with large tumors abutting the optic apparatus. Prospective studies are needed to validate these findings and identify factors suggesting optimal fractionation approaches.
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Affiliation(s)
| | - Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, 2220 Pierce Avenue, Preston Research Building, Rm B-1003, Nashville, TN, 37232-5671, USA.
| | - Mark C Xu
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Patrick Kelly
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, 2220 Pierce Avenue, Preston Research Building, Rm B-1003, Nashville, TN, 37232-5671, USA
| | - Andrea L Utz
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
- Division of Diabetes, Endocrinology & Metabolism, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Pituitary Center, Nashville, TN, USA
| | - Lola B Chambless
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, 2220 Pierce Avenue, Preston Research Building, Rm B-1003, Nashville, TN, 37232-5671, USA
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, 2220 Pierce Avenue, Preston Research Building, Rm B-1003, Nashville, TN, 37232-5671, USA
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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Scudder DR, Sherry AD, Jarrett RT, Fernando S, Kuhn AW, Fleming AE. Fundamental Curriculum Change with 1-Year Pre-Clerkship Phase and Effect on Stress Associated with Residency Specialty Selection. Med Sci Educ 2019; 29:1033-1042. [PMID: 34457581 PMCID: PMC8368347 DOI: 10.1007/s40670-019-00800-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Vanderbilt University School of Medicine recently changed from 2 pre-clerkship years (Traditional curriculum) to a 1.5-year pre-clerkship phase for one class (Hybrid curriculum) to a 1-year pre-clerkship phase (Curriculum 2.0). This study investigated the relationship between shortened pre-clerkship training and stress associated with selecting a residency field. The surveyed graduating medical student population included one cohort from the Traditional and Hybrid curricula, and the first two cohorts from Curriculum 2.0. The authors modeled recollected stress levels using a Zero-Inflated Linear Mixed Model with additional covariate and random effects adjustments. Specialty decision-related stress levels increased in the Hybrid curriculum by 10.208 points [p = 0.0115, 95% CI 2.293, 18.122] on a 0-100 point scale. Curriculum 2.0 students had an insignificant increase in stress of 4.062 points [p = 0.304, 95% CI - 3.690, 11.814] relative to the Traditional curriculum. Time since starting medical school and time when a specialty was chosen were the largest factors associated with stress. While this study only evaluated a single facet of the potential downstream effects of curricular change, these data should inspire confidence for reform efforts as a significant increase in specialty decision-related stress present in Hybrid curriculum resolved in both cohorts of Curriculum 2.0.
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Affiliation(s)
- David R. Scudder
- Vanderbilt University School of Medicine, Nashville, TN USA
- Departments of Internal Medicine and Pediatrics, University of Colorado School of Medicine, Aurora, CO USA
| | | | - Ryan T. Jarrett
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN USA
| | - Shanik Fernando
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, TN USA
| | - Andrew W. Kuhn
- Vanderbilt University School of Medicine, Nashville, TN USA
| | - Amy E. Fleming
- Vanderbilt University School of Medicine, Nashville, TN USA
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Khattab MH, Sherry AD, Cmelak AJ, Attia A. In Reply: A Retrospective Cohort Study of Longitudinal Audiologic Assessment in Single and Fractionated Stereotactic Radiosurgery for Vestibular Schwannoma. Neurosurgery 2019; 85:E1127-E1129. [PMID: 31529045 DOI: 10.1093/neuros/nyz373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Mohamed H Khattab
- Department of Radiation Oncology Vanderbilt University Medical Center Nashville, Tennessee
| | | | - Anthony J Cmelak
- Department of Radiation Oncology Vanderbilt University Medical Center Nashville, Tennessee
| | - Albert Attia
- Department of Radiation Oncology Vanderbilt University Medical Center Nashville, Tennessee.,Department of Neurological Surgery Vanderbilt University Medical Center Nashville, Tennessee
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Khattab MH, Newman NB, Wharton DM, Sherry AD, Luo G, Manzoor NF, Rivas A, Davis LT, Chambless LB, Attia A, Cmelak AJ. Longitudinal Radiographic Outcomes of Vestibular Schwannoma in Single and Fractionated Stereotactic Radiosurgery: A Retrospective Cohort Study. J Neurol Surg B Skull Base 2019; 81:308-316. [PMID: 32500007 DOI: 10.1055/s-0039-1692642] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 03/20/2019] [Indexed: 02/08/2023] Open
Abstract
