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Tringale KR, Lin A, Miller AM, Khan A, Chen L, Zinovoy M, Yamada Y, Yu Y, Pike LRG, Imber BS. Real-World Use of Hypofractionated Radiotherapy for Primary CNS Tumors in the Elderly, and Implications on Medicare Spending. J Natl Compr Canc Netw 2024:1-7. [PMID: 38688308 DOI: 10.6004/jnccn.2023.7109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 11/13/2023] [Indexed: 05/02/2024]
Abstract
BACKGROUND For elderly patients with high-grade gliomas, 3-week hypofractionated radiotherapy (HFRT) is noninferior to standard long-course radiotherapy (LCRT). We analyzed real-world utilization of HFRT with and without systemic therapy in Medicare beneficiaries treated with RT for primary central nervous system (CNS) tumors using Centers for Medicare & Medicaid Services data. METHODS Radiation modality, year, age (65-74, 75-84, or ≥85 years), and site of care (freestanding vs hospital-affiliated) were evaluated. Utilization of HFRT (11-20 fractions) versus LCRT (21-30 or 31-40 fractions) and systemic therapy was evaluated by multivariable logistic regression. Medicare spending over the 90-day episode after RT planning initiation was analyzed using multivariable linear regression. RESULTS From 2015 to 2019, a total of 10,702 RT courses (ie, episodes) were included (28% HFRT; 65% of patients aged 65-74 years). A considerable minority died within 90 days of RT planning initiation (n=1,251; 12%), and 765 (61%) of those received HFRT. HFRT utilization increased (24% in 2015 to 31% in 2019; odds ratio [OR], 1.2 per year; 95% CI, 1.1-1.2) and was associated with older age (≥85 vs 65-74 years; OR, 6.8; 95% CI, 5.5-8.4), death within 90 days of RT planning initiation (OR, 5.0; 95% CI, 4.4-5.8), hospital-affiliated sites (OR, 1.4; 95% CI, 1.3-1.6), conventional external-beam RT (vs intensity-modulated RT; OR, 2.7; 95% CI, 2.3-3.1), and no systemic therapy (OR, 1.2; 95% CI, 1.1-1.3; P<.001 for all). Increasing use of HFRT was concentrated in hospital-affiliated sites (P=.002 for interaction). Most patients (69%) received systemic therapy with no differences by site of care (P=.12). Systemic therapy utilization increased (67% in 2015 to 71% in 2019; OR, 1.1 per year; 95% CI, 1.0-1.1) and was less likely for older patients, patients who died within 90 days of RT planning initiation, those who received conventional external-beam RT, and those who received HFRT. HFRT significantly reduced spending compared with LCRT (adjusted β for LCRT = +$8,649; 95% CI, $8,544-$8,755), whereas spending modestly increased with systemic therapy (adjusted β for systemic therapy = +$270; 95% CI, $176-$365). CONCLUSIONS Although most Medicare beneficiaries received LCRT for primary brain tumors, HFRT utilization increased in hospital-affiliated centers. Despite high-level evidence for elderly patients, discrepancy in HFRT implementation by site of care persists. Further investigation is needed to understand why patients with short survival may still receive LCRT, because this has major quality-of-life and Medicare spending implications.
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Affiliation(s)
- Kathryn R Tringale
- 1Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andrew Lin
- 2Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alexandra M Miller
- 2Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Atif Khan
- 1Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Linda Chen
- 1Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Melissa Zinovoy
- 1Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Yoshiya Yamada
- 1Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Yao Yu
- 1Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Luke R G Pike
- 1Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Brandon S Imber
- 1Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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Leithner D, Flynn JR, Devlin SM, Mauguen A, Fei T, Zeng S, Zheng J, Imber BS, Hubbeling H, Mayerhoefer ME, Bedmutha A, Luttwak E, Corona M, Dahi PB, Luna de Abia A, Landego I, Lin RJ, Palomba ML, Scordo M, Park JH, Tomas AA, Salles G, Lafontaine D, Michaud L, Shah GL, Perales MA, Shouval R, Schöder H. Conventional and novel [ 18F]FDG PET/CT features as predictors of CAR-T cell therapy outcome in large B-cell lymphoma. J Hematol Oncol 2024; 17:21. [PMID: 38649972 PMCID: PMC11035117 DOI: 10.1186/s13045-024-01540-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 04/02/2024] [Indexed: 04/25/2024] Open
Abstract
Relapse and toxicity limit the effectiveness of chimeric antigen receptor T-cell (CAR-T) therapy for large B-cell lymphoma (LBCL), yet biomarkers that predict outcomes and toxicity are lacking. We examined radiomic features extracted from pre-CAR-T 18F-fluorodeoxyglucose positron emission tomography/computed tomography ([18F]FDG PET/CT) scans (n = 341) of 180 patients (121 male; median age, 66 years). Three conventional (maximum standardized uptake value [SUVmax], metabolic tumor volume [MTV], total lesion glycolysis [TLG]) and 116 novel radiomic features were assessed, along with inflammatory markers, toxicities, and outcomes. At both pre-apheresis and pre-infusion time points, conventional PET features of disease correlated with elevated inflammatory markers. At pre-infusion, MTV was associated with grade ≥ 2 cytokine release syndrome (odds ratio [OR] for 100 mL increase: 1.08 [95% confidence interval (CI), 1.01-1.20], P = 0.031), and SUVmax was associated with failure to achieve complete response (CR) (OR 1.72 [95% CI, 1.24-2.43], P < 0.001). Higher pre-apheresis and pre-infusion MTV values were associated with shorter progression-free survival (PFS) (HR for 10-unit increase: 1.11 [95% CI, 1.05-1.17], P < 0.001; 1.04 [95% CI, 1.02-1.07], P < 0.001) and shorter overall survival (HR for 100-unit increase: 1.14 [95% CI, 1.07-1.21], P < 0.001; 1.04 [95% CI, 1.02-1.06], P < 0.001). A combined MTV and LDH measure stratified patients into high and low PFS risk groups. Multiple pre-infusion novel radiomic features were associated with CR. These quantitative conventional [18F]FDG PET/CT features obtained before CAR-T cell infusion, which were correlated with inflammation markers, may provide prognostic biomarkers for CAR-T therapy efficacy and toxicity. The use of conventional and novel radiomic features may thus help identify high-risk patients for earlier interventions.
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Affiliation(s)
- Doris Leithner
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, USA
- Department of Radiology, NYU Grossman School of Medicine, New York, USA
| | - Jessica R Flynn
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sean M Devlin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Audrey Mauguen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Teng Fei
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Shang Zeng
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Junting Zheng
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Brandon S Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Harper Hubbeling
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Marius E Mayerhoefer
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, USA
- Department of Radiology, NYU Grossman School of Medicine, New York, USA
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Akshay Bedmutha
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Efrat Luttwak
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Magdalena Corona
- Department of Medicine, Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, 530 E74th Street, NY, 10021, New York, USA
- Hematology and Hemotherapy Service, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Parastoo B Dahi
- Department of Medicine, Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, 530 E74th Street, NY, 10021, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Alejandro Luna de Abia
- Department of Medicine, Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, 530 E74th Street, NY, 10021, New York, USA
- Bone Marrow Transplantation Unit, Hematology Service, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Ivan Landego
- Department of Medicine, Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, 530 E74th Street, NY, 10021, New York, USA
| | - Richard J Lin
- Department of Medicine, Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, 530 E74th Street, NY, 10021, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - M Lia Palomba
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Michael Scordo
- Department of Medicine, Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, 530 E74th Street, NY, 10021, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Jae H Park
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
- Department of Medicine, Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ana Alarcon Tomas
- Department of Medicine, Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, 530 E74th Street, NY, 10021, New York, USA
- Department of Hematology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Gilles Salles
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Daniel Lafontaine
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Laure Michaud
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, USA
- Department of Nuclear Medicine and Molecular ImagingLausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Gunjan L Shah
- Department of Medicine, Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, 530 E74th Street, NY, 10021, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Miguel-Angel Perales
- Department of Medicine, Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, 530 E74th Street, NY, 10021, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Roni Shouval
- Department of Medicine, Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, 530 E74th Street, NY, 10021, New York, USA.
