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Kubeczko M, Jarząb M, Gabryś D, Krzywon A, Cortez AJ, Xu AJ. Corrigendum to "Safety and feasibility of CDK4/6 inhibitors treatment combined with radiotherapy in patients with HR-positive/HER2-negative breast cancer. A systematic review and meta-analysis" [Radiother. Oncol. 187 (2023) 109839]. Radiother Oncol 2024; 194:110188. [PMID: 38447357 DOI: 10.1016/j.radonc.2024.110188] [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: 03/08/2024]
Affiliation(s)
- Marcin Kubeczko
- Breast Cancer Center, Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Poland.
| | - Michał Jarząb
- Breast Cancer Center, Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Poland
| | - Dorota Gabryś
- Department of Radiotherapy, Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Poland
| | - Aleksandra Krzywon
- Department of Biostatistics and Bioinformatics, Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Poland
| | - Alexander J Cortez
- Department of Biostatistics and Bioinformatics, Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Poland
| | - Amy J Xu
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York City, USA
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Moore A, Zhang Z, Fei T, Zhang L, Accomando L, Schmitt AM, Higginson DS, Mueller BA, Zinovoy M, Gelblum DY, Yerramilli D, Xu AJ, Brennan VS, Guttmann DM, Grossman CE, Dover LL, Shaverdian N, Pike LRG, Cuaron JJ, Dreyfuss A, Lis E, Barzilai O, Bilsky MH, Yamada Y. 40 Gray in 5 Fractions for Salvage Reirradiation of Spine Lesions Previously Treated With Stereotactic Body Radiotherapy. Neurosurgery 2024:00006123-990000000-01077. [PMID: 38456696 DOI: 10.1227/neu.0000000000002889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 01/04/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND AND PURPOSE A retrospective single-center analysis of the safety and efficacy of reirradiation to 40 Gy in 5 fractions (reSBRT) in patients previously treated with stereotactic body radiotherapy to the spine was performed. METHODS We identified 102 consecutive patients treated with reSBRT for 105 lesions between 3/2013 and 8/2021. Sixty-three patients (61.8%) were treated to the same vertebral level, and 39 (38.2%) to overlapping immediately adjacent levels. Local control was defined as the absence of progression within the treated target volume. The probability of local progression was estimated using a cumulative incidence curve. Death without local progression was considered a competing risk. RESULTS Most patients had extensive metastatic disease (54.9%) and were treated to the thoracic spine (53.8%). The most common regimen in the first course of stereotactic body radiotherapy was 27 Gy in 3 fractions, and the median time to reSBRT was 16.4 months. At the time of simulation, 44% of lesions had advanced epidural disease. Accordingly, 80% had myelogram simulations. Both the vertebral body and posterior elements were treated in 86% of lesions. At a median follow-up time of 13.2 months, local failure occurred in 10 lesions (9.5%). The 6- and 12-month cumulative incidences of local failure were 4.8% and 6%, respectively. Seven patients developed radiation-related neuropathy, and 1 patient developed myelopathy. The vertebral compression fracture rate was 16.7%. CONCLUSION In patients with extensive disease involvement, reSBRT of spine metastases with 40 Gy in 5 fractions seems to be safe and effective. Prospective trials are needed to determine the optimal dose and fractionation in this clinical scenario.
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Affiliation(s)
- Assaf Moore
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Radiation Oncology, Davidoff Cancer Center, Petach Tikva, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Teng Fei
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Lei Zhang
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Laura Accomando
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Adam M Schmitt
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Daniel S Higginson
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Boris A Mueller
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Melissa Zinovoy
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Daphna Y Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Divya Yerramilli
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Amy J Xu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Victoria S Brennan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - David M Guttmann
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Craig E Grossman
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Laura L Dover
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Narek Shaverdian
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Luke R G Pike
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - John J Cuaron
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Alexandra Dreyfuss
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Eric Lis
- Department of Imaging, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ori Barzilai
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Mark H Bilsky
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Yoshiya Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Choi JI, McCormick B, Park P, Millar M, Walker K, Tung CC, Huang S, Florio P, Chen CC, Lozano A, Hanlon AL, Fox J, Xu AJ, Zinovoy M, Mueller B, Bakst R, LaPlant Q, Braunstein LZ, Khan AJ, Powell SN, Cahlon O. Comparative Evaluation of Proton Therapy and Volumetric Modulated Arc Therapy for Brachial Plexus Sparing in the Comprehensive Reirradiation of High-Risk Recurrent Breast Cancer. Adv Radiat Oncol 2024; 9:101355. [PMID: 38405315 PMCID: PMC10885571 DOI: 10.1016/j.adro.2023.101355] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 08/07/2023] [Indexed: 02/27/2024] Open
Abstract
Purpose Recurrent or new primary breast cancer requiring comprehensive regional nodal irradiation after prior radiation therapy (RT) to the supraclavicular area and upper axilla is challenging due to cumulative brachial plexus (BP) dose tolerance. We assessed BP dose sparing achieved with pencil beam scanning proton therapy (PBS-PT) and photon volumetric modulated arc therapy (VMAT). Methods and Materials In an institutional review board-approved planning study, all patients with ipsilateral recurrent breast cancer treated with PBS-PT re-RT (PBT1) with at least partial BP overlap from prior photon RT were identified. Comparative VMAT plans (XRT1) using matched BP dose constraints were developed. A second pair of proton (PBT2) and VMAT (XRT2) plans using standardized target volumes were created, applying uniform prescription dose of 50.4 per 1.8 Gy and a maximum BP constraint <25 Gy. Incidence of brachial plexopathy was also assessed. Results Ten consecutive patients were identified. Median time between RT courses was 48 months (15-276). Median first, second, and cumulative RT doses were 50.4 Gy (range, 42.6-60.0), 50.4 Gy relative biologic effectiveness (RBE) (45.0-64.4), and 102.4 Gy (RBE) (95.0-120.0), respectively. Median follow-up was 15 months (5-33) and 18 months for living patients (11-33) Mean BP max was 37.5 Gy (RBE) for PBT1 and 36.9 Gy for XRT1. Target volume coverage of V85% (volume receiving 85% of prescription dose), V90%, and V95% were numerically lower for XRT1 versus PBT1. Similarly, axilla I-III and supraclavicular area coverage were significantly higher for PBT2 than XRT2 at dose levels of V55%, V65%, V75%, V85%, and V95%. Only axilla I V55% did not reach significance (P = .06) favoring PBS-PT. Two patients with high cumulative BPmax (95.2 Gy [RBE], 101.6 Gy [RBE]) developed brachial plexopathy symptoms with ulnar nerve distribution neuropathy without pain or weakness (1 of 2 had symptom resolution after 6 months without intervention). Conclusions PBS-PT improved BP sparing and target volume coverage versus VMAT. For patients requiring comprehensive re-RT for high-risk, nonmetastatic breast cancer recurrence with BP overlap and reasonable expectation for prolonged life expectancy, PBT may be the preferred treatment modality.