Management of vestibular schwannoma (VS) includes stereotactic radiosurgery (SRS) in single or fractionated treatments. There is a paucity of literature on the three-dimensional (3D) volumetric kinetics and radiological changes following SRS and no consensus on appropriate post-SRS surveillance imaging timeline. This is a retrospective cohort study with institutional review board approval. A total of 55 patients met study criteria. We collected volumetric kinetic data in VS treated with SRS over time using a target volume contouring software. We also tracked radiographic phenomena such as pseudoprogression and necrosis. A secondary objective was to describe our overall treatment success rate and any failures. For all treatments groups, pseudoprogression most typically occurred within 12 months post-SRS, after which tumor volumes on average normalized and then decreased from pretreatment size at the last follow-up. Only two patients required salvage therapy post-SRS and were considered SRS treatment failures. Both patients were in the five-fraction cohort but with a lower biologically equivalent dose. Our study is first to collect 3D volumetric kinetics of VS following single and fractionated SRS in contrast to extrapolations from single and two-dimensional measurements. Our longitudinal data also show initial increases in volume in the first 12 months post-SRS followed by later declines, setting up interesting questions regarding the utility of early posttreatment surveillance imaging in the asymptomatic patient. Finally, we show low rates of treatment failure (3.6%) and show in our cohort that SRS dose de-escalation posed a risk of treatment failure.
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Affiliation(s)
- Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Neil B Newman
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - David M Wharton
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Alexander D Sherry
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Nauman F Manzoor
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Alejandro Rivas
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - L Taylor Davis
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Lola B Chambless
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
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Funk AM, Wen X, Hever T, Maptue NR, Khemtong C, Sherry AD, Malloy CR. Effects of deuteration on transamination and oxidation of hyperpolarized 13C-Pyruvate in the isolated heart. J Magn Reson 2019; 301:102-108. [PMID: 30861456 PMCID: PMC6666394 DOI: 10.1016/j.jmr.2019.03.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/01/2019] [Accepted: 03/03/2019] [Indexed: 06/04/2023]
Abstract
This study was designed to determine the effects of deuteration in pyruvate on exchange reactions in alanine aminotransferase (ALT), lactate dehydrogenase (LDH) and flux through pyruvate dehydrogenase (PDH). Although deuteration of a 13C enriched substrate is commonly used to increase the lifetime of a probe for hyperpolarization experiments, the potential impact of kinetic isotope effects on such substitutions has not been studied in detail. Metabolism of deuterated pyruvate was investigated in isolated rat hearts. Hearts were perfused with a 1:1 mixture of [U-13C3]pyruvate and [2-13C1]pyruvate or a 1:1 mixture of [U-13C3]pyruvate plus [2-13C1, U-2H3]pyruvate for 30 min before being freeze clamped. Another set of hearts received [2-13C1, U-2H3]pyruvate and was freeze-clamped at 3 min or 6 min. Tissue extracts were analyzed by 1H and 13C{1H} NMR spectroscopy. The chemical shift isotope effect of 2H was monitored in the 13C NMR spectra of the C2 resonance of lactate and alanine plus the C5 of glutamate. There was little kinetic isotope effect of 2H in pyruvate on flux through PDH, LDH or ALT as detected by the distribution of 13C, but the distribution of 2H differed markedly between alanine and lactate. At steady-state, alanine was a mixture of deuterated species, while lactate was largely perdeuterated. Consistent with results at steady-state, hearts freeze-clamped at 3 min or 6 min showed rapid removal of deuterium in alanine but not in lactate. Metabolism of hyperpolarized [1-13C1]pyruvate was compared to [1-13C1,U-2H3]pyruvate in isolated hearts. Consistent with the results from tissue extracts, there was little effect of deuteration on the kinetics of appearance of lactate, alanine or bicarbonate, but there was a small, time-dependent upfield chemical shift in the HP[1-13C1]alanine signal reflecting exchange of methyl deuterons with water protons. Together, these results demonstrate that (1) the kinetics of pyruvate metabolism in hearts detected by 13C NMR are not affected by replacement of the pyruvate methyl protons with deuterons and (2) that the loss of deuterium from the methyl position occurs rapidly during the conversion of pyruvate to alanine. The majority of the deuterium atoms are lost on the time-scale of a hyperpolarization experiment.