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA.
| | - Heiko Schöder
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, USA
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Tringale KR, Skakodub A, Egger J, Eichholz J, Yu Y, Gomez D, Rimner A, Li B, Yamada Y, Wilcox J, Moss N, Imber BS, Rekhtman N, Baine MK, Rudin CM, Pike LRG. Prognostic Implications of Small Cell Lung Cancer Transcriptional Subtyping for CNS Metastases. JCO Precis Oncol 2024; 8:e2300470. [PMID: 38691815 DOI: 10.1200/po.23.00470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 01/12/2024] [Accepted: 03/13/2024] [Indexed: 05/03/2024] Open
Abstract
PURPOSE Small cell lung cancer (SCLC) often metastasizes to the brain and has poor prognosis. SCLC subtypes distinguished by expressing transcriptional factors ASCL1 or NEUROD1 have been identified. This study investigates the impact of transcription factor-defined SCLC subtype on incidence and outcomes of brain metastases (BMs). METHODS Patients with SCLC with ASCL1 (A) and NEUROD1 (N) immunohistochemical expression status were identified and classified: (1) A+/N-, (2) A+/N+, (3) A-/N+, and (4) A-/N-. Cumulative incidence competing risk analyses were used to assess incidence of CNS progression. Cox proportional hazards models were used for multivariable analyses of overall survival (OS) and CNS progression-free survival (CNS-PFS). RESULTS Of 164 patients, most were either A+/N- or A+/N+ (n = 62, n = 63, respectively). BMs were present at diagnosis in 24 patients (15%). Among them, the 12-month cumulative incidence of subsequent CNS progression was numerically highest for A+/N- (50% [95% CI, 10.5 to 74.7]; P = .47). Among those BM-free at diagnosis, the 12-month cumulative incidence of CNS progression was numerically the highest for A+/N- (16% [95% CI, 7.5 to 27.9]) and A-/N+ (9.1% [95% CI, 0.0 to 34.8]; P = .20). Both subtypes, A+/N- and A-/N+, had worse OS compared with A+/N+ (A+/N-: hazard ratio [HR], 1.62 [95% CI, 1.01 to 2.51]; P < .05; A-/N+: HR, 3.02 [95% CI, 1.35 to 6.76]; P = .007). Excellent response rates (28, 65% CR/PR) across subtypes were seen in patients who had CNS-directed radiotherapy versus systemic therapy alone (9, 36% CR/PR). CONCLUSION To our knowledge, this report is the first to investigate CNS-specific outcomes based on transcription factor subtypes in patients with SCLC. BM-free patients at diagnosis with A+/N- or A-/N+ subtypes had worse outcomes compared with those with transcriptional factor coexpression. Further investigation into the mechanisms and implications of SCLC subtyping on CNS-specific outcomes is warranted to ultimately guide personalized care.
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Affiliation(s)
- Kathryn R Tringale
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, CA
| | - Anna Skakodub
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jacklynn Egger
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jordan Eichholz
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Yao Yu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Daniel Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
- Biomarker Development Program, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
- Biomarker Development Program, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Bob Li
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Biomarker Development Program, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Yoshiya Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jessica Wilcox
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nelson Moss
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Brain Metastasis Program, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Brandon S Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
- Brain Metastasis Program, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Natasha Rekhtman
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Marina K Baine
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Charles M Rudin
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Luke R G Pike
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
- Biomarker Development Program, Memorial Sloan Kettering Cancer Center, New York, NY
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4
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Lee NY, Sherman EJ, Schöder H, Wray R, Boyle JO, Singh B, Grkovski M, Paudyal R, Cunningham L, Zhang Z, Hatzoglou V, Katabi N, Diplas BH, Han J, Imber BS, Pham K, Yu Y, Zakeri K, McBride SM, Kang JJ, Tsai CJ, Chen LC, Gelblum DY, Shah JP, Ganly I, Cohen MA, Cracchiolo JR, Morris LG, Dunn LA, Michel LS, Fetten JV, Kripani A, Pfister DG, Ho AL, Shukla-Dave A, Humm JL, Powell SN, Li BT, Reis-Filho JS, Diaz LA, Wong RJ, Riaz N. Hypoxia-Directed Treatment of Human Papillomavirus-Related Oropharyngeal Carcinoma. J Clin Oncol 2024; 42:940-950. [PMID: 38241600 PMCID: PMC10927322 DOI: 10.1200/jco.23.01308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 09/18/2023] [Accepted: 11/08/2023] [Indexed: 01/21/2024] Open
Abstract
PURPOSE Standard curative-intent chemoradiotherapy for human papillomavirus (HPV)-related oropharyngeal carcinoma results in significant toxicity. Since hypoxic tumors are radioresistant, we posited that the aerobic state of a tumor could identify patients eligible for de-escalation of chemoradiotherapy while maintaining treatment efficacy. METHODS We enrolled patients with HPV-related oropharyngeal carcinoma to receive de-escalated definitive chemoradiotherapy in a phase II study (ClinicalTrials.gov identifier: NCT03323463). Patients first underwent surgical removal of disease at their primary site, but not of gross disease in the neck. A baseline 18F-fluoromisonidazole positron emission tomography scan was used to measure tumor hypoxia and was repeated 1-2 weeks intratreatment. Patients with nonhypoxic tumors received 30 Gy (3 weeks) with chemotherapy, whereas those with hypoxic tumors received standard chemoradiotherapy to 70 Gy (7 weeks). The primary objective was achieving a 2-year locoregional control (LRC) of 95% with a 7% noninferiority margin. RESULTS One hundred fifty-eight patients with T0-2/N1-N2c were enrolled, of which 152 patients were eligible for analyses. Of these, 128 patients met criteria for 30 Gy and 24 patients received 70 Gy. The 2-year LRC was 94.7% (95% CI, 89.8 to 97.7), meeting our primary objective. With a median follow-up time of 38.3 (range, 22.1-58.4) months, the 2-year progression-free survival (PFS) and overall survival (OS) rates were 94% and 100%, respectively, for the 30-Gy cohort. The 70-Gy cohort had similar 2-year PFS and OS rates at 96% and 96%, respectively. Acute grade 3-4 adverse events were more common in 70 Gy versus 30 Gy (58.3% v 32%; P = .02). Late grade 3-4 adverse events only occurred in the 70-Gy cohort, in which 4.5% complained of late dysphagia. CONCLUSION Tumor hypoxia is a promising approach to direct dosing of curative-intent chemoradiotherapy for HPV-related carcinomas with preserved efficacy and substantially reduced toxicity that requires further investigation.
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Affiliation(s)
- Nancy Y. Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Eric J. Sherman
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - HeiKo Schöder
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Rick Wray
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jay O. Boyle
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Bhuvanesh Singh
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Milan Grkovski
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ramesh Paudyal
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Louise Cunningham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Zhigang Zhang
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Vaios Hatzoglou
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nora Katabi
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Bill H. Diplas
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - James Han
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Brandon S. Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Khoi Pham
- Department of Finance, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Yao Yu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kaveh Zakeri
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sean M. McBride
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jung J. Kang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - C. Jillian Tsai
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Linda C. Chen
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Daphna Y. Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jatin P. Shah
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ian Ganly
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Marc A. Cohen
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Luc G.T. Morris
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Lara A. Dunn
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Loren S. Michel
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - James V. Fetten
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Anuja Kripani
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David G. Pfister
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alan L. Ho
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Amita Shukla-Dave
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - John L. Humm
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Simon N. Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Bob T. Li
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jorge S. Reis-Filho
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Luis A. Diaz
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Richard J. Wong
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nadeem Riaz
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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Imber BS, Sehgal R, Saganty R, Reiner AS, Ilica AT, Miao E, Li BT, Riely GJ, Yu HA, Panageas KS, Young RJ, Pike LR, Moss NS. Intracranial Outcomes of De Novo Brain Metastases Treated With Osimertinib Alone in Patients With Newly Diagnosed EGFR-Mutant NSCLC. JTO Clin Res Rep 2023; 4:100607. [PMID: 38124791 PMCID: PMC10730363 DOI: 10.1016/j.jtocrr.2023.100607] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 11/08/2023] [Accepted: 11/15/2023] [Indexed: 12/23/2023] Open
Abstract
Introduction Patients with EGFR-mutant NSCLC have a high incidence of brain metastases. The EGFR-directed tyrosine kinase inhibitor osimertinib has intracranial activity, making the role of local central nervous system (CNS)-directed therapies, such as radiation and surgery, less clear. Methods Patients with EGFR-mutant NSCLC and brain metastases who received osimertinib as initial therapy after brain metastasis diagnosis were included. Individual lesion responses were assessed using adapted RANO-BM criteria. CNS progression and local progression of brain metastasis from osimertinib start were analyzed using cumulative incidence treating death as a competing risk. Overall survival was estimated using Kaplan-Meier methodology. Results There were 36 patients who had a median interval from brain metastasis diagnosis to first-line osimertinib initiation of 25 days. In total, 136 previously untreated brain metastases were tracked from baseline. Overall, 105 lesions (77.2%) had complete response and 31 had partial response reflecting best objective response of 100%. Best response occurred at a median of 96 days (range: 28-1113 d) from baseline magnetic resonance imaging. This reflects a best objective response rate of 100%. Two-year overall survival was 80%. CNS progression rates at 1-, 2-, and 3-years post-osimertinib were 21%, 32%, and 41%, respectively. Lesion-level local failure was estimated to be 0.7% and 4.7% at 1- and 2-years post-osimertinib, respectively. No clinicodemographic factors including brain metastasis number were associated with post-osimertinib progression. Conclusions Intracranial response to osimertinib is excellent for patients with EGFR-mutant NSCLC with de novo, previously untreated brain metastases. Very low local failure rates support a strategy of upfront osimertinib alone in selected patients.