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Affiliation(s)
- J. Isabelle Choi
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
- New York Proton Center, New York, New York
| | - Beryl McCormick
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Peter Park
- New York Proton Center, New York, New York
| | | | - Katherine Walker
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | - Peter Florio
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Alicia Lozano
- Center for Biostatistics and Health Data Science, Department of Statistics, Virginia Tech, Roanoke, Virginia
| | - Alexandra L. Hanlon
- Center for Biostatistics and Health Data Science, Department of Statistics, Virginia Tech, Roanoke, Virginia
| | - Jana Fox
- New York Proton Center, New York, New York
- Department of Radiation Oncology, Montefiore Medical Center
| | - Amy J. Xu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Melissa Zinovoy
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Boris Mueller
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Richard Bakst
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Radiation Oncology, Mt. Sinai Health System, New York, New York
| | - Quincey LaPlant
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lior Z. Braunstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Atif J. Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Simon N. Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Radiation Oncology, New York University Langone, New York, New York
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Chakraborty MA, Khan AJ, Cahlon O, Xu AJ, Braunstein LZ, Powell SN, Choi JI. Proton Reirradiation for High-Risk Recurrent or New Primary Breast Cancer. Cancers (Basel) 2023; 15:5722. [PMID: 38136268 PMCID: PMC10742022 DOI: 10.3390/cancers15245722] [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: 11/12/2023] [Revised: 12/01/2023] [Accepted: 12/04/2023] [Indexed: 12/24/2023] Open
Abstract
Radiotherapy is an integral component of multidisciplinary breast cancer care. Given how commonly radiotherapy is used in the treatment of breast cancer, many patients with recurrences have received previous radiotherapy. Patients with new primary breast cancer may also have received previous radiotherapy to the thoracic region. Curative doses and comprehensive field photon reirradiation (reRT) have often been avoided in these patients due to concerns for severe toxicities to organs-at-risk (OARs), such as the heart, lungs, brachial plexus, and soft tissue. However, many patients may benefit from definitive-intent reRT, such as patients with high-risk disease features such as lymph node involvement and dermal/epidermal invasion. Proton therapy is a potentially advantageous treatment option for delivery of reRT due to its lack of exit dose and greater conformality that allow for enhanced non-target tissue sparing of previously irradiated tissues. In this review, we discuss the clinical applications of proton therapy for patients with breast cancer requiring reRT, the currently available literature and how it compares to historical photon reRT outcomes, treatment planning considerations, and questions in this area warranting further study. Given the dosimetric advantages of protons and the data reported to date, proton therapy is a promising option for patients who would benefit from the added locoregional disease control provided by reRT for recurrent or new primary breast cancer.
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Affiliation(s)
- Molly A. Chakraborty
- Rutgers New Jersey Medical School, Newark, NJ 07103, USA
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Atif J. Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Oren Cahlon
- Department of Radiation Oncology, New York University, New York, NY 10016, USA
| | - Amy J. Xu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Lior Z. Braunstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Simon N. Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - J. Isabelle Choi
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
- New York Proton Center, New York, NY 10035, USA
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Lapen K, Fiasconaro M, Zhang Z, Abaya A, McCormick B, Xu AJ, Cuaron J, Powell SN, Kahn AJ, Gillespie EF, Braunstein LZ. Accelerated Partial Breast Irradiation: Association of Dosimetric Parameters With Patient-Reported Outcomes. Adv Radiat Oncol 2023; 8:101263. [PMID: 37305071 PMCID: PMC10248091 DOI: 10.1016/j.adro.2023.101263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 04/25/2023] [Indexed: 06/13/2023] Open
Abstract
Purpose Accelerated partial breast irradiation (APBI) after breast-conserving surgery offers a well-tolerated adjuvant radiation therapy option for patients with breast cancer. We sought to describe patient-reported acute toxicity as a function of salient dosimetric parameters during and after an APBI regimen of 40 Gy in 10 once-daily fractions. Methods and Materials From June 2019 to July 2020, patients undergoing APBI were assigned a weekly, response-adapted, patient reported outcomes-common terminology criteria for adverse events-based acute toxicity assessment. Patients reported acute toxicity during treatment and for up to 8 weeks after treatment. Dosimetric treatment parameters were collected. Descriptive statistics and univariable analyses were used to summarize patient-reported outcomes and their correlation to corresponding dosimetric measures, respectively. Results Overall, 55 patients who received APBI completed a total of 351 assessments. Median planning target volume was 210 cc (range, 64-580 cc), and median planning target volume:ipsilateral breast volume ratio was 0.17 (range, 0.05-0.44). Overall, 22% of patients reported moderate breast enlargement and 27% reported maximum skin toxicity as severe or very severe. Furthermore, 35% of patients reported fatigue, and 44% of patients reported pain in the radiated area as moderate to very severe. Median time to first report of any moderate to very severe symptom was 10 days (interquartile range, 6-27 days). By 8 weeks after APBI, most patients reported resolution of symptoms, with 16% reporting residual moderate symptoms. Upon univariable analysis, none of the ascertained salient dosimetric parameters were associated with maximum symptoms or with the presence of moderate to very severe toxicity. Conclusions Weekly assessments during and after APBI showed that patients experienced moderate to very severe toxicities, most commonly skin toxicity, but that these typically resolved by 8 weeks after radiation therapy. More comprehensive evaluations among larger cohorts are warranted to define the precise dosimetric parameters that correspond to outcomes of interest.
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Affiliation(s)
- Kaitlyn Lapen
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Megan Fiasconaro
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anthony Abaya
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Beryl McCormick
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Amy J. Xu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - John Cuaron
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Simon N. Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Atif J. Kahn
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Erin F. Gillespie
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lior Z. Braunstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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Kubeczko M, Jarząb M, Gabryś D, Krzywon A, Cortez AJ, Xu AJ. Moderate adverse events and regional differences in CDK4/6 inhibitor treatment combined with palliative radiotherapy. Radiother Oncol 2023; 188:109908. [PMID: 37690666 DOI: 10.1016/j.radonc.2023.109908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 09/04/2023] [Indexed: 09/12/2023]
Affiliation(s)
- Marcin Kubeczko
- Breast Cancer Center, Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Poland.
| | - Michał Jarząb
- Breast Cancer Center, Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Poland
| | - Dorota Gabryś
- Department of Radiotherapy, Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Poland
| | - Aleksandra Krzywon
- Department of Biostatistics and Bioinformatics, Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Poland
| | - Alexander J Cortez
- Department of Biostatistics and Bioinformatics, Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Poland
| | - Amy J Xu
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York City, United States
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Dreyfuss A, Max D, Flynn J, Zhang Z, Gillespie EF, Xu AJ, Cuaron J, Mueller BA, Khan AJ, Cahlon O, Powell SN, McCormick B, Braunstein LZ. Locoregional Control Benefit of a Tumor Bed Boost for Ductal Carcinoma In Situ (DCIS). Int J Radiat Oncol Biol Phys 2023; 117:e174. [PMID: 37784787 DOI: 10.1016/j.ijrobp.2023.06.1018] [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) Radiotherapy (RT) following breast conserving surgery (BCS) for ductal carcinoma in situ (DCIS) reduces invasive and in situ recurrences. Whereas landmark studies suggest that a tumor bed boost improves local control for invasive breast cancer, the benefit in DCIS remains less certain. We evaluated outcomes of DCIS patients treated with or without a boost and hypothesized that a tumor bed boost would improve locoregional control rates. MATERIALS/METHODS The study cohort comprised patients with DCIS who underwent BCS at our institution from 2004-2018. Clinicopathologic features, treatment parameters and outcomes were ascertained from medical records. Patient and tumor characteristics were evaluated relative to outcomes using univariable and multivariable Cox models. Recurrence-free survival (RFS) estimates were generated using the Kaplan Meier method. RESULTS We identified 1675 patients who underwent BCS for DCIS (median age 56 [interquartile range (IQR) 49, 64]). Boost RT was employed in 68% of cases (n = 1146) and endocrine therapy in 32% (n = 536). At a median follow-up of 4.2 years (IQR 1.4, 7.0), we observed 61 locoregional recurrence events (56 local, 5 regional) and 21 deaths. Univariable logistic regression demonstrated that boost RT was more common among younger patients (p<0.001) with positive/close margins (p<0.001), and with larger tumors (p<0.001) of higher grade (p = 0.025). The 10-year RFS rate was 88.8% among those receiving a boost and 84.3% among those without a boost (p = 0.3), and neither univariable nor multivariable analyses revealed an association between boost RT and locoregional recurrence. CONCLUSION Among patients with DCIS who underwent BCS, use of a tumor bed boost was not associated with locoregional recurrence or RFS. Despite a preponderance of adverse features among the boost cohort, outcomes were similar to those not receiving a boost, suggesting that a boost may mitigate risk of recurrence among patients with high-risk features. Ongoing studies will elucidate the extent to which a tumor bed boost influences disease control rates.