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Affiliation(s)
- Alexander M Funk
- Advanced Imaging Research Center, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Xiaodong Wen
- Advanced Imaging Research Center, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Thomas Hever
- Advanced Imaging Research Center, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Nesmine R Maptue
- Advanced Imaging Research Center, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Chalermchai Khemtong
- Advanced Imaging Research Center, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - A D Sherry
- Advanced Imaging Research Center, University of Texas Southwestern Medical Center, Dallas, TX, United States; Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, United States; Department of Chemistry, University of Texas at Dallas, Richardson, TX, United States
| | - Craig R Malloy
- Advanced Imaging Research Center, University of Texas Southwestern Medical Center, Dallas, TX, United States; Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, United States; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States; Veterans Affairs North Texas Healthcare System, Dallas, TX, United States.
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Khattab MH, Sherry AD, Ahlers CG, Kirschner AN. Radiation-associated epithelial-myoepithelial carcinoma among five secondary malignancies: A case report and review of literature. World J Clin Oncol 2018; 9:200-207. [PMID: 30622928 PMCID: PMC6314863 DOI: 10.5306/wjco.v9.i8.200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 11/07/2018] [Accepted: 11/15/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Epithelial-myoepithelial carcinoma (EMC) is a rare, low-grade, malignant tumor that constitutes less than one percent of all salivary gland tumors. To date, only one other case report has described radiation-associated EMC in the English language medical literature.
CASE SUMMARY In this report, we describe the case of a 56-year-old male patient who presented with a neck mass diagnosed as EMC of the left submandibular gland approximately 30 years after mantle field radiation and chemotherapy for Hodgkin lymphoma. Treatment included resection, re-resection with nodal dissection, and adjuvant chemoradiotherapy. This patient was also diagnosed with 4 other secondary malignancies, including stage IV diffuse large B cell lymphoma in the abdomen with subsequent brain metastases, low-grade neuroendocrine carcinoma of the lung, Hurthle cell adenoma, and small B cell lymphoma before the patient expired. This case provides important information regarding the pathology, clinical sequelae, and management of a patient diagnosed with radiation-associated EMC amidst four concurrent malignancies.
CONCLUSION Further investigation is needed on the efficacy of adjuvant radiotherapy in EMC, especially atypical EMC.
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Affiliation(s)
- Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN 37232, United States
| | - Alexander D Sherry
- Vanderbilt University School of Medicine, Nashville, TN 37232, United States
| | - Carolyn G Ahlers
- Vanderbilt University School of Medicine, Nashville, TN 37232, United States
| | - Austin N Kirschner
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN 37232, United States
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Sherry AD, Barlow CL. Incorporating Formative Assessments Into the Preclerkship Lecture. Acad Med 2017; 92:734-735. [PMID: 28557927 DOI: 10.1097/acm.0000000000001706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Alexander D Sherry
- First-year medical student, Vanderbilt University School of Medicine, Nashville, Tennessee; . High school science teacher, Chapel Hill High School, Chapel Hill, North Carolina
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Vander Elst L, Zhang S, Sherry AD, Laurent S, Botteman F, Muller RN. Dy-complexes as high field T2 contrast agents: influence of water exchange rates. Acad Radiol 2002; 9 Suppl 2:S297-9. [PMID: 12188253 DOI: 10.1016/s1076-6332(03)80208-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Dy complexes can act as suitable negative (T2) contrast agents for Magnetic Resonance Imaging (MRI). As clinical MRI moves toward higher fields, tuning of the exchange rate of coordinated water molecules will become necessary to optimize the r2 relaxivity. For Dy complexes, this will require lengthening of the water residence time, a strategy opposite that required to optimize the r1 relaxivity of Gd complexes. However, very slow water exchange can be deleterious. This is illustrated here by a Dy complex that is characterized by a very slow water exchange. This complex, Dy-DOTA-4AmCE, is compared with several Dy-DTPA derivatives known for their efficacy as T2 contrast agents at high magnetic fields.