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Affiliation(s)
- Brandon S. Imber
- Department of Radiation Oncology and Multidisciplinary Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ryka Sehgal
- Department of Neurosurgery and Multidisciplinary Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Rachel Saganty
- Department of Radiation Oncology and Multidisciplinary Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anne S. Reiner
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - A. Turan Ilica
- Division of Neuroradiology, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Emily Miao
- Department of Radiation Oncology and Multidisciplinary Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Bob T. Li
- Division of Solid Tumor Oncology, Memorial Sloan Kettering Cancer Center, New York, New York and Weill Cornell Medical College, New York, New York
| | - Gregory J. Riely
- Division of Solid Tumor Oncology, Memorial Sloan Kettering Cancer Center, New York, New York and Weill Cornell Medical College, New York, New York
| | - Helena A. Yu
- Division of Solid Tumor Oncology, Memorial Sloan Kettering Cancer Center, New York, New York and Weill Cornell Medical College, New York, New York
| | - Katherine S. Panageas
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Robert J. Young
- Division of Neuroradiology, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Luke R.G. Pike
- Department of Radiation Oncology and Multidisciplinary Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nelson S. Moss
- Department of Neurosurgery and Multidisciplinary Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
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Freret ME, Tringale KR, Boe L, Imber BS, Joffe E, Yahalom J, Hajj C. Very low-dose radiotherapy for extranodal marginal zone lymphoma of bronchus-associated lymphoid tissue. Leuk Lymphoma 2023; 64:2195-2201. [PMID: 37706509 PMCID: PMC10962616 DOI: 10.1080/10428194.2023.2255706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/30/2023] [Accepted: 08/31/2023] [Indexed: 09/15/2023]
Abstract
Extranodal marginal zone lymphoma of bronchus-associated lymphoid tissue (BALT) is a rare cancer for which optimal treatment strategies are undefined. Retrospective analyses suggest excellent outcomes with surgical resection for localized BALT lymphoma; however, the role of radiotherapy remains underexplored. We report the largest-to-date single-center analysis of 13 primary BALT lymphoma patients treated with radiotherapy. Of 15 treated lesions, we report a 100% response rate with complete response (CR) achieved in 67% of lesions. Among 10 lesions treated with very low-dose radiotherapy (VLDRT; 4 Gray [Gy]), 6 (60%) achieved a CR; among 5 lesions treated with full-dose radiotherapy (24-36 Gy), 4 (80%) achieved a CR. There were no local recurrences. Only one patient, treated with 30 Gy, developed an acute grade 3/4 toxic effect. There were no events of radiation-induced secondary malignancies. Our institutional experience indicates that radiotherapy, including VLDRT, is a safe and effective treatment for primary BALT lymphoma.
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Affiliation(s)
- Morgan E. Freret
- Radiation Oncology, Memorial Sloan Kettering Cancer Center (MSKCC), New York, NY, USA
| | - Kathryn R. Tringale
- Radiation Oncology, Memorial Sloan Kettering Cancer Center (MSKCC), New York, NY, USA
| | - Lillian Boe
- Epidemiology and Biostatistics, MSKCC, New York, NY, USA
| | - Brandon S. Imber
- Radiation Oncology, Memorial Sloan Kettering Cancer Center (MSKCC), New York, NY, USA
| | - Erel Joffe
- Lymphoma Service, MSKCC, New York, NY, USA
| | - Joachim Yahalom
- Radiation Oncology, Memorial Sloan Kettering Cancer Center (MSKCC), New York, NY, USA
| | - Carla Hajj
- Radiation Oncology, Memorial Sloan Kettering Cancer Center (MSKCC), New York, NY, USA
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Grkovski M, O'Donoghue JA, Imber BS, Andl G, Tu C, Lafontaine D, Schwartz J, Thor M, Zelefsky MJ, Humm JL, Bodei L. Lesion Dosimetry for [ 177Lu]Lu-PSMA-617 Radiopharmaceutical Therapy Combined with Stereotactic Body Radiotherapy in Patients with Oligometastatic Castration-Sensitive Prostate Cancer. J Nucl Med 2023; 64:1779-1787. [PMID: 37652541 PMCID: PMC10626375 DOI: 10.2967/jnumed.123.265763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 07/11/2023] [Indexed: 09/02/2023] Open
Abstract
A single-institution prospective pilot clinical trial was performed to demonstrate the feasibility of combining [177Lu]Lu-PSMA-617 radiopharmaceutical therapy (RPT) with stereotactic body radiotherapy (SBRT) for the treatment of oligometastatic castration-sensitive prostate cancer. Methods: Six patients with 9 prostate-specific membrane antigen (PSMA)-positive oligometastases received 2 cycles of [177Lu]Lu-PSMA-617 RPT followed by SBRT. After the first intravenous infusion of [177Lu]Lu-PSMA-617 (7.46 ± 0.15 GBq), patients underwent SPECT/CT at 3.2 ± 0.5, 23.9 ± 0.4, and 87.4 ± 12.0 h. Voxel-based dosimetry was performed with calibration factors (11.7 counts per second/MBq) and recovery coefficients derived from in-house phantom experiments. Lesions were segmented on baseline PSMA PET/CT (50% SUVmax). After a second cycle of [177Lu]Lu-PSMA-617 (44 ± 3 d; 7.50 ± 0.10 GBq) and an interim PSMA PET/CT scan, SBRT (27 Gy in 3 fractions) was delivered to all PSMA-avid oligometastatic sites, followed by post-PSMA PET/CT. RPT and SBRT voxelwise dose maps were scaled (α/β = 3 Gy; repair half-time, 1.5 h) to calculate the biologically effective dose (BED). Results: All patients completed the combination therapy without complications. No grade 3+ toxicities were noted. The median of the lesion SUVmax as measured on PSMA PET was 16.8 (interquartile range [IQR], 11.6) (baseline), 6.2 (IQR, 2.7) (interim), and 2.9 (IQR, 1.4) (post). PET-derived lesion volumes were 0.4-1.7 cm3 The median lesion-absorbed dose (AD) from the first cycle of [177Lu]Lu-PSMA-617 RPT (ADRPT) was 27.7 Gy (range, 8.3-58.2 Gy; corresponding to 3.7 Gy/GBq, range, 1.1-7.7 Gy/GBq), whereas the median lesion AD from SBRT was 28.1 Gy (range, 26.7-28.8 Gy). Spearman rank correlation, ρ, was 0.90 between the baseline lesion PET SUVmax and SPECT SUVmax (P = 0.005), 0.74 (P = 0.046) between the baseline PET SUVmax and the lesion ADRPT, and -0.81 (P = 0.022) between the lesion ADRPT and the percent change in PET SUVmax (baseline to interim). The median for the lesion BED from RPT and SBRT was 159 Gy (range, 124-219 Gy). ρ between the BED from RPT and SBRT and the percent change in PET SUVmax (baseline to post) was -0.88 (P = 0.007). Two cycles of [177Lu]Lu-PSMA-617 RPT contributed approximately 40% to the maximum BED from RPT and SBRT. Conclusion: Lesional dosimetry in patients with oligometastatic castration-sensitive prostate cancer undergoing [177Lu]Lu-PSMA-617 RPT followed by SBRT is feasible. Combined RPT and SBRT may provide an efficient method to maximize the delivery of meaningful doses to oligometastatic disease while addressing potential microscopic disease reservoirs and limiting the dose exposure to normal tissues.