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Affiliation(s)
- A Dreyfuss
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - D Max
- University of California in Los Angeles, Los Angeles, CA
| | - J Flynn
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Z Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - E F Gillespie
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - A J Xu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - J Cuaron
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - B A Mueller
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - A J Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - O Cahlon
- New York University Langone Health, New York, NY
| | - S N Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - B McCormick
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - L Z Braunstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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Kubeczko M, Jarząb M, Gabryś D, Krzywon A, Cortez AJ, Xu AJ. Safety and feasibility of CDK4/6 inhibitors treatment combined with radiotherapy in patients with HR-positive/HER2-negative breast cancer. A systematic review and meta-analysis. Radiother Oncol 2023; 187:109839. [PMID: 37536378 DOI: 10.1016/j.radonc.2023.109839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/17/2023] [Accepted: 07/23/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND AND PURPOSE The addition of cyclin-dependent kinase 4/6 inhibitors (CDK4/6i) to endocrine therapy in hormone receptor-positive (HR+) human epidermal growth factor 2-negative (HER2-) breast cancer has led to practice-changing improvements in overall survival. However, there are conflicting data concerning the safety of CDK4/6i combination with radiotherapy, and no consensus guidelines exist to guide practice. We conducted a meta-analysis to assess the safety and feasibility of CDK4/6i treatment with radiotherapy. MATERIALS AND METHODS A comprehensive search was performed in PubMed/MEDLINE, Web of Science, and Scopus, for studies in advanced/metastatic breast cancer receiving CDK4/6i and radiotherapy with the provided safety data on the occurrence of toxicity. The main outcomes were safety (grade 3-5 adverse events), CDK 4/6i dose reduction, and the discontinuation rate due to toxicity. RESULTS Fifteen studies comprising 1133 patients with HR+/HER2- breast cancer patients were included. Among them, 617 pts received CDK4/6i and radiotherapy; the median follow-up was 17.0 months (IQR 9.2 - 18.0), and the median age was 58.8 years (IQR 55.5---62.5). The pooled prevalence of severe hematologic toxicity was 29.4% (95% CI 14.0% - 47.4%; I2 = 93%; τ2 = 0.084; p < 0.01 and severe non-hematologic toxicity was 2.8% (95% CI 1.1% - 4.8%; I2 = 0%; τ2 = 0.0; p = 0.67). The pooled prevalence of CDK4/6i dose reduction was 24.0% (95% CI 11.1% - 39.4%; I2 = 90%; τ2 = 0.052; p < 0.01) with no difference between CDK4/6i plus RT vs. CDK4/6i (odds ratio of 0.934; 95% CI 0.66 - 1.33; I2 = 0%; τ2 = 0.0; p = 0.56). The pooled prevalence of CDK4/6i discontinuation due to toxicity was 2.3% (95% CI 0.4% - 5.2%; I2 = 23%; τ2 = 0.002; p = 0.24). CONCLUSION The findings of this study suggest that radiotherapy in addition to CDK4/6i treatment in breast cancer patients is generally safe and well tolerated and remains a viable treatment option.
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Affiliation(s)
- Marcin Kubeczko
- Breast Cancer Center, Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Poland.
| | - Michał Jarząb
- Breast Cancer Center, Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Poland
| | - Dorota Gabryś
- Department of Radiotherapy, Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Poland
| | - Aleksandra Krzywon
- Department of Biostatistics and Bioinformatics, Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Poland
| | - Alexander J Cortez
- Department of Biostatistics and Bioinformatics, Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Poland
| | - Amy J Xu
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York City, USA
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Dee EC, Freret ME, Brennan VS, Yamada Y, Gomez DR, McBride S, Xu AJ, Yerramilli D. Inpatient Simulation Resource Utilization for Inpatient Radiation Oncology Consults. Int J Radiat Oncol Biol Phys 2023; 117:e98. [PMID: 37786227 DOI: 10.1016/j.ijrobp.2023.06.864] [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) Previous data have shown that inpatient radiation oncology consult services result in high-value care, with decreased length of stay, adoption and delivery of shorter fractionation schedules, and lower hospital costs. As such, institutions are increasingly creating inpatient radiation oncology services, although little is known about the allocation of limited resources for patients who may have limited prognosis, complex simulation requirements, and may have difficulty tolerating treatment. Thus, we sought to examine the utilization of simulation appointments for inpatient emergencies. MATERIALS/METHODS At our institution, inpatient consults are placed to a specialized inpatient palliative radiation oncology service, consisting of radiation oncologists specialized in metastatic and palliative RT, dedicated advanced practitioners, and nurses who specifically assess patients for medical appropriateness prior to simulation, including changes in disposition, medical stability, and adequate premedication. Electronic health record data was used to explore utilization trends of a single-institution inpatient radiation oncology consult service in 2020. Data regarding the nature and timing of consults, subsequent simulations and treatments, and patient outcomes including 14-day mortality and 30-day mortality from radiation (RT) start were assessed. Descriptive statistics are presented. RESULTS From 1/1/2020-12/31/2020, 1557 consults were placed. These consults led to 220 (14.1%) inpatient simulations. Of these planned simulations, 210 (95.5%) simulations occurred (of which 10 [4.8%] were rescheduled and eventually completed) and 179 (85.2%) completed treatment. Of 169 with mortality data available, 16 (9.5%) died within 14 days of RT start, and 41 (24.5%) died within 30 days of RT start. Of those with scheduling data (N = 193), 122 were same-day simulations (63.2%), and 507 (93.8%) occurred within 7 days or fewer. CONCLUSION Of 1557 inpatient consultations in one year, with appropriate metastatic and palliative experience, only a minority of consultations required inpatient simulation (14.1%). With appropriate nursing assessment, over 95% were able to complete simulation, with nearly two-thirds completing simulation on the same day, and nearly all patients completing simulation within a week of consultation. Most of these patients completed treatment and survived 30 days from treatment start. Thus, with highly specialized radiation oncologist clinical judgment in conjunction with appropriate nursing assessment prior to simulation scheduling, patients booked for simulation represent high-value utilization of resources.
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Affiliation(s)
- E C Dee
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - M E Freret
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - V S Brennan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Y Yamada
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - D R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - S McBride
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - A J Xu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - D Yerramilli
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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10
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Cederquist G, Boe L, Walsh MF, Stadler Z, Xu AJ, Mueller BA, Roth O'Brien DA, Bernstein MB, Cuaron J, Bakhoum SF, Powell SN, Khan AJ, Robson ME, Maxwell K, Taunk NK, Braunstein LZ. Risk of Radiation-Associated Secondary Malignancies among Patients with Breast Cancer Harboring TP53 Germline Variants. Int J Radiat Oncol Biol Phys 2023; 117:S45-S46. [PMID: 37784503 DOI: 10.1016/j.ijrobp.2023.06.323] [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) Radiation-associated malignancies are rare and poorly understood. TP53 encodes a multifunctional protein that maintains genome integrity and is the most common somatically mutated gene in cancer. Germline pathogenic variants of TP53 predispose carriers to several cancers comprising the Li-Fraumeni syndrome. It is hypothesized that carriers are also at increased risk of radiotherapy (RT)-associated secondary malignancies; however, reports are mixed. We evaluated the risk of secondary malignancies after breast RT among patients with Li-Fraumeni syndrome. MATERIALS/METHODS This multi-institutional cohort study included carriers of TP53 germline variants who underwent surgical treatment for breast cancer between 1980 and 2020. Patients were stratified based on germline TP53 classification (pathogenic variants [PV] vs variants of uncertain significance [VUS]). The primary outcome of interest was the cumulative incidence risk of developing an in-field secondary cancer after radiotherapy for primary breast carcinoma. RESULTS Ninety-one patients (57 PV and 34 VUS) were evaluated with a median age of 36 years (interquartile range [IQR] 31, 42) and a median follow up of 7.9 years (IQR 4.7, 14.4). Among those with PV who received RT (n = 22), 4 secondary non-breast cancers developed in the radiation field (15-year cumulative incidence 19% [95% CI: 4-43%]), whereas, among those with PV who did not receive RT (n = 35), 0 secondary non-breast cancers were observed in the treated breast (15-year cumulative incidence 0%; p = 0.043). We observed 3 radiation-associated sarcomas among patients with PV who received RT (15-year risk 12% [95% CI 2-33%]) compared with 0 among those who did not receive RT (p = 0.08). No RT-associated sarcomas were observed among 18 patients with TP53 VUS who received RT. RT was not associated with overall survival, despite higher T and N breast cancer stage among those receiving RT (p = 0.33). As expected, patients with PV were more likely than those with VUS to develop any secondary cancer following breast cancer treatment (15-year risk: 54% [95% CI: 33-72%] vs. 14% [95% CI: 3-36%]). CONCLUSION Carriers of pathogenic variants of TP53 are at elevated risk of developing secondary malignancies after breast cancer treatment. This population is at particular risk of developing in-field secondary cancers following RT. This iatrogenic risk must be weighed against the anticipated therapeutic benefit of tumor control. Shared decision making is crucial in the radiotherapeutic management of breast cancer patients harboring the Li-Fraumeni syndrome.