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Affiliation(s)
- L Vander Elst
- Department of Organic Chemistry, University of Mons-Hainaut, Mons, Belgium
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Caravan P, Greenfield MT, Li X, Sherry AD. The Gd(3+) complex of a fatty acid analogue of DOTP binds to multiple albumin sites with variable water relaxivities. Inorg Chem 2001; 40:6580-7. [PMID: 11735466 DOI: 10.1021/ic0102900] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The 20 MHz water relaxivity (r(1)) of gadolinium(III) complexes formed with two fatty acid analogues of 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetrakis(methylene phosphonate) were shown to increase substantially in the presence of albumin. The r(1) values of Gd(C(8)-DOTP)(5-) and Gd(C(11)-DOTP)(5-) in water were similar to that of the parent GdDOTP(5-), a q = 0 complex known to relax water very efficiently via an outer-sphere mechanism. Neither fatty acid analogue formed apparent aggregates or micelles in water up to 20 mM, but both showed dramatic increases in r(1) upon addition of albumin. Further ultrafiltration studies of Gd(C(11)-DOTP)(5-) in the presence of non-defatted HSA showed that the complex binds at a minimum of five high-affinity fatty acid sites with stepwise binding constants ranging from 1.27 x 10(5) to 2.7 x 10(3) M(-1). The 20 MHz relaxivity of Gd(C(11)-DOTP)(5-) in the presence of excess HSA was 23 mM(-1) s(-1) at 25 degrees C. The NMRD curve showed a broad maximum 20-30 MHz which fitted well to standard theory for a q = 0 complex with rapid outer-sphere water exchange. The r(1b) of Gd(C(11)-DOTP)(5-) bound at the tightest site on HSA was approximately 40 mM(-1) s(-1) at 5 degrees C, an extraordinarily high value for an outer-sphere complex. However, the r(1b) of Gd(C(11)-DOTP)(5-) bound at the weaker sites on HSA was considerably lower, approaching the relaxivity of the free complex in water. This suggests that the complex bound in the highest affinity fatty acid site is less mobile than the same complex bound at the weaker affinity fatty acid sites. This combined ultrafiltration and relaxivity study demonstrates that the common assumption of a single r(1b) value for a Gd(3+) complex bound at several protein sites is not a valid approximation.
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Affiliation(s)
- P Caravan
- EPIX Medical, 71 Rogers Street, Cambridge, Massachusetts 02142, USA
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Li X, Zhang S, Zhao P, Kovacs Z, Sherry AD. Synthesis and NMR studies of new DOTP-like lanthanide(III) complexes containing a hydrophobic substituent on one phosphonate side arm. Inorg Chem 2001; 40:6572-9. [PMID: 11735465 DOI: 10.1021/ic010291s] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Three derivatives of 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetrakis(methylene phosphonic acid) (DOTP) containing a hydrophobic substituent on one side chain were prepared and their lanthanide complexes examined by NMR. The new ligands include 1-(1-octyl-methyl-phosphonic acid)-4,7,10-tris(methylene phosphonic acid)-1,4,7,10-tetraazacyclododecane (C(8)-DOTP), 1-(1-undecyl-methyl-phosphonic acid)-4,7,10-tris(methylene phosphonic acid)-1,4,7,10-tetraazacyclododecane (C(11)-DOTP), and 1-(1-4-nitro-phenyl-methyl-phosphonic acid)-4,7,10-tris(methylene phosphonic acid)-1,4,7,10-tetraazacyclododecane (NO(2)-Ph-DOTP). (1)H NMR spectra of the ytterbium(III) complexes were assigned by using a combination of COSY spectroscopy and a fitting procedure that matches experimental NMR hyperfine shifts with those estimated from a MMX-derived structure. The analysis showed that a single isomer is present in solution and that the bulky hydrophobic substituent occupies the less sterically demanding H(6) equatorial position in the YbL(5)(-) complexes. Although the YbL(5)(-) complexes have lower symmetry due to the added substituent, the average (1)H hyperfine shifts are 5-10% larger in these complexes compared to YbDOTP(5)(-). This was magnified further in the hyperfine (23)Na NMR shifts of ion-paired sodium ions where the extracellular Na(+) signal in perfused rat hearts displayed a 28% larger hyperfine shift in the presence of Tm(C(11)-DOTP)(5)(-) than with an equivalent amount of TmDOTP(5)(-).