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Affiliation(s)
- Milan Grkovski
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York;
| | - Joseph A O'Donoghue
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Brandon S Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - George Andl
- Varian Medical Systems Inc., Palo Alto, California; and
| | - Cheng Tu
- Varian Medical Systems Inc., Palo Alto, California; and
| | - Daniel Lafontaine
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jazmin Schwartz
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Maria Thor
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael J Zelefsky
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - John L Humm
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lisa Bodei
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
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8
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Bander ED, El Ahmadieh TY, Chen J, Reiner AS, Brown S, Giantini-Larsen AM, Young RJ, Beal K, Imber BS, Pike LRG, Brennan CW, Tabar V, Panageas KS, Moss NS. Outcomes Following Early Postoperative Adjuvant Radiosurgery for Brain Metastases. JAMA Netw Open 2023; 6:e2340654. [PMID: 37906192 PMCID: PMC10618851 DOI: 10.1001/jamanetworkopen.2023.40654] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/19/2023] [Indexed: 11/02/2023] Open
Abstract
Importance Adjuvant stereotactic radiosurgery (SRS) enhances the local control of resected brain metastases (BrM). However, the risks of local failure (LF) and potential for posttreatment adverse radiation effects (PTRE) after early postoperative adjuvant SRS have not yet been established. Objective To evaluate whether adjuvant SRS delivered within a median of 14 days after surgery is associated with improved LF without a concomitant increase in PTRE. Design, Setting, and Participants This prospective cohort study examines a clinical workflow (RapidRT) that was implemented from 2019 to 2022 to deliver SRS to surgical patients within a median of 14 days, ensuring all patients were treated within 30 days postoperatively. This prospective cohort was compared with a historical cohort (StanRT) of patients with BrM resected between 2013 and 2019 to assess the association of the RapidRT workflow with LF and PTRE. The 2 cohorts were combined to identify optimal SRS timing, with a median follow-up of 3.3 years for survivors. Exposure Timing of adjuvant SRS (14, 21, and 30 days postoperatively). Main Outcomes and Measures LF and PTRE, according to modified Response Assessment in Neuro-Oncology Brain Metastases criteria. Results There were 438 patients (265 [60.5%] female patients; 23 [5.3%] Asian, 27 [6.2%] Black, and 364 [83.1%] White patients) with a mean (SD) age of 62 (13) years; 377 were in the StanRT cohort and 61 in the RapidRT cohort. LF and PTRE rates at 1 year were not significantly different between RapidRT and StanRT cohorts. Timing of SRS was associated with radiographic PTRE. Patients receiving radiation within 14 days had the highest 1-year PTRE rate (18.08%; 95% CI, 8.31%-30.86%), and patients receiving radiation between 22 and 30 days had the lowest 1-year PTRE rate (4.10%; 95% CI, 1.52%-8.73%; P = .03). LF rates were highest for patients receiving radiation more than 30 days from surgery (10.65%; 95% CI, 6.90%-15.32%) but comparable for patients receiving radiation within 14 days, between 15 and 21 days, and between 22 and 30 days (≤14 days: 5.12%; 95% CI, 0.86%-15.60%; 15 to ≤21 days: 3.21%; 95% CI, 0.59%-9.99%; 22 to ≤30 days: 6.58%; 95% CI, 3.06%-11.94%; P = .20). Conclusions and Relevance In this cohort study of adjuvant SRS timing following surgical resection of BrM, the optimal timing for adjuvant SRS appears to be within 22 to 30 days following surgery. The findings of this study suggest that this timing allows for a balanced approach that minimizes the risks associated with LF and PTRE.
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Affiliation(s)
- Evan D. Bander
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Neurosurgery, New York Presbyterian Hospital/Weill Cornell Medical College, New York
| | - Tarek Y. El Ahmadieh
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Neurosurgery, Loma Linda University Health, Loma Linda, California
| | - Justin Chen
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anne S. Reiner
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Samantha Brown
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alexandra M. Giantini-Larsen
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Neurosurgery, New York Presbyterian Hospital/Weill Cornell Medical College, New York
| | - Robert J. Young
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kathryn Beal
- Department of Radiation Oncology and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Brandon S. Imber
- Department of Radiation Oncology and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Luke R. G. Pike
- Department of Radiation Oncology and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Cameron W. Brennan
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Viviane Tabar
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Katherine S. Panageas
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nelson S. Moss
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York
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9
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Eichholz J, Gaeta B, Walch H, Boe L, Kratochvil L, Del Balzo LA, Yamada Y, Yu Y, Zinovoy M, Gomez DR, Imber BS, Isbell J, Li BT, Murciano-Goroff Y, Arbour K, Schultz N, Lebow ES, Pike LRG. The Impact of Co-Alterations on Outcomes after Local Therapy for Patients with KRAS-Mutant Lung Adenocarcinoma Brain Metastases. Int J Radiat Oncol Biol Phys 2023; 117:e101-e102. [PMID: 37784628 DOI: 10.1016/j.ijrobp.2023.06.871] [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) Brain metastases are common in NSCLC with up to 25% of patients having brain metastases (BMs) at the time of diagnosis and 30% developing BMs during their disease course. KRAS is an oncogenic driver in approximately 25% of lung adenocarcinomas. Genomic alterations co-occurring with KRAS are associated with distinct biological landscapes which may influence prognosis. Herein, we sought to identify correlations between genomic profiles, intracranial progression free survival (iPFS), and overall survival (OS). MATERIALS/METHODS We retrospectively reviewed 156 patients with KRAS-mutant lung adenocarcinoma BM who underwent SRS for their BMs at MSKCC from 2010-2022. Each patient had at least one tumor sample profiled with MSK-IMPACT, a custom FDA-cleared next-generation sequencing. Mutations, copy number alterations, and fusions were filtered for driver alterations using OncoKB. Survival outcomes were calculated from date of MRI indicating metastatic brain disease. RESULTS Of the 156 patients, 80 patients presented with BMs at diagnosis whereas 76 developed BMs during their disease course, with a median 2 lines of therapy prior to BM diagnosis. The most common KRAS mutation was G12C (n = 64; 41%), G12V (n = 26, 17%), G12D (n = 17; 11%), and G12A (n = 11; 7%). The most frequently co-altered genes were TP53 (n = 71, 46%), STK11 (n = 51, 33%), CDKN2A (n = 27, 17%), KEAP1 (n = 17, 11%), and SMARCA4 (n = 10, 6%). The presence of a KEAP1 co-occurring alteration was associated with inferior iPFS (HR 1.95, 95% CI 1.05 - 3.59, p = 0.035) and the presence of SMARCA4 was also associated with inferior iPFS (HR 2.28, 95% CI 1.05 - 4.95, p = 0.038). The presence of an STK11 mutation was associated with worse OS (HR 1.57, 95% 1.01 - 2.43, p = 0.045). In a multi-variate clinico-genomic model, KEAP1 and STK11 co-occurring alterations remained significantly associated with iPFS. Patients with KEAP1-altered tumors had an increased incidence of intracranial regional progression. The 24-month cumulative incidence of regional progression amongst KEAP1-altered tumors was 57% (95% CI, 29%-77%) compared with 37% (95% CI, 29%-46%) among KEAP1-wildtype tumors (P = 0.041). Patients with CDKN2A-altered tumors had an increased incidence of leptomeningeal disease (LMD) as a form of intracranial progression. The 24-month cumulative incidence of LMD amongst CDKN2A-altered tumors was 11% (95% CI, 2.7%-27%) compared with 4.1% (95% CI, 1.5%-8.8%) among CDKN2A-wildtype tumors (P = 0.023). CONCLUSION In our cohort of molecularly profiled KRAS-mutant lung adenocarcinoma BM patients treated with SRS, we found that co-occurring KEAP1 and STK11 were significantly associated with worse iPFS. We also observed that CDKN2A co-altered tumors had an increased incidence of LMD. These findings have implications for future efforts to personalize brain metastasis management based on comprehensive genomic profiling.
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Affiliation(s)
- J Eichholz
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - B Gaeta
- Weill Cornell Medical School, New York, NY
| | - H Walch
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - L Boe
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - L Kratochvil
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Y Yamada
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Y Yu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - M Zinovoy
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - D R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - B S Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - J Isbell
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - B T Li
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - K Arbour
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - N Schultz
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - E S Lebow
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - L R G Pike
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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10
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Mankuzhy NP, Tringale KR, Hajj C, Yahalom J, Imber BS. Thirty-Year Experience of Radiotherapy for Primary Intraocular Lymphoma with and without Chemotherapy. Int J Radiat Oncol Biol Phys 2023; 117:e477. [PMID: 37785512 DOI: 10.1016/j.ijrobp.2023.06.1692] [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) Primary intraocular lymphoma (PIOL) is a rare presentation of primary central nervous system lymphoma (PCNSL). We previously reported that ocular radiation therapy (RT) is an excellent option that can spare appropriate patients' upfront toxicity of whole brain radiotherapy (WBRT) and aggressive chemotherapy. A decade later, we expanded this series with almost double median follow up time. MATERIALS/METHODS We identified all patients seen at our institution from 1990-2022 treated for PCNSL or who received RT to the orbits. Detailed chart review was completed for cases with isolated ocular involvement at presentation (PIOL) who received RT to unilateral or bilateral orbits. Patients with disease on MRI brain or CSF cytology were excluded. Analysis included Kaplan-Meier method, log-rank-test, and Wilcoxon rank sum test. Overall survival (OS) was measured from diagnosis. Freedom-from-recurrence (FFR) measured time from RT start to first recurrence identified on imaging (parenchymal), slit-lamp exam (ocular), or biopsy. RESULTS A total of 75 patients were treated with RT to the orbits as part of management of PCNSL. 29 had PIOL with median follow up of 52 months from diagnosis. Of this subset, 22 (76%) received RT at our institution, median age at diagnosis was 65 (31-84) and 18 (62%) had bilateral disease. The majority were diagnosed by vitrectomy or vitreoretinal biopsy with B-cell lymphoma or unspecified lymphoma and 3 were clinically diagnosed. 17 patients received RT alone, 10 received RT after induction chemotherapy and 2 with induction and consolidation chemotherapy. Younger patients received chemotherapy (median age 60 vs 70, p = 0.03). RT dose ranged from 30 to 45 Gy, and 20 (69%) received 36 Gy, primarily with 1.8 Gy fractions. 22 (76%) received RT to bilateral orbits. 21 (72%) developed recurrence (Table 1), of which 6 (28.5%) recurred in a RT-treated eye and 11 (52.4%) isolated in the brain. 2 got salvage orbital RT and 4 got WBRT. Median OS was 5.4 years (95% CI 3.9, 7.6) and FFR was 8.4 months (95% CI 5.0, 25). There was no difference in OS (p = 0.4) or FFR (p = 0.3) between combined modality therapy versus RT alone. CONCLUSION In this updated experience, we demonstrate that RT alone remains an effective option for isolated PIOL, especially for those at risk of poor toleration of chemotherapy. Systemic therapy or WBRT can be utilized at recurrence, which primarily occurs in the brain. Future comparisons are needed to compare orbital RT to intravitreal therapies, and to investigate how these methods can complement each other to further improve management.