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Affiliation(s)
- G Cederquist
- Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - L Boe
- Memorial Sloan Kettering, New York, NY
| | - M F Walsh
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Z Stadler
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - A J Xu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - B A Mueller
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - D A Roth O'Brien
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - M B Bernstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - J Cuaron
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - S F Bakhoum
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - S N Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - A J Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - M E Robson
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - K Maxwell
- University of Pennsylvania, Philadelphia, PA
| | - N K Taunk
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - L Z Braunstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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11
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O'Brien DAR, Boe LA, Mueller BA, Cuaron J, Xu AJ, Bernstein MB, McCormick B, Powell SN, Khan AJ, Braunstein LZ. Accelerated Partial Breast Irradiation (APBI) For HER2+ Early-Stage Breast Cancer. Int J Radiat Oncol Biol Phys 2023; 117:e204. [PMID: 37784860 DOI: 10.1016/j.ijrobp.2023.06.1085] [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) Historically, HER2+ breast cancer exhibited poor outcomes and, hence, has not been well-studied among trials of accelerated partial breast irradiation (APBI). We hypothesized that in contemporary practice with effective HER2-targeted agents, patients with HER2+ breast cancer now have excellent disease control and survival outcomes when treated with adjuvant APBI. MATERIALS/METHODS Using a prospectively-maintained institutional database, we identified all HER2+ breast cancer patients treated with breast conserving surgery (BCS) and adjuvant APBI from 2000 - 2022. Salient clinicopathologic parameters were collected, as were receipt of systemic and endocrine therapies. All patients received external beam APBI to a total dose of 40Gy in 10 daily fractions over 2 weeks. We analyzed outcomes including local recurrence (LR), regional recurrence, distant recurrence, and death. Cumulative incidence functions were calculated to estimate the incidence of LR with the competing risk of death. All statistical analyses were performed in R version 4.2.2. RESULTS The study cohort comprised 52 patients with HER2+ breast cancer (median age 64 years; range 44-87). Nearly all had T1 tumors (98%; median size 15 mm; range 1 - 21 mm). Approximately 10% had multifocal disease, with one exhibiting suspicion for lymphovascular invasion. Most patients had ER+ disease (88%). All patients had negative final surgical margins. Nearly all underwent sentinel node biopsy (94%), with the remainder undergoing no surgical axillary evaluation. 42 (81%) received chemotherapy, 40 (77%) endocrine therapy, and 42 (81%) HER2-directed therapy, most commonly trastuzumab. At 143.8 person-years of follow-up (range 7 - 226 months for each patient), we observed two LR events, at 14 and 26 months, yielding a 2-year LR rate of 3.8%. No regional or distant recurrences were observed, nor were any contralateral invasive breast cancer events or breast-specific mortality events. Two deaths were noted in the cohort, both without evidence of disease. CONCLUSION Among a cohort of HER2+ early-stage breast cancer patients managed with BCS and APBI, we observed a 2-year LR rate of 3.8% with no regional or distant recurrences, and excellent overall survival. These findings merit longer term follow-up among larger cohorts, although are thus far consistent with the results of contemporary randomized trials of APBI unselected for HER2-status.
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Affiliation(s)
- D A Roth O'Brien
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - L A Boe
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - B A Mueller
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - J Cuaron
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York City, NY
| | - A J Xu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - M B Bernstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - B McCormick
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - S N Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - A J Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - L Z Braunstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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12
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Koleoso OA, Toumbacaris N, Zhang Z, Braunstein LZ, El-Tamer M, Moo TA, Morrow M, Brogi E, Xu AJ, Powell SN, Khan AJ. The Presence of Extensive Lymphovascular Invasion (LVI) is Associated with Higher Risk of Recurrence in Curatively Treated Breast Cancer Patients. Int J Radiat Oncol Biol Phys 2023; 117:S135-S136. [PMID: 37784346 DOI: 10.1016/j.ijrobp.2023.06.539] [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) Lymphovascular invasion (LVI) is a pathological feature seen in breast cancer that may be an important step in cancer metastasis. Multiple datasets have demonstrated a correlation between LVI and local-regional recurrence (LRR). Whether the extent of LVI is an incremental determinant of LRR risk is unknown. We describe clinical outcomes in women with invasive breast cancer stratified by: 1) absence of LVI (neg), 2) LVI focal or suspicious (FS-LVI), 3) usual (non-extensive) LVI (LVI) and 4) extensive LVI (E-LVI). MATERIALS/METHODS Between December 2009 and August 2021, there were 8,837 patients with early-stage breast cancer (T1-2 and N0-2a) were treated with curative intent and were evaluable. Clinical-pathological details were abstracted by retrospective review. The description of LVI was abstracted from pathology reports. Recurrence and survival outcomes were compared based on the extent of LVI. RESULTS Of the 8837 patients studied, 5584 were neg, 461 had FS-LVI, 2315 had LVI, and 477 had E-LVI. The E-LVI cohort had baseline characteristics suggestive of higher risk such as younger median age, higher proportion of grade 3, more nodal positivity, more mastectomy (67% vs 48%), and higher use of chemotherapy compared to LVI. The cumulative incidence of LRR and DM was highest in the E-LVI group. Using LVI as the reference, the presence of E-LVI, age, tumor size, ER status, grade, mastectomy, and close/positive margins were independent variables for LRR on Cox multivariable regression (Table 1). To assess the effect with an alternate statistical method, we created propensity matched cohorts (matched for age, size, receptors, grade, surgery type, margins and chemotherapy/RT use); a statistical difference in OS was noted between groups with LVI vs E-LVI (HR 1.44 (CI 1.06-1.96, p = 0.018), but not in LRR (HR 1.31 (CI 0.87-1.97, p = 0.2) or DM (HR 1.16 (CI 0.88-1.53, p = 0.3). CONCLUSION Our work suggests that patients with E-LVI are at a higher risk for LRR compared to patients with usual LVI, despite maximal standard of care treatment. This is important because E-LVI can be determined from breast specimens, and may help define indications for RNI/PMRT when nodal information is not available.
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Affiliation(s)
- O A Koleoso
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - N Toumbacaris
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Z Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - L Z Braunstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - M El-Tamer
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - T A Moo
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - M Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - E Brogi
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - A J Xu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - S N Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - A J Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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13
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Koleoso OA, Ehrich F, Grabensetter A, Wen HY, Zhang Z, Braunstein LZ, Xu AJ, McCormick B, Morrow M, Powell SN, Khan AJ. Oncotype Recurrence Score (RS) at the Extremes of Tumor Size: Which Drives Clinical Outcomes? Int J Radiat Oncol Biol Phys 2023; 117:e188. [PMID: 37784818 DOI: 10.1016/j.ijrobp.2023.06.1048] [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) Tumor size is an established and independent risk factor for local-regional recurrence (LRR) and distant recurrence (DM). More recently, the recurrence score calculated from a 21-gene expression assay (Oncotype DXTM, Exact Sciences) has also been correlated with LRR and DM. We sought to determine the impact of the interaction between tumor size and Oncotype RS, particularly when the variables are in discrepancy with each other. More specifically, we evaluated clinical outcomes in patients with small tumors (≤1 cm) and high RS (≥26) and, separately, in patients with large tumors (>5 cm) with low RS. MATERIALS/METHODS Between 2008 and 2020, 310 patients were identified retrospectively as having been treated for early-stage, hormone-receptor positive, Her2-negative breast cancers with tumor size ≤1 cm that were node-negative and had RS ≥ 26 at our institution. In addition, 64 patients were identified with tumor size >5 cm and RS < 26 (irrespective of nodal status). Locoregional recurrence rates (LRR) and invasive recurrence rates (composite of LRR and distant recurrence) were estimated using the Kaplan-Meier method. RESULTS Patient characteristics are shown in Table 1. In the group of patients with small tumors and high RS, the 5- and 10-year invasive recurrence rates with 95% CI were 8% (4.2-12) and 17% (8.2-26). The 5- and 10-year locoregional recurrence rates with 95% CI were 5.8% (2.7-8.8) and 15% (6.2-23). In the group of patients with large tumors and low RS, 10-year rates could not be estimated with the available data. The 5- and 8-year invasive recurrence rates with 95% CI were 3.2% (0-7.5) and 3.2% (0-7.5). The 5- and 8-year locoregional recurrence rates with 95% CI were 1.6% (0-4.7) and 1.6% (0-4.7). CONCLUSION Our findings suggest that patients with small tumors and high RS are at a higher risk for LRR compared to the average ≤1 cm node-negative breast cancer based on published data on the effect of tumor size on LRR and DM. Similarly, tumors larger than 5 cm with low RS appear to behave indolently and in a manner consistent with more favorable risk (despite their large size). These findings may have important implications for the tailoring of local-regional treatment strategies.