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Affiliation(s)
- X Li
- Department of Chemistry, University of Texas at Dallas, Richardson, Texas 75083, USA
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Abstract
Hepatic glucose synthesis from glycogen, glycerol, and the tricarboxylic acid (TCA) cycle was measured in five overnight-fasted subjects by (1)H, (2)H, and (13)C NMR analysis of blood glucose, urinary acetaminophen glucuronide, and urinary phenylacetylglutamine after administration of [1,6-(13)C(2)]glucose, (2)H(2)O, and [U-(13)C(3)]propionate. This combination of tracers allows three separate elements of hepatic glucose production (GP) to be probed simultaneously in a single study: 1) endogenous GP, 2) the contribution of glycogen, phosphoenolpyruvate (PEP), and glycerol to GP, and 3) flux through PEP carboxykinase, pyruvate recycling, and the TCA cycle. Isotope-dilution measurements of [1,6-(13)C(2)] glucose by (1)H and (13)C NMR indicated that GP in 16-h-fasted humans was 10.7 +/- 0.9 micromol.kg(-1).min(-1). (2)H NMR spectra of monoacetone glucose (derived from plasma glucose) provided the relative (2)H enrichment at glucose H-2, H-5, and H-6S, which, in turn, reflects the contribution of glycogen, PEP, and glycerol to total GP (5.5 +/- 0.7, 4.8 +/- 1.0, and 0.4 +/- 0.3 micromol.kg(-1).min(-1), respectively). Interestingly, (13)C NMR isotopomer analysis of phenylacetylglutamine and acetaminophen glucuronide reported different values for PEP carboxykinase flux (68.8 +/- 9.8 vs. 37.5 +/- 7.9 micromol.kg(-1).min(-1)), PEP recycling flux (59.1 +/- 9.8 vs. 27.8 +/- 6.8 micromol.kg(-1).min(-1)), and TCA cycle flux (10.9 +/- 1.4 vs. 5.4 +/- 1.4 micromol.kg(-1).min(-1)). These differences may reflect zonation of propionate metabolism in the liver.
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Affiliation(s)
- J G Jones
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas 75235, USA
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Burgess SC, Babcock EE, Jeffrey FM, Sherry AD, Malloy CR. NMR indirect detection of glutamate to measure citric acid cycle flux in the isolated perfused mouse heart. FEBS Lett 2001; 505:163-7. [PMID: 11557062 DOI: 10.1016/s0014-5793(01)02799-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
(13)C-edited proton nuclear magnetic resonance (NMR) spectroscopy was used to follow enrichment of glutamate C3 and C4 with a temporal resolution of approximately 20 s in mouse hearts perfused with (13)C-enriched substrates. A fit of the NMR data to a kinetic model of the tricarboxylic acid (TCA) cycle and related exchange reactions yielded TCA cycle (V(tca)) and exchange (V(x)) fluxes between alpha-ketoglutarate and glutamate. These fluxes were substrate-dependent and decreased in the order acetate (V(tca)=14.1 micromol g(-1) min(-1); V(x)=26.5 micromol g(-1) min(-1))>octanoate (V(tca)=6.0 micromol g(-1) min(-1); V(x)=16.1 micromol g(-1) min(-1))>lactate (V(tca)=4.2 micromol g(-1) min(-1); V(x)=6.3 micromol g(-1) min(-1)).