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Affiliation(s)
- N P Mankuzhy
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - K R Tringale
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - C Hajj
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - J Yahalom
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - B S Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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11
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Fregonese B, Schieffelin L, Lee J, Boe L, Imber BS, Yahalom J, Hajj C. Radiation Therapy in the Management of Primary Gastric Diffuse Large B-Cell Lymphomas: Long-Term Outcomes of 82 Patients. Int J Radiat Oncol Biol Phys 2023; 117:S64. [PMID: 37784544 DOI: 10.1016/j.ijrobp.2023.06.365] [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) Our group has recently published its long-term experience treating gastric MALT lymphomas with involved site radiation therapy (ISRT) and supported the use of RT alone as standard of care for H pylori independent MALT. For primary gastric (PG) diffuse large B-cell lymphomas (DLBCL), R-CHOP is the mainstay of therapy, but RT to the stomach primarily as consolidation has rarely been analyzed. In this study, we focus on pts with PG DLBCL who received combined modality therapy. MATERIALS/METHODS Two hundred eighty-five consecutive pts with PG lymphomas treated with RT between January 2000 and January 2021 at our institution were retrospectively identified. Baseline characteristics and follow-up data were abstracted. Overall response rate (ORR) was assessed with Lugano PET criteria and endoscopy. Overall survival (OS) was calculated using Kaplan-Meier. Toxicity was assessed with CTCAE version 4.0. RESULTS Of 285 pts, 203 (71%) had PG MALT and 82 (29%) PG DLBCL. Baseline characteristics are summarized in Table 1. In the DLBCL pts, 74 (90%) received consolidation RT after limited (3-4 cycles) or full (6 cycles) chemoimmunotherapy (CT), 4 (5%) received RT after 2 lines of CT, 2 (3%) received first line RT followed by CT, 1 (1%) had 3 lines of CT and RT, and 1 (1%) was treated with surgery, 2 lines of CT, and RT. In the 74 pts who received CT+RT as first line treatment, the median RT dose was 3060 cGy (range 1620-3600). Based on post-chemo pre-RT EGD and PET, 61 (82%) pts were in CR, 7 (10%) had PR, 3 (4%) had SD and 3 (4%) pts were not assessed. Overall, 66 (89%) pts who received RT after CT achieved a CR. Of the remaining 8 (11%) pts who did not achieve a CR after RT, 4 had PR, 1 had SD, 1 was lost to FU, 1 started additional CT before response assessment and 1 pt died. The 2 pts in the DLBCL group who received first line RT achieved CR after RT. Side effects after RT were mild and limited to nausea and fatigue. The median follow-up time was 5.4 yrs (95% CI 0.4, 20.4) in DLBCL pts and 6.3 yrs (95% CI 0.3, 22.1) in MALT pts. The 5-yr OS was 80% (95% CI 71-90%) for DLBCL and 96% (95% CI 93-99%) for MALT. CONCLUSION Adding stomach RT following chemoimmunotherapy is feasible, well-tolerated and safe. More in depth analysis PG DLBCL is underway, with a plan to compare outcomes of patients treated with CT alone versus CT followed by RT, and further analyze treatment-related toxicities, progression-free survival, and patterns of recurrence.
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Affiliation(s)
- B Fregonese
- Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - L Schieffelin
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - J Lee
- Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - L Boe
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - B S Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - J Yahalom
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - C Hajj
- Memorial Sloan Kettering Cancer Center, New York, NY
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12
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Aristophanous M, Hsu DG, Imber BS, Gui C, Daly J, Jancasz J, Huang C, Ballangrud A, Kuo L, Della Biancia C, Moran JM. Failure Mode and Effects Analysis Prior to the Introduction of AI Generated GTVs for Brain Metastases in the Clinical Workflow. Int J Radiat Oncol Biol Phys 2023; 117:S88. [PMID: 37784595 DOI: 10.1016/j.ijrobp.2023.06.413] [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) AI autosegmentation of organs-at-risk (OARs) is common practice at many radiotherapy clinics. Despite the abundance of gross tumor volume (GTV) autosegmentation algorithms, adoption in clinical care has been slow due to the high risk associated with errors in GTV delineation. Here we present a failure mode and effects analysis (FMEA) to evaluate the risk associated with introducing AI derived GTVs in patients treated with stereotactic radiosurgery (SRS). MATERIALS/METHODS An AI GTV autosegmentation algorithm for brain metastases was developed in-house based on a V-Net 3D CNN. Registered CT and MR images and a contour of the brain are input into the software and all identified lesions are returned in a DICOM-RT structure set. Following algorithm evaluation, a workflow was developed to enable AI GTV autosegmentation to be introduced clinically for every SRS patient. The following steps were added to existing procedures: 1) workflow to send CT/MR and brain structure to external server, 2) autosegmentation run on the server, 3) AI GTV structures with a standard nomenclature added to existing OAR structure set, and 4) MD review, editing, and approval of AI GTVs. After successfully completing the physics evaluation testing of the new process, we formed a team of 10 faculty and staff including physicists, residents, physicians, and planners to perform the FMEA prior to clinical implementation. The team met to map the process, identify potential failure modes, and score their frequency of occurrence, severity, and detectability. A 3-point scale (1, 3, or 5) was used to simplify the scoring process. Occurrence was defined as rare, sometimes, or often; severity as low, medium, or high; and detectability as obvious, possible, or challenging. The risk probability numbers (RPNs) were calculated and the steps in the process with the highest RPNs were flagged for further discussion. RESULTS The FMEA team completed their process map and analysis primarily in 4 meetings. The process map began with acquisition of the patients CT simulation scan and ended with physician approval of final volumes for treatment planning. We identified 17 process steps and 72 possible failure modes, of which 26 were associated with the new workflow. Eighteen failure modes had an RPN greater than 30 (highest risk score in at least one category) and were flagged to assess mitigation strategies. Five were unique to the new AI GTV workflow and mitigation strategies will be designed prior to clinical use. Those involved risks related to inaccurate AI GTV contours, false positives, and an incomplete review stemming from over-reliance by team members on AI. CONCLUSION AI is increasingly being employed at every step of radiotherapy to automate and streamline processes. The FMEA analysis resulted in the identification of the riskiest parts of using AI GTV autosegmentation. This can be an effective tool in the development of checks to ensure that GTV autosegmentation methods can be safely introduced in support of patient care.
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Affiliation(s)
- M Aristophanous
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - D G Hsu
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - B S Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - C Gui
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - J Daly
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - J Jancasz
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - C Huang
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - A Ballangrud
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - L Kuo
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - C Della Biancia
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - J M Moran
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
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13
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Dreyfuss A, Fregonese B, Ma J, Sarkar RR, Lee J, Cederquist G, Hubbeling HG, Tringale KR, Wijetunga NA, Usmani S, Hajj C, Imber BS, Yahalom J. Radiation in a New Era of Multiple Myeloma Management: Patterns of Utilization, Clinical, Radiologic, and Biochemical Outcomes, and Possible Genomic Correlates of Response. Int J Radiat Oncol Biol Phys 2023; 117:S108-S109. [PMID: 37784286 DOI: 10.1016/j.ijrobp.2023.06.072] [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) Systemic therapies for multiple myeloma (MM) have advanced considerably, improving patient outcomes. Yet, the use of radiotherapy (RT) has remained heterogeneous, and even controversial, due to minimal data on outcomes. With the ultimate goal of guiding the design of prospective trials incorporating RT, we initiated a study of our institutional experience treating MM with RT since 1/1/2000. Here we report a preliminary feasibility analysis of an initial sample cohort, identifying patterns of RT utilization, outcomes, and impact of RT on radiographic and biochemical markers, with genomic characterization for more recently treated patients. MATERIALS/METHODS Five hundred six pathologically confirmed MM patients who received RT to 1190 sites between January 1, 2000, and June 1, 2022, were identified. Patient, disease, and treatment characteristics were analyzed for 50 consecutive patients treated in 2019 and tested for association with local and distant failure (LF, DF) using univariable and multivariable analysis. Genomic data was obtained via next generation sequencing using an institutional targeted sequencing panel. RESULTS Amongthe 50 patients analyzed (median 63 years), 90 lesions were treated with RT, 33% with concurrent systemic therapy, to median dose of 20 Gy (8-46 Gy) over a median of 5 fractions (1-25). RT Indications were pain (56%), critical structure involvement (25%), peri-operative (9%), salvage/consolidation (8%), and bridging therapy (2%). Median size of RT-treated lesions was 4.2 cm (1.4-7.9) and included non-vertebral bones (62%), spine (24%), and extramedullary sites (14%). The median number of lines of pre-RT therapy was 7 (1-14) and 51% had >9 lesions on imaging, 47% involving both medullary and extramedullary sites. With median follow-up of 12.4 months (0.5-46), LF occurred in 5% of treated sites and 89% had DF, most commonly in both medullary + extramedullary (51.4%) sites. Absolute decreases 1-week to 1-month post-RT were observed in % of marrow plasma cell (median 4.0%), M spike (0.30 g/dL), total protein (0.3 g/dL), K:L ratio (0.01), lesion size (1.5cm), and lesion SUV (3.1) but in this limited sample, none were significantly associated with disease control. A cohort of 62 RT-treated MM patients from 2016-2022 had genomic data available; most common tumor mutations were in TP53 (35%), HIST1 (34%), NRAS (34%), and KRAS (23%). CONCLUSION In this pilot analysis of a sampling cohort of RT-treated MM, we report on patterns of utilization, outcomes, and biochemical and radiographic correlates. At the meeting, we will present the full analysis of the >500 MM patients and further analyze emerging genomic data. We aim to characterize the role of RT in the modern era of systemic therapy to guide the design of future prospective trials and to inform novel approaches for incorporating RT into the treatment paradigm.