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Affiliation(s)
- O A Koleoso
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - F Ehrich
- Memorial Sloan Kettering Cancer center, New York, NY
| | | | - H Y Wen
- Memorial Sloan Kettering Cancer center, New York, NY; Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Z Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - L Z Braunstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - A J Xu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - B McCormick
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - M Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - S N Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - A J Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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14
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Narayan P, Kostrzewa CE, Zhang Z, O'Brien DAR, Mueller BA, Cuaron JJ, Xu AJ, Bernstein MB, McCormick B, Powell SN, Khan AJ, Wen HY, Braunstein LZ. Metaplastic carcinoma of the breast: matched cohort analysis of recurrence and survival. Breast Cancer Res Treat 2023; 199:355-361. [PMID: 36976395 DOI: 10.1007/s10549-023-06923-1] [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] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 03/17/2023] [Indexed: 03/29/2023]
Abstract
PURPOSE Metaplastic breast carcinoma (MBC) is a rare subtype of breast cancer, defined as mammary carcinoma with squamous or mesenchymal differentiation, that may include spindle cell, chondroid, osseous, or rhabdomyoid differentiation patterns. The implications of MBC recurrence and survival outcomes remains unclear. METHODS Cases were ascertained from a prospectively maintained institutional database of patients treated from 1998 to 2015. Patients with MBC were matched 1:1 to non-MBC cases. Cox proportional-hazards models and Kaplan-Meier estimates were used to evaluate outcome differences between cohorts. RESULTS 111 patients with MBC were matched 1:1 with non-MBC patients from an initial set of 2400 patients. Median follow-up time was 8 years. Most patients with MBC received chemotherapy (88%) and radiotherapy (71%). On univariate competing risk regression, MBC was not associated with locoregional recurrence (HR = 1.08; p = 0.8), distant recurrence (HR = 1.65; p = 0.092); disease-free survival (HR = 1.52; p = 0.065), or overall survival (HR = 1.56; p = 0.1). Absolute differences were noted in 8-year disease-free survival (49.6% MBC vs 66.4% non-MBC) and overall survival (61.3% MBC vs 74.4% non-MBC), though neither of these reached statistical significance (p = 0.07 and 0.11, respectively). CONCLUSION Appropriately-treated MBC may exhibit recurrence and survival outcomes that are difficult to distinguish from those of non-MBC. While prior studies suggest that MBC has a worse natural history than non-MBC triple-negative breast cancer, prudent use of chemotherapy and radiotherapy may narrow these differences, although studies with more power will be required to inform clinical management. Longer follow-up among larger populations may further elucidate the clinical and therapeutic implications of MBC.
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Affiliation(s)
| | | | - Zhigang Zhang
- Departments of Biostatistic and Epidemiology, New York, NY, USA
| | - Diana A Roth O'Brien
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY, 10065, USA
| | - Boris A Mueller
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY, 10065, USA
| | - John J Cuaron
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY, 10065, USA
| | - Amy J Xu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY, 10065, USA
| | - Michael B Bernstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY, 10065, USA
| | - Beryl McCormick
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY, 10065, USA
| | - Simon N Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY, 10065, USA
| | - Atif J Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY, 10065, USA
| | - Hannah Y Wen
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lior Z Braunstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY, 10065, USA.
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15
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Freret ME, Wijetunga NA, Shamseddine AA, Higginson DS, Schmitt AM, Yamada Y, Lis E, Boire A, Yang JT, Xu AJ. Early Detection of Leptomeningeal Metastases Among Patients Undergoing Spinal Stereotactic Radiosurgery. Adv Radiat Oncol 2023; 8:101154. [PMID: 36845624 PMCID: PMC9943781 DOI: 10.1016/j.adro.2022.101154] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 12/15/2022] [Indexed: 12/27/2022] Open
Abstract
Purpose The management of patients with advanced solid malignancies increasingly uses stereotactic body radiation therapy (SBRT). Advanced cancer patients are at risk for developing leptomeningeal metastasis (LM), a fatal complication of metastatic cancer. Cerebrospinal fluid (CSF) is routinely collected during computed tomography (CT) myelography for spinal SBRT planning, offering an opportunity for early LM detection by CSF cytology in the absence of radiographic LM or LM symptoms (subclinical LM). This study tested the hypothesis that early detection of tumor cells in CSF in patients undergoing spine SBRT portends a similarly poor prognosis compared with clinically overt LM. Methods and Materials We retrospectively analyzed clinical records for 495 patients with metastatic solid tumors who underwent CT myelography for spinal SBRT planning at a single institution from 2014 to 2019. Results Among patients planned for SBRT, 51 (10.3%) developed LM. Eight patients (1.6%) had subclinical LM. Median survival with LM was similar between patients with subclinical versus clinically evident LM (3.6 vs 3.0 months, P = .30). Patients harboring both parenchymal brain metastases and LM (29/51) demonstrated shorter survival than those with LM alone (2.4 vs 7.1 months, P = .02). Conclusions LM remains a fatal complication of metastatic cancer. Subclinical LM detected by CSF cytology in spine SBRT patients has a similarly poor prognosis compared with standardly detected LM and warrants consideration of central nervous system-directed therapies. As aggressive local therapies are increasingly used for metastatic patients, more sensitive CSF evaluation may further identify patients with subclinical LM and should be evaluated prospectively.
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Affiliation(s)
- Morgan E. Freret
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - N. Ari Wijetunga
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Achraf A. Shamseddine
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel S. Higginson
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Adam M. Schmitt
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yoshiya Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Eric Lis
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Adrienne Boire
- Department of Neurology, Human Oncology and Pathogenesis Program, Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonathan T. Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Amy J. Xu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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16
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Xu AJ, Yerramilli D, Cahlon O, Powell SN, Yang JT, Gomez DR. Novel Inpatient Radiation Oncology Consult Service Model Reduces Hospital Length of Stay. JCO Oncol Pract 2021; 17:e1930-e1934. [PMID: 33788624 PMCID: PMC9810125 DOI: 10.1200/op.20.00923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Palliative care and radiation therapy have played an expanding role in the management of patients with advanced cancers. Recent advances in our understanding of oligometastatic disease have led to increasing demand for familiarity with ablative techniques. Recognizing the demands of hospitalized patients for rapid access to care, we created an inpatient radiation oncology consult service (IROC) with consolidated expertise in palliative radiation and ablative techniques. In this quality improvement cohort study, we analyzed inpatient radiation oncology consults placed before and after IROC implementation and found that IROC led to increased delivery of specialty care and decreased hospital length of stay (median 8 days v 7 days, P = .005). This difference was most pronounced for patients for whom radiation therapy was indicated (14.5 v 11 days, P = .007). Our institutional experience demonstrates the value of recognizing metastatic disease as a distinct discipline and providing rapid access to palliative treatments for patients with advanced malignancies.