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Affiliation(s)
- S C Burgess
- Department of Chemistry, University of Texas at Dallas, USA
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Carvalho RA, Zhao P, Wiegers CB, Jeffrey FM, Malloy CR, Sherry AD. TCA cycle kinetics in the rat heart by analysis of (13)C isotopomers using indirect (1)H. Am J Physiol Heart Circ Physiol 2001; 281:H1413-21. [PMID: 11514314 DOI: 10.1152/ajpheart.2001.281.3.h1413] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This study was designed to test the hypothesis that indirect (1)H[(13)C] detection of tricarboxylic acid (TCA) cycle intermediates using heteronuclear multiple quantum correlation-total correlation spectroscopy (HMQC-TOCSY) nuclear magnetic resonance (NMR) spectroscopy provides additional (13)C isotopomer information that better describes the kinetic exchanges that occur between intracellular compartments than direct (13)C NMR detection. NMR data were collected on extracts of rat hearts perfused at various times with combinations of [2-(13)C]acetate, propionate, the transaminase inhibitor aminooxyacetate, and (13)C multiplet areas derived from spectra of tissue glutamate were fit to a standard kinetic model of the TCA cycle. Although the two NMR methods detect different populations of (13)C isotopomers, similar values were found for TCA cycle and exchange fluxes by analyzing the two data sets. Perfusion of hearts with unlabeled propionate in addition to [2-(13)C]acetate resulted in an increase in the pool size of all four-carbon TCA cycle intermediates. This allowed the addition of isotopomer data from aspartate and malate in addition to the more abundant glutamate. This study illustrates that metabolic inhibitors can provide new insights into metabolic transport processes in intact tissues.
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Affiliation(s)
- R A Carvalho
- Mary Nell and Ralph B. Rogers Magnetic Resonance Center, Department of Radiology, University of Texas Southwestern Medical Center, Dallas 75390-9085, USA
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Zhang S, Wu K, Biewer MC, Sherry AD. 1H and (17)O NMR detection of a lanthanide-bound water molecule at ambient temperatures in pure water as solvent. Inorg Chem 2001; 40:4284-90. [PMID: 11487334 DOI: 10.1021/ic0003877] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Lanthanide complexes of a tetra-amide derivative of DOTA (structure 4 in text) with four extended carboxymethyl esters have been characterized by X-ray crystallography and multinuclear NMR spectroscopy. [Eu(4)(H(2)O)](triflate)(3) crystallized from water in the monoclinic, P(21/)(c) space group (a = 10.366 A, b = 22.504 A, c = 23.975 A, and beta = 97.05 degrees ). The Eu(3+) cation is bound to four macrocyclic nitrogen atoms (mean Eu-N = 2.627 A) and four amide oxygen atoms (mean Eu-O(amide) = 2.335 A) in a square antiprismatic geometry with a twist angle of 38.5 degrees between the N4 and O4 planes. A single bound water molecule (Eu-O(W) = 2.414 A) occupies a typical monocapped position on the O4 surface. In pure water, resonances corresponding to a single Eu(3+)-bound water molecule were observed in the (1)H (53 ppm) and (17)O (-897 ppm) NMR spectra of [Eu(4)(H(2)O)](triflate)(3) at 25 degrees C. A fit of the temperature-dependent Eu(3+)-bound (1)H and (17)O water resonance line widths in acetonitrile-d(3) (containing 4% v/v (17)O enriched water) gave identical lifetimes (tau(m)(298)) of 789 +/- 50 micros (in water as solvent; a line shape analysis of the Eu(3+)-bound water resonance gave a tau(m)(298) = 382 +/- 5 micros). Slow water exchange was also evidenced by the water proton relaxivity of Gd(4) (R(1) = 2.2 mM(-1) s(-1), a value characteristic of pure outer-sphere relaxation at 25 degrees C). With increasing temperature, the inner-sphere contribution gradually increased due to accelerated chemical exchange between bound water and bulk water protons. A fitting of the relaxation data (T(1)) to standard SBM theory gave a water proton lifetime (tau(m)(298)) of 159 micros, somewhat shorter than the value determined by high-resolution (1)H and (17)O NMR of Eu(4). Exchange of the bound water protons in Gd(4) with bulk water protons was catalyzed by addition of exogenous phosphate at 25 degrees C (R(1) increased to 10.0 mM(-1) s(-1) in the presence of 1500-fold excess HPO(4)(2-)).
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Affiliation(s)
- S Zhang
- Department of Chemistry, University of Texas at Dallas, P.O. Box 830688, Richardson, Texas 75083, USA
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