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Affiliation(s)
- A Dreyfuss
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - B Fregonese
- Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - J Ma
- Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - R R Sarkar
- Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - J Lee
- Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - G Cederquist
- Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - H G Hubbeling
- Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - K R Tringale
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - N A Wijetunga
- Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - S Usmani
- Hematology, Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - C Hajj
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - B S Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - J Yahalom
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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14
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Imber BS, Bodei L, Humm J, Ionescu A, Wu W, Grkovski M, O'Donoghue J, Reddy RP, Rimner A, Shasha D, Zhang Z, Schoder H, Morris M, Zelefsky MJ. A Pilot Study of Stereotactic Body Radiotherapy and 177Lu-PSMA-617 for Oligometastatic Hormone Sensitive Prostate Cancer. Int J Radiat Oncol Biol Phys 2023; 117:e112. [PMID: 37784650 DOI: 10.1016/j.ijrobp.2023.06.891] [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) Stereotactic body radiotherapy (SBRT) is increasingly used for oligorecurrent prostate cancer (OPC). Despite excellent local control, distant metastasis free survival rates are more modest. We hypothesized SBRT outcomes could be optimized with improved staging imaging and integration of a well-tolerated targeted radiopharmaceutical therapy (RLT) for microscopic disease. We report initial results of a prospective, single-institution pilot (NCT05079698) of a novel, PSMA-based theranostic strategy for OPC. MATERIALS/METHODS Men with castrate sensitive OPC and 1-3 sites of PSMA PET avid disease ("index lesions") and no PSMA non-avid sites were eligible. No androgen deprivation therapy was permitted. Subjects first received 2 cycles of 177Lu-PSMA-617 RLT (7.47±0.14 GBq) spaced 6 weeks apart. In vivo dosimetry was performed during cycle 1. Four weeks post-cycle 2, patients were restaged with 68Ga-PSMA PET for an interim (post-RLT) response assessment. Index lesions were then consolidated with SBRT (9 Gy x 3) irrespective of post-RLT PET response. The primary outcome was feasibility defined as successful completion of protocol-mandated therapy without intercurrent distant failure on post-RLT PET. RESULTS Six men were treated with nine total index lesions (5 nodal, 3 osseous, 1 visceral). The study met its primary endpoint; all completed required interventions and no distant progression was seen on interim PSMA PET. Treatment was well tolerated; no grade 3+ toxicities, 2/6 had grade 2 toxicities (transient anemia and hyperbilirubinemia) and 5/6 had grade 1 toxicities. Median baseline lesion-level PSMA SUVmax was 16.8±8.7. Median interim SUVmax was 6.2±2.5 and declined for all but one lesion post-RLT (median -65%). Median SUVmax at 3-mos post-SBRT was 3.3±2.5 and decreased for all evaluable lesions (median -80%). Median baseline PSA was 2.01 ng/mL (range: 0.72-4.56) which declined in 5/6 post-RLT. The 6th patient experienced biochemical rise with interim PET showing only greater avidity in the known index lesion and SBRT was completed per protocol. All 4 evaluable patients with at least one post-SBRT follow-up have improved PSA at last visit (range 5.5-12 mos from cycle 1), and 2/4 have undetectable PSA. Composite dosimetry, correlatives and quality of life studies are forthcoming. CONCLUSION Our pilot study demonstrates the feasibility of a novel PSMA anchored theranostic strategy combining SBRT with targeted RLT for OPC. Preliminary data suggests promising outcomes, including the possibility of achieving an undetectable biochemical disease state without hormone therapy.
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Affiliation(s)
- B S Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - L Bodei
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - J Humm
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - A Ionescu
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - W Wu
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - M Grkovski
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - J O'Donoghue
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - R P Reddy
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - A Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - D Shasha
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Z Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - H Schoder
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - M Morris
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - M J Zelefsky
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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15
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Hajj C, Lee J, Boe LA, Fregonese B, Lebow ES, Wijetunga NA, Hubbeling HG, Tringale KR, Freret ME, Imber BS, Yahalom J. Very Low Dose Radiation Therapy for Indolent Lymphomas: Comparing "Big Boom" (4 Gy x 1) vs. "Boom Boom" (2 Gy x 2). Int J Radiat Oncol Biol Phys 2023; 117:S160. [PMID: 37784402 DOI: 10.1016/j.ijrobp.2023.06.252] [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) Indolent lymphomas are exquisitely sensitive to radiation therapy (RT). Programs of 2 Gy x 2 were shown to be highly effective in controlling irradiated site(s). During the COVID-19 pandemic, the International Lymphoma Radiation Oncology Group (ILROG) proposed guidelines that offered substitution of the Boom Boom (BB) (2 Gy x 2) regimen with Big Boom (Big B) of 4 Gy x 1. This report compares our center's experience with both regimens. MATERIALS/METHODS We included patients with indolent lymphomas in this retrospective single institution study. After April 2020 both options of very low dose and choice of a standard full dose of 24 Gy were discussed with the patient. Patients were treated with a definitive or palliative intent depending on disease stage and prior therapy exposure. Patients treated with 24 Gy are not included in this report. Toxicity was reported as per CTCAE v4.0. Overall response rate (ORR) was assessed with Lugano PET criteria at the initial post-RT imaging. Differences between the two groups were examined using the Fisher's exact test and Mann-Whitney test. RESULTS We evaluated a total of 471 lesions in 386 patients, including 172 lesions (37%) treated with 4 Gy x 1 and 299 lesions (63%) treated with 2 Gy x 2. Table 1 summarizes the patient and treatment characteristics. Age at the time of RT and sex were not significantly different between the two groups. The BB cohort was more likely to have follicular lymphomas (FL) (66% vs 54%, p = 0.011), though the proportion of higher-grade FL was similar between cohorts. The ORR was similar (Big B = 86%, BB = 87%) at the first post-RT evaluation (median of 2.23 months from RT for both cohorts). There was no significant difference in the rate of complete response, partial response, stable disease, or progressive disease between the cohorts at initial post-RT imaging. For both regimens, no directly related short-term side effects were observed. CONCLUSION Both the 4 Gyx1 and 2 Gyx2 regimens demonstrated excellent ORR at the initial post-RT imaging assessment among patients with indolent lymphomas. While longer term follow-up is required to confirm durability of these findings, our initial experience suggests that 4 Gyx1 regimen recommended by ILROG during the pandemic is an effective treatment approach.