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Affiliation(s)
- Amy J. Xu
- Precision Radiation for Oligometastatic and Metastatic Disease (PROMISE) Program, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY,Amy J. Xu, MD, PhD, Memorial Sloan Kettering Cancer Center, 1275 York Ave New York, NY 10065; e-mail:
| | - Divya Yerramilli
- Precision Radiation for Oligometastatic and Metastatic Disease (PROMISE) Program, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Simon N. Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jonathan T. Yang
- Precision Radiation for Oligometastatic and Metastatic Disease (PROMISE) Program, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Daniel R. Gomez
- Precision Radiation for Oligometastatic and Metastatic Disease (PROMISE) Program, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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Wijetunga NA, dos Anjos CH, Zhi WI, Robson M, Tsai CJ, Yamada Y, Dover L, Gillespie EF, Xu AJ, Yang JT. Long-term disease control and survival observed after stereotactic ablative body radiotherapy for oligometastatic breast cancer. Cancer Med 2021; 10:5163-5174. [PMID: 34159748 PMCID: PMC8335830 DOI: 10.1002/cam4.4068] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 03/12/2021] [Accepted: 06/03/2021] [Indexed: 12/23/2022] Open
Abstract
PURPOSE We examined the characteristics of breast cancer patients with oligometastases (OM) treated with stereotactic ablative body radiotherapy (SABR) to identify factors associated with local progression, distant metastasis progression, time to subsequent therapy, progression-free survival (PFS), and overall survival (OS). METHODS We retrospectively reviewed a single-institution database of patients treated with radiotherapy between 2008 and 2018 and identified 79 patients who received SABR to OM. Twenty-seven patients had genetic testing of metastatic tumors using an institutional targeted sequencing platform. Kaplan-Meier analysis, Cox regression, and competing risk models were used to compare clinical and genetic correlates with outcomes. RESULTS Median follow-up was 50 months (IQR: 29-66) with 67% of patients alive at the last follow-up. Of the 65% of patients who progressed, 82% progressed outside of the radiation field, 18% experienced local failure, and 80% had oligoprogression. Median OS was 86 months (IQR: 29-66), and PFS was 33 months (IQR: 10-38). Less than 5 years from diagnosis to SABR and triple-negative breast cancer (TNBC) were associated with worse OS. Advanced T stage, any prior chemotherapy, and TNBC were associated with worse PFS. Alterations in CEBPB, RB1, TBX3, PTEN, and CDK4 were associated with worse survival outcomes. CONCLUSION Long-term systemic disease control and survival can be achieved with SABR for oligometastatic breast cancer. Hormone receptor-positive patients with a long disease interval from initial diagnosis and limited systemic progression history may be ideal for SABR to all sites of disease.
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Affiliation(s)
- N. Ari Wijetunga
- Department of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Carlos H. dos Anjos
- Department of MedicineDivision of Solid Tumor OncologyBreast Medicine ServiceMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - W. Iris Zhi
- Department of MedicineDivision of Solid Tumor OncologyBreast Medicine ServiceMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Mark Robson
- Department of MedicineDivision of Solid Tumor OncologyBreast Medicine ServiceMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - C. Jillian Tsai
- Department of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
- Precision Radiation for Oligometastatic and Metastatic Disease (PROMISE) ProgramDepartment of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Yoshiya Yamada
- Department of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
- Precision Radiation for Oligometastatic and Metastatic Disease (PROMISE) ProgramDepartment of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Laura Dover
- Department of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
- Precision Radiation for Oligometastatic and Metastatic Disease (PROMISE) ProgramDepartment of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Erin F. Gillespie
- Department of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
- Precision Radiation for Oligometastatic and Metastatic Disease (PROMISE) ProgramDepartment of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Amy J. Xu
- Department of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
- Precision Radiation for Oligometastatic and Metastatic Disease (PROMISE) ProgramDepartment of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Jonathan T. Yang
- Department of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
- Precision Radiation for Oligometastatic and Metastatic Disease (PROMISE) ProgramDepartment of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
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Chen I, Botty Van den Bruele AM, Gillespie EF, Mueller BA, Xu AJ, Cuaron J, Khan AJ, McCormick B, Cahlon O, Powell SN, Cody H, Braunstein LZ. Salvage of locally recurrent breast cancer with repeat breast conservation using 45 Gy hyperfractionated partial breast re-irradiation. Breast Cancer Res Treat 2021; 188:409-414. [PMID: 33770311 DOI: 10.1007/s10549-021-06206-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/19/2021] [Indexed: 01/22/2023]
Abstract
PURPOSE Mastectomy has long been the preferred approach for local salvage of recurrent breast cancer following breast-conservation therapy (BCT). Growing interest in avoiding mastectomy prompted RTOG 1014, a landmark phase two study demonstrating the feasibility of repeat BCT using a novel radiotherapy (RT) regimen (i.e., 45 Gy administered in 30 fractions of 1.5 Gy twice-daily to the partial breast, "rePBI"). We adopted this regimen as our institutional standard and report our observations regarding the safety and efficacy of rePBI as salvage therapy. METHODS All patients at our institution who underwent repeat BCT and subsequently received rePBI from 2011 to 2019 were identified. Clinicopathologic features and treatment characteristics for both primary breast cancers and recurrences were collected, as were rates of subsequent recurrence and treatment-associated toxicities. RESULTS The cohort included 34 patients with a median age of 65.8 (46.2-78.2) at the time of rePBI. At a median follow-up of 23.5 months, there were two subsequent locoregional recurrences (2-year local control rate 97%). There was no grade ≥ 3 toxicity. The most common acute toxicity (< 3 months) was radiation dermatitis (100%), and common grade 1-2 late toxicities (> 3 months) included fibrosis in 14 (41%), breast asymmetry in 12 (35%), and chest wall pain in 11 (32%). CONCLUSIONS Repeat breast conservation using the hyperfractionated partial breast RT regimen defined by RTOG 1014 (45 Gy administered in 30 1.5 Gy twice-daily fractions) appears effective and well tolerated. No grade 3 or higher toxicities were observed and local control was excellent. Longer term follow-up among larger cohorts will define whether salvage mastectomy should remain the preferred standard.
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Affiliation(s)
- Ishita Chen
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY , 10044, USA
| | | | - Erin F Gillespie
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY , 10044, USA
| | - Boris A Mueller
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY , 10044, USA
| | | | - John Cuaron
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY , 10044, USA
| | - Atif J Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY , 10044, USA
| | - Beryl McCormick
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY , 10044, USA
| | - Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY , 10044, USA
| | - Simon N Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY , 10044, USA
| | - Hiram Cody
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lior Z Braunstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY , 10044, USA.
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Tringale KR, Berger ER, Sevilimedu V, Wen HY, Gillespie EF, Mueller BA, McCormick B, Xu AJ, Cuaron JJ, Cahlon O, Khan AJ, Powell SN, Morrow M, Heerdt AS, Braunstein LZ. Breast conservation among older patients with early-stage breast cancer: Locoregional recurrence following adjuvant radiation or hormonal therapy. Cancer 2021; 127:1749-1757. [PMID: 33496354 DOI: 10.1002/cncr.33422] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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: 07/16/2020] [Revised: 10/16/2020] [Accepted: 11/07/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND For patients with breast cancer undergoing breast-conserving surgery (BCS), adjuvant radiation (RT) and hormonal therapy (HT) reduce the risk of locoregional recurrence (LRR). Although several studies have evaluated adjuvant HT ± RT, the outcomes of HT versus RT monotherapy remain less clear. In this study, the risk of LRR is characterized among older patients with early-stage breast cancer following adjuvant RT alone, HT alone, neither, or both. METHODS This study included female patients from the Memorial Sloan Kettering Cancer Center (New York, New York) who were aged ≥65 years with estrogen receptor-positive (ER+)/human epidermal growth factor receptor 2-negative (HER2-) T1N0 breast cancer treated with BCS. The primary endpoint was time to LRR evaluated by Cox regression analysis. RESULTS There were 888 women evaluated with a median age of 71 years (range, 65-100 years) and median follow-up of 4.9 years (range, 0.0-9.5 years). There were 27 LRR events (3.0%). Five-year LRR was 11% for those receiving no adjuvant treatment, 3% for HT alone, 4% for RT alone, and 1% for HT and RT. LRR rates were significantly different between the groups (P < .001). Compared with neither HT nor RT, HT or RT monotherapy each yielded similar LRR reductions: HT alone (HR, 0.27; 95% CI, 0.10-0.68; P = .006) and RT alone (HR, 0.32; 95% CI, 0.11-0.92; P = .034). Distant recurrence and breast cancer-specific survival rates did not significantly differ between groups. CONCLUSIONS LRR risk following BCS is low among women aged ≥65 years with T1N0, ER+/HER2- breast cancer. Adjuvant RT and HT monotherapy each similarly reduce this risk; the combination yields a marginal improvement. Further study is needed to elucidate whether appropriate patients may feasibly receive adjuvant RT monotherapy versus the current standards of HT monotherapy or combined RT/HT.