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Affiliation(s)
- C Hajj
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - J Lee
- Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - L A Boe
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - B Fregonese
- Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - E S Lebow
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - N A Wijetunga
- Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - H G Hubbeling
- Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - K R Tringale
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - M E Freret
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - B S Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - J Yahalom
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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16
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Cederquist G, Tringale KR, Hajj C, Hubbeling HG, Sarkar RR, Ma J, Dreyfuss A, Fregonese B, Lee J, Pike LRG, Falchi L, Scordo M, Grommes C, Yahalom J, Imber BS. Salvage Radiotherapy as a Bridge for Relapsed Secondary CNS Lymphoma. Int J Radiat Oncol Biol Phys 2023; 117:e459. [PMID: 37785470 DOI: 10.1016/j.ijrobp.2023.06.1654] [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) Secondary CNS lymphoma (SCNSL) is a challenging clinical scenario observed in 2-5% of non-Hodgkin lymphoma patients, for which a standard of care has not been defined. We studied the indications for, and outcomes of SCNSL patients referred for radiotherapy (RT). MATERIALS/METHODS We identified patients with aggressive B cell lymphoma who received brain RT for SCNSL between 1999-2023 at a tertiary cancer center. Patients were grouped and analyzed by RT indication. Overall survival (OS) was determined from RT start using the Kaplan-Meier method. OS analysis comparing patients who did and did not receive therapy after RT was landmarked at 60 days from start of RT to minimize immortal time bias. "SCNSL-directed therapy" is defined as systemic therapy for the treatment of SCNSL, as opposed to CNS prophylaxis. RESULTS We identified 99 SCNSL patients treated with RT. To account for the heterogeneity of RT referrals, we focused on the most common indication: salvage of radiographic progression after SCNSL-directed systemic therapy (n = 58). Among this group, median age was 62 (interquartile range [IQR]: 48-69) and 86% had diffuse large B cell histology. At initial lymphoma diagnosis, 10% of patients had CNS involvement, 90% received Rituximab-based therapy, and 25% received prior CNS prophylaxis. For SCNSL directed therapy, 90% received methotrexate (MTX)-based regimen. Median time from initial SCNSL diagnosis to RT was 4.4 months (IQR 1.7-7.0), with a median of 2.0 lines of therapy prior to RT (IQR 1.0-3.0). 86% of patients were symptomatic at RT with median KPS of 70 (IQR: 60-80). RT targets included whole brain (86%) and partial brain (14%). 1 patient had craniospinal RT. Median RT dose was 30 Gy (IQR: 24-30) over 10 fractions. Median OS for the entire salvage cohort was 3.5 months (m). Landmark analysis 2m post RT showed that median OS differed when patients were stratified by receipt of further therapy: CAR-T (9.4m, n = 4), hematopoietic cell transplant (8.5m, n = 6), other systemic therapy (4.4m, n = 17), no systemic therapy (0.6m, n = 10) (p = 0.0004). 29% of patients who received further therapy after RT achieved long term survival. CONCLUSION In our cohort, most SCNSL patients are referred for salvage RT, with a median OS of 3.5m. 86% of patients had neurologic symptoms after having failed a median of 2 lines of SCNSL-directed therapy; the clinical urgency of this scenario implies that without RT, patients may not have been suitable candidates for further therapy. However, among patients for whom RT was successfully used to bridge to additional therapy, 29% could achieve long-term survival. This study supports further investigation of RT as a combined modality strategy for relapsed/refractory SCNSL, including with emerging cellular therapies.
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Affiliation(s)
- G Cederquist
- Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - K R Tringale
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - C Hajj
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - H G Hubbeling
- Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - R R Sarkar
- Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - J Ma
- Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - A Dreyfuss
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - B Fregonese
- Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - J Lee
- Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - L R G Pike
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - L Falchi
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - M Scordo
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - C Grommes
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - J Yahalom
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - B S Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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17
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Stuver R, Drill E, Qualls D, Okwali M, Lee Batlevi C, Caron PC, Dogan A, Epstein-Peterson ZD, Falchi L, Hamlin PA, Horwitz SM, Imber BS, Intlekofer AM, Johnson WT, Khan N, Kumar A, Lahoud OB, Lue JK, Matasar MJ, Moskowitz AJ, Noy A, Owens CN, Palomba ML, Schöder H, Vardhana SA, Yahalom J, Zelenetz AD, Salles G, Straus DJ. Retrospective characterization of nodal marginal zone lymphoma. Blood Adv 2023; 7:4838-4847. [PMID: 37307213 PMCID: PMC10469082 DOI: 10.1182/bloodadvances.2022009587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 05/08/2023] [Accepted: 05/31/2023] [Indexed: 06/14/2023] Open
Abstract
Nodal marginal zone lymphoma (NMZL) is a rare non-Hodgkin B-cell lymphoma that has historically been difficult to define, though is now formally recognized by the World Health Organization Classification. To better characterize the clinical outcomes of patients with NMZL, we reviewed a sequential cohort of 187 patients with NMZL to describe baseline characteristics, survival outcomes, and time-to-event data. Initial management strategies were classified into five categories: observation, radiation, anti-CD20 monoclonal antibody therapy, chemoimmunotherapy, or other. Baseline Follicular Lymphoma International Prognostic Index scores were calculated to evaluate prognosis. A total of 187 patients were analyzed. The five-year overall survival was 91% (95% confidence interval [CI], 87-95), with a median follow-up time of 71 months (range, 8-253) among survivors. A total of 139 patients received active treatment at any point, with a median follow-up time of 56 months (range, 13-253) among survivors who were never treated. The probability of remaining untreated at five years was 25% (95% CI, 19-33). For those initially observed, the median time to active treatment was 72 months (95% CI, 49-not reached). For those who received at least one active treatment, the cumulative incidence of receiving a second active treatment at 60 months was 37%. Transformation to large B-cell lymphoma was rare, with a cumulative incidence of 15% at 10 years. In summary, our series is a large cohort of uniformly diagnosed NMZL with detailed analyses of survival and time to event analyses. We showed that NMZL commonly presents as an indolent lymphoma for which initial observation is often a reasonable strategy.
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Affiliation(s)
- Robert Stuver
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Esther Drill
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David Qualls
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Michelle Okwali
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Connie Lee Batlevi
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Philip C. Caron
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ahmet Dogan
- Department of Pathology and Laboratory Medicine, Hematopathology Service, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Zachary D. Epstein-Peterson
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Lorenzo Falchi
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Paul A. Hamlin
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Steven M. Horwitz
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
- Department of Medicine, Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Brandon S. Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andrew M. Intlekofer
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
- Human Oncology & Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY
| | - William T. Johnson
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
- Department of Medicine, Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Niloufer Khan
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Anita Kumar
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Oscar B. Lahoud
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
- Department of Medicine, Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jennifer Kimberly Lue
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Matthew J. Matasar
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Alison J. Moskowitz
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Ariela Noy
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Colette N. Owens
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - M. Lia Palomba
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
- Department of Medicine, Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Heiko Schöder
- Department of Medicine, Weill Cornell Medical College, New York, NY
- Department of Radiology, Molecular Imaging and Therapy Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Santosha A. Vardhana
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
- Human Oncology & Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Joachim Yahalom
- Department of Medicine, Weill Cornell Medical College, New York, NY
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andrew D. Zelenetz
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Gilles Salles
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - David J. Straus
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
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18
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Skakodub A, Walch H, Tringale KR, Eichholz J, Imber BS, Vasudevan HN, Li BT, Moss NS, Hei Yu KK, Mueller BA, Powell S, Razavi P, Yu HA, Reis-Filho JS, Gomez D, Schultz N, Pike LRG. Genomic analysis and clinical correlations of non-small cell lung cancer brain metastasis. Nat Commun 2023; 14:4980. [PMID: 37591896 PMCID: PMC10435547 DOI: 10.1038/s41467-023-40793-x] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 08/10/2023] [Indexed: 08/19/2023] Open
Abstract
Up to 50% of patients with non-small cell lung cancer (NSCLC) develop brain metastasis (BM), yet the study of BM genomics has been limited by tissue access, incomplete clinical data, and a lack of comparison with paired extracranial specimens. Here we report a cohort of 233 patients with resected and sequenced (MSK-IMPACT) NSCLC BM and comprehensive clinical data. With matched samples (47 primary tumor, 42 extracranial metastatic), we show CDKN2A/B deletions and cell cycle pathway alterations to be enriched in the BM samples. Meaningful clinico-genomic correlations are noted, namely EGFR alterations in leptomeningeal disease (LMD) and MYC amplifications in multifocal regional brain progression. Patients who developed early LMD frequently have had uncommon, multiple, and persistently detectable EGFR driver mutations. The distinct mutational patterns identified in BM specimens compared to other tissue sites suggest specific biologic underpinnings of intracranial progression.
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Affiliation(s)
- Anna Skakodub
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
- Biomarker Development Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Henry Walch
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Kathryn R Tringale
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Jordan Eichholz
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Brandon S Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Harish N Vasudevan
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, 94118, USA
- Department of Neurological Surgery, University of California, San Francisco, CA, 94118, USA
| | - Bob T Li
- Biomarker Development Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Nelson S Moss
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Kenny Kwok Hei Yu
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Boris A Mueller
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Simon Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Pedram Razavi
- Biomarker Development Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, 10065, USA
| | - Helena A Yu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, 10065, USA
| | - Jorge S Reis-Filho
- Biomarker Development Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
- Biomarker Development Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nikolaus Schultz
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Luke R G Pike
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA.