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Affiliation(s)
- Kathryn R Tringale
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Elizabeth R Berger
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Varadan Sevilimedu
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hannah Y Wen
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Erin F Gillespie
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Boris A Mueller
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Beryl McCormick
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Amy J Xu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - John J Cuaron
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Atif J Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Simon N Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alexandra S Heerdt
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lior Z Braunstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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20
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Gillespie EF, Lapen K, Wang DG, Wijetunga N, Pastrana GL, Kollmeier MA, Yamada J, Schmitt AM, Higginson DS, Vaynrub M, Santos Martin E, Xu AJ, Tsai C, Yerramilli D, Cahlon O, Yang T. Replacing 30 Gy in 10 fractions with stereotactic body radiation therapy for bone metastases: A large multi-site single institution experience 2016-2018. Clin Transl Radiat Oncol 2020; 25:75-80. [PMID: 33102818 PMCID: PMC7575833 DOI: 10.1016/j.ctro.2020.10.001] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 10/02/2020] [Indexed: 12/25/2022] Open
Abstract
Contemporary trends in radiation technique and fractionation for bone metastases at a large academic center with a specialized metastatic program. Stereotactic body radiation therapy (SBRT) is replacing long-course conventional RT for bone metastases. Complexity of RT is increasing, particularly in the community-based regional clinic setting. Single-fraction conventional RT is preferentially employed at the end of life, but prognostic algorithms are needed to further optimize use.
Background Bone metastases cause significant morbidity in patients with cancer, and radiation therapy (RT) is an effective treatment approach. Indications for more complex ablative techniques are emerging. We sought to evaluate RT trends at a large multi-site tertiary cancer center. Methods Patients who received RT for bone metastases at a single institution (including regional outpatient clinics) from 2016 to 2018 were identified. Patients were grouped by RT regimen: single-fraction conventional RT (8 Gy × 1), 30 Gy in 10 fractions, SBRT, and “other”. Multinomial logistic regression was performed to assess trends in regimens over time. Binary logistic regression was performed to evaluate factors associated with receipt of SBRT. Results Between 2016 and 2018, 5,952 RT episodes were received by 2,969 patients with bone metastases. Overall, 76% of episodes were ≤ 5 fractions. The median number of fractions planned for SBRT and non-SBRT episodes was 3 (IQR 3–3) and 5 (IQR 5–10), respectively. Use of SBRT increased from 2016 to 2018 (39% to 53%, p < 0.01) while use of 30 Gy in 10 fractions decreased (26% to 12%, p < 0.01), and 8 Gy × 1 was stable (5.3% to 6.9%, p = 0.28). SBRT was associated with higher performance status (p < 0.01) and non-radiosensitive histology (p < 0.01). Use of SBRT increased in the regional network (19% to 48%, p < 0.01) and at the main center (52% to 59%, p = 0.02), but did not increase within 30 days of death. More patients treated with 8 Gy × 1 than SBRT died within 30 days of treatment (24% vs 3.8%, respectively, p < 0.01). Conclusions SBRT is replacing 30 Gy in 10 fractions for bone metastases, especially among patients with high performance status and non-radiosensitive histologies. Better prognostic algorithms could further improve patient-centered treatment selection at the end of life.
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Affiliation(s)
- Erin F Gillespie
- Department of Radiation Oncology, Precision Radiation for Oligometastatic and Metastatic Disease (PROMISE) Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kaitlyn Lapen
- Department of Radiation Oncology, Precision Radiation for Oligometastatic and Metastatic Disease (PROMISE) Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Diana G Wang
- Department of Radiation Oncology, Precision Radiation for Oligometastatic and Metastatic Disease (PROMISE) Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - N Wijetunga
- Department of Radiation Oncology, Precision Radiation for Oligometastatic and Metastatic Disease (PROMISE) Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Gerri L Pastrana
- Department of Radiation Oncology, Precision Radiation for Oligometastatic and Metastatic Disease (PROMISE) Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Marisa A Kollmeier
- Department of Radiation Oncology, Precision Radiation for Oligometastatic and Metastatic Disease (PROMISE) Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Josh Yamada
- Department of Radiation Oncology, Precision Radiation for Oligometastatic and Metastatic Disease (PROMISE) Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Adam M Schmitt
- Department of Radiation Oncology, Precision Radiation for Oligometastatic and Metastatic Disease (PROMISE) Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel S Higginson
- Department of Radiation Oncology, Precision Radiation for Oligometastatic and Metastatic Disease (PROMISE) Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Max Vaynrub
- Department of Surgery, Orthopaedic Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ernesto Santos Martin
- Department of Interventional Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Amy J Xu
- Department of Radiation Oncology, Precision Radiation for Oligometastatic and Metastatic Disease (PROMISE) Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - C Tsai
- Department of Radiation Oncology, Precision Radiation for Oligometastatic and Metastatic Disease (PROMISE) Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Divya Yerramilli
- Department of Radiation Oncology, Precision Radiation for Oligometastatic and Metastatic Disease (PROMISE) Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Oren Cahlon
- Department of Radiation Oncology, Precision Radiation for Oligometastatic and Metastatic Disease (PROMISE) Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - T Yang
- Department of Radiation Oncology, Precision Radiation for Oligometastatic and Metastatic Disease (PROMISE) Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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21
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Xu AJ, Luo L, Leeman JE, Romesser PB, Spielsinger D, Sabol C, Waldenberg T, Brinkman T, Riaz N, McBride S, Kang J, Lee N, Tsai CJ. Beyond reirradiation: Efficacy and safety of three or more courses of radiation for head and neck malignancies. Clin Transl Radiat Oncol 2020; 23:30-34. [PMID: 32382663 PMCID: PMC7200775 DOI: 10.1016/j.ctro.2020.04.009] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 04/19/2020] [Accepted: 04/21/2020] [Indexed: 11/16/2022] Open
Abstract
Median local recurrence free survival after repeat reirradiation was 9.1 months. Grade 4 toxicities were reported in 21% of patients. 61% of patients underwent subsequent therapies following repeat reirradiation. Subsequent therapies following repeat reirradiation included surgery, chemotherapy and immunotherapy. Repeat reirradiation is feasible and should be balanced against risk for toxicities.
Purpose Recurrent head and neck cancers are associated with significant morbidity and mortality. Outcomes of multiple courses of radiation have not yet been described. Methods and Materials A single institution database was queried to retrospectively review treatment plans and select patients who underwent ≥ 3 courses of radiation to the head and neck region. Results Thirty-three patients were found to have ≥ 3 courses of radiation with overlapping fields. Median local recurrence free survival after last course of reirradiation was 9.1 months and median overall survival was 10 months. Grade 3 and above toxicities were reported in 15 patients (45%). Grade 4 and above toxicities were reported in seven patients (21%). There was no grade 5 toxicity. 20 patients (61%) underwent subsequent therapies following completion of repeat reirradiation. Conclusions Repeat reirradiation to the head and neck region is feasible and carries significant risks that are most appropriately managed with a multi-disciplinary team and must be balanced against the potential for local control and opportunities for emerging systemic therapies.
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Yerramilli D, Xu AJ, Gillespie EF, Shepherd AF, Beal K, Gomez D, Yamada J, Tsai CJ, Yang TJ. Palliative Radiation Therapy for Oncologic Emergencies in the Setting of COVID-19: Approaches to Balancing Risks and Benefits. Adv Radiat Oncol 2020; 5:589-594. [PMID: 32363243 PMCID: PMC7194647 DOI: 10.1016/j.adro.2020.04.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 03/31/2020] [Accepted: 04/01/2020] [Indexed: 12/15/2022] Open
Abstract
Palliation of metastatic disease compromises a significant portion of radiation treatments in the United States. These patients present a unique challenge in resource-limited settings, as expeditious treatment is often required to prevent serious morbidity. In order to reduce the risk of infection with severe acute respiratory syndrome coronavirus-2 and maximize the benefit to patients, we present evidence-based recommendations for radiation in patients with oncologic emergencies. Radiation oncologists with expertise in the treatment of metastatic disease at a high-volume comprehensive cancer center reviewed the available evidence and recommended best practices for the treatment of common oncologic emergencies, with attention to balancing the risk of infection with severe acute respiratory syndrome coronavirus-2 and the potential morbidity of delaying treatment. Many prospective trials and national guidelines support the use of abbreviated courses of radiotherapy for patients with oncologic emergencies. As such, in the setting of the current coronavirus disease 2019 pandemic, the use of hypofractionated radiation therapy for patients requiring palliation for oncologic emergencies achieves desirable functional outcomes without compromising care.
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Affiliation(s)
- Divya Yerramilli
- PROMISE (Precision Radiation for Oligometastatic and Metastatic Disease) Program, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Amy J Xu
- PROMISE (Precision Radiation for Oligometastatic and Metastatic Disease) Program, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Erin F Gillespie
- PROMISE (Precision Radiation for Oligometastatic and Metastatic Disease) Program, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Annemarie F Shepherd
- PROMISE (Precision Radiation for Oligometastatic and Metastatic Disease) Program, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kathryn Beal
- PROMISE (Precision Radiation for Oligometastatic and Metastatic Disease) Program, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel Gomez
- PROMISE (Precision Radiation for Oligometastatic and Metastatic Disease) Program, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Josh Yamada
- PROMISE (Precision Radiation for Oligometastatic and Metastatic Disease) Program, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - C Jillian Tsai
- PROMISE (Precision Radiation for Oligometastatic and Metastatic Disease) Program, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - T Jonathan Yang
- PROMISE (Precision Radiation for Oligometastatic and Metastatic Disease) Program, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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23
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Xu AJ, DeSelm CJ, Ho AY, Gillespie EF, Braunstein LZ, Khan AJ, McCormick B, Powell SN, Cahlon O. Overall Survival of Breast Cancer Patients With Locoregional Failures Involving Internal Mammary Nodes. Adv Radiat Oncol 2019; 4:447-452. [PMID: 31360798 PMCID: PMC6639740 DOI: 10.1016/j.adro.2019.02.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 02/14/2019] [Indexed: 12/30/2022] Open
Abstract
Purpose Internal mammary node recurrence after definitive breast cancer treatment is poorly characterized, with limited data to guide clinical management. The aim of this study was to analyze the outcomes of patients with recurrent breast cancer involving internal mammary nodes to understand their natural history and determine prognostic factors associated with improved overall survival. Methods and Materials We performed a retrospective analysis of 553 patients with recurrent breast cancer and identified 161 patients with radiographic evidence of locoregional recurrence as a first event. A total of 67 patients (42%) were identified with internal mammary involvement. Median follow-up times were 76 months from date of initial diagnosis and 30 months from date of recurrence. Results Of the 67 patients identified with internal mammary node failures, 10 (15%) presented with isolated recurrence, 14 (21%) presented with other sites of locoregional disease, and 43 (64%) presented with concomitant distant metastases. Median overall survival was 2.5 years and significantly associated with extent of disease (P < .0001). On multivariable analysis, concomitant distant metastases, inflammatory breast cancer, and triple negative histologic type were associated with worse overall survival, whereas salvage radiation therapy was associated with improved overall survival. Among the 10 patients with isolated internal mammary node failures, median progression-free survival was 6.0 years and salvage therapy with surgery, radiation, and chemotherapy were associated with the best outcomes. Conclusions Patients with isolated internal mammary node recurrences achieved long-term survival with aggressive therapies, and salvage radiation therapy was associated with improved survival.
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Affiliation(s)
- Amy J Xu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Carl J DeSelm
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alice Y Ho
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Erin F Gillespie
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lior Z Braunstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Atif J Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Beryl McCormick
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Simon N Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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Cao H, Ji TW, Lan Q, Lin F, Dong Y, Xu AJ, Liu J, Ding HY, Fan HM, Liu ZM. [Establishment of rat model of cardiorenal syndrome by transabdominal subtotal nephrectomy]. Zhonghua Yi Xue Za Zhi 2019; 99:447-452. [PMID: 30786340 DOI: 10.3760/cma.j.issn.0376-2491.2019.06.013] [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] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective: To evaluate the changes of rat renal function and cardiac function after transabdominal subtotal nephrectomy (STNx) and provide an ideal animal model for the study of chronic kidney disease (CKD) and cardiorenal syndrome (CRS). Methods: The SD rats (male, 5-6 weeks) were randomly divided into Sham group (n=10) and STNx group (n=10). The rats from Sham group underwent sham surgery, and the right nephrectomy plus the 2/3 left kidney artery ligation through abdominal incision were performed in the rats from STNx group. Twelve weeks after operation, the rat serum creatinine and renal pathology were examined, the size and fibrosis of cardiac cells were also observed, after the changes of cardiac function being detected by echocardiography. Results: Twelve weeks after the operation, STNx group rats were generally in poor condition, with a emaciated body, absorption of the renal infarct tissue, uneven surface, and residual renal tissue compensatory hypertrophy. The serum creatinine in Sham group and STNx group was (22.10±1.64) μmol/L and (52.80±3.34) μmol/L, respectively, and there was a statistically significant difference between the two groups (P<0.001). Compared with Sham group, the echocardiography results demonstrated that the thickness of left ventricular wall of rats from STNx group increased, the left ventricular volume decreased, and the diastolic and systolic function of left ventricular descended. The HE staining showed that the glomerulus, tubules and interstitial renal morphology were normal in Sham group, and glomerular sclerosis was observed in STNx group. And the Masson staining declared that the renal fibrous tissue distribution was normal in Sham group, and severe renal interstitial fibrosis was observed in STNx group. The wheat germ agglutinin (WGA) staining of myocardial tissue showed that myocardial cells in STNx group were larger than those in Sham group (1.293±0.060 vs 1.000±0.059, P<0.001). Moreover, the HE staining showed that there was partial myocardial tissue necrosis and fibrosis in STNx group, and severe myocardial fibrosis was observed in STNx group by Masson staining. Conclusion: Similar pathophysiological changes in human CKD were observed in the rats CKD model by transabdominal STNx, and the cardiac effects of this model make it an ideal choice to study CRS.
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Affiliation(s)
- H Cao
- Department of Cardiovascular Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - T W Ji
- Department of Cardiovascular Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Q Lan
- Shanghai Institute of Heart Failure, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - F Lin
- Shanghai Institute of Heart Failure, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Y Dong
- Department of Echocardiography, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - A J Xu
- Department of Cardiovascular Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - J Liu
- Department of Cardiovascular Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - H Y Ding
- Department of Cardiovascular Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - H M Fan
- Shanghai Institute of Heart Failure, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Z M Liu
- Department of Cardiovascular Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
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25
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Abstract
von Willebrand Factor (VWF) is an ultralong, concatameric, and adhesive glycoprotein. On short time scales, adhesiveness for platelets is activated by elongation of VWF by altered hydrodynamics at sites of hemostasis. Over longer time scales, the length of VWF is regulated by ADAMTS13 (a disintegrin and metalloprotease with a thrombospondin type 1 motif, member 13), cleavage by which in the VWF A2 domain is dependent on elongational force. Patients with von Willebrand disease type 2A present with increased bleeding due to mutations within the VWF A2 domain that enhance cleavage. We tested using temperature and force the hypothesis that von Willebrand disease mutations disrupt A2 force sensing by destabilizing the folded state. Mutations R1597W, M1528V, and E1638K reduced A2 thermal stability by 10-18 °C. M1528V and E1638K showed a marked further decrease in stability upon calcium removal. In contrast, R1597W, which resides within the A2 calcium-binding loop, exhibited similar stability in the presence and absence of calcium. Using single molecule optical tweezers and R1597W, we measured the force dependence of unfolding and refolding kinetics. In the presence of calcium, the R1597W mutation slowed the rate of refolding but had no effect on unfolding. The three mutations highlight the calcium-binding loop (R1597W), the hydrophobic core around the vicinal disulfide (M1528V), and hydrogen bonds to the α4-less loop (E1638K), as structural features critically important to the function of A2 as a force sensor in regulating thrombogenic activity in the vasculature.
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Affiliation(s)
- Amy J Xu
- Program in Cellular and Molecular Medicine, Children's Hospital Boston, and Department of Biological Chemistry and Molecular Pharmacology, Harvard Medical School, Boston, Massachusetts 02115, USA
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