- Biomarker Development Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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19
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McLaughlin LA, Yildirim O, Rosenblum MK, Imber BS, Haseltine JM, Zelefsky MJ, Schöder H, Morris MJ, Rafelson WM, Krebs S, Moss NS. Identification of incidental brain tumors in prostate cancer patients via PSMA PET/CT. J Neurooncol 2023; 163:455-462. [PMID: 37247180 PMCID: PMC10746351 DOI: 10.1007/s11060-023-04355-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 05/24/2023] [Indexed: 05/30/2023]
Abstract
PURPOSE Brain metastases are rare in patients with prostate cancer and portend poor outcome. Prostate-specific membrane antigen positron emission tomography (PSMA PET)/CT scans including the brain have identified incidental tumors. We sought to identify the incidental brain tumor detection rate of PSMA PET/CT performed at initial diagnosis or in the setting of biochemical recurrence. METHODS An institutional database was queried for patients who underwent 68Ga-PSMA-11 or 18F-DCFPyL (18F-piflufolastat) PET/CT imaging at an NCI-designated Comprehensive Cancer Center from 1/2018 to 12/2022. Imaging reports and clinical courses were reviewed to identify brain lesions and describe clinical and pathologic features. RESULTS Two-thousand seven hundred and sixty-three patients underwent 3363 PSMA PET/CT scans in the absence of neurologic symptoms. Forty-four brain lesions were identified, including 33 PSMA-avid lesions: 10 intraparenchymal metastases (30%), 4 dural-based metastases (12%), 16 meningiomas (48%), 2 pituitary macroadenomas (6%), and 1 epidermal inclusion cyst (3%) (incidences of 0.36, 0.14, 0.58, 0.07, and 0.04%). The mean parenchymal metastasis diameter and mean SUVmax were 1.99 cm (95%CI:1.25-2.73) and 4.49 (95%CI:2.41-6.57), respectively. At the time of parenchymal brain metastasis detection, 57% of patients had no concurrent extracranial disease, 14% had localized prostate disease only, and 29% had extracranial metastases. Seven of 8 patients with parenchymal brain metastases remain alive at a median 8.8 months follow-up. CONCLUSION Prostate cancer brain metastases are rare, especially in the absence of widespread metastatic disease. Nevertheless, incidentally detected brain foci of PSMA uptake may represent previously unknown prostate cancer metastases, even in small lesions and in the absence of systemic disease.
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Affiliation(s)
- Lily A McLaughlin
- Georgetown University School of Medicine, Washington, DC, USA
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Onur Yildirim
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Marc K Rosenblum
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Brandon S Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Multidisciplinary Brain Metastasis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Justin M Haseltine
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michael J Zelefsky
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Heiko Schöder
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michael J Morris
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - William M Rafelson
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Simone Krebs
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nelson S Moss
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Multidisciplinary Brain Metastasis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
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20
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Walch H, Skakodub A, Tringale KR, Vasudevan HN, Eichholz J, Kelly DW, Lebow E, Moss NS, Yu KKH, Li BT, Mueller B, Khan A, Yu Y, Powell S, Reis-Filho JS, Imber BS, Razavi P, Gomez DR, Schultz N, Pike LR. Abstract 6063: Genomic characterization of non-small cell lung cancer (NSCLC) brain metastasis (BM) patients identifies novel alterations associated with tropisms and disease progression. Cancer Res 2023. [DOI: 10.1158/1538-7445.am2023-6063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
Abstract
Intro: Half of all patients with NSCLC develop BM during their clinical course. While modern NSCLC-directed agents yield excellent systemic response, most patients require focal BM treatment. Prior reports of BM genomics have been limited by low numbers and a lack of matched specimens. Here, we report the largest cohort to date of molecularly-profiled NSCLC BM samples with comprehensive clinical follow-up.
Methods: Clinical data and outcomes for 244 patients with NSCLC and resected BM were identified. Samples were assessed using MSK-IMPACT, a custom tumor-normal next generation sequencing assay. 51 (20.9%) patients had matched primary site tissue, and 44 (18%) patients had matched tissue from another metastatic site or CSF. Genomic alterations were filtered for driver variants using OncoKB. Publicly available genomic data for NSCLC primary samples was used for comparison against the primary samples from our BM cohort.
Results: The most frequently altered genes in BM tumors were TP53 (72%), CDKN2A (34%), KRAS (31%), KEAP1 (26%), and EGFR (21%). CDKN2A was more frequently altered in BM samples compared to NSCLC primary lesions (34% vs 14%, p = 0.003). Additionally, cell cycle pathway alterations were enriched in BM (56% vs 31%, p = 0.002). BM samples also had a significantly higher fraction of genome altered (FGA) relative to primary samples (p < 0.0001). We then compared primary samples from BM patients against primary samples from metastatic NSCLC patients without BM and primary samples from non-metastatic NSCLC patients. We found an enrichment of alterations in TP53 (68.6% vs 27.7%, p < 0.0001), NKX2-1 (11.4% vs 1.7%, p = 0.006), SMARCA4 (11.4% vs 2.1%, p = 0.01), RB1 (11.4% vs 1.7%, p = 0.006), and FOXA1 (11.4% vs 0.9%, p = 0.001) in the primary samples from BM patients compared to non-metastatic patients. Next, we grouped patients based on CNS progression patterns and found that EGFR alterations were enriched in patients with leptomeningeal progression when compared to patients without progression (42% vs 18%, p = 0.03).
Conclusions: In our cohort of molecularly-profiled NSCLC BM, we found an enrichment of cell cycle pathway alterations and a higher FGA in BMs compared to their primary tumor controls. Additionally, several genes were enriched in the primary tissue of patients that developed BM compared to primary tissue from non-metastatic patients. EGFR alterations were enriched in patients who develop leptomeningeal disease (LMD). Our work herein characterizes the genomic profiles of NSCLC patients with BM and identifies specific genes enriched in the primary tissue of BM patients compared to primary tissue from both non-BM metastatic patients and non-metastatic patients. Finally, our finding that EGFR alterations were enriched in patients with LMD suggests specific biologic underpinnings driving patterns of CNS progression.
Citation Format: Henry Walch, Anna Skakodub, Kathryn R. Tringale, Harish N. Vasudevan, Jordan Eichholz, Daniel W. Kelly, Emily Lebow, Nelson S. Moss, Kenny Kwok Hei Yu, Bob T. Li, Boris Mueller, Atif Khan, Yao Yu, Simon Powell, Jorge S. Reis-Filho, Brandon S. Imber, Pedram Razavi, Daniel R. Gomez, Nikolaus Schultz, Luke R. Pike. Genomic characterization of non-small cell lung cancer (NSCLC) brain metastasis (BM) patients identifies novel alterations associated with tropisms and disease progression [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 6063.
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Affiliation(s)
- Henry Walch
- 1Memorial Sloan Kettering Cancer Center, New York, NY
| | - Anna Skakodub
- 1Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | | | - Emily Lebow
- 1Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Bob T. Li
- 1Memorial Sloan Kettering Cancer Center, New York, NY
| | - Boris Mueller
- 1Memorial Sloan Kettering Cancer Center, New York, NY
| | - Atif Khan
- 1Memorial Sloan Kettering Cancer Center, New York, NY
| | - Yao Yu
- 1Memorial Sloan Kettering Cancer Center, New York, NY
| | - Simon Powell
- 1Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Pedram Razavi
- 1Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Luke R. Pike
- 1Memorial Sloan Kettering Cancer Center, New York, NY
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21
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Miao E, Eichholz JE, Lebow ES, Flynn J, Zhang Z, Walch H, Hubbeling H, Beal K, Moss NS, Yu KK, Meng A, Kelly DW, Gomez DR, Li BT, Rimner A, Schultz N, Drilon A, Imber BS, Pike LRG. Characterization of Central Nervous System Clinico-Genomic Outcomes in ALK-Positive Non-Small Cell Lung Cancer Patients with Brain Metastases Treated with Alectinib. Lung Cancer 2023; 178:57-65. [PMID: 36780766 PMCID: PMC10065905 DOI: 10.1016/j.lungcan.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 01/11/2023] [Accepted: 02/04/2023] [Indexed: 02/11/2023]
Abstract
INTRODUCTION Highly effective brain-penetrant ALK-targeted tyrosine kinase inhibitors (TKIs) have been developed for the management of NSCLC patients with brain metastases (BM). Local therapy (LT) such as SRS or therapeutic craniotomy is increasingly being deferred for such patients. Herein we report detailed patient- and lesion-level intracranial outcomes and co-mutational genomic profiles from a cohort of NSCLC patients with BM treated with alectinib, with or without LT. METHODS We retrospectively reviewed ALK fusion-positive NSCLC patients with BMs who received alectinib at the diagnosis of BM from 1/2012 and 5/2021. Outcome variables included intracranial progression-free survival (iPFS), overall survival (OS), duration of TKI therapy, and CNS response rates. Genomic characteristics from tumor specimens were assessed with MSK-IMPACT, a next-generation sequencing (NGS)-based genomic profiling assay. RESULTS A total of 38 patients with 114 CNS lesions were included. Twelve of these patients also received contemporaneous LT (SRS, WBRT, or surgical resection). Maximal BM diameter in the TKI + LT group was greater (p < 0.003) but despite this difference, iPFS (TKI only, HR 1.21, 95 % CI 0.51-2.89; p = 0.66) and OS (TKI only, HR 5.99, 95 % CI 0.77-46.6; p = 0.052) were similar between groups and trended towards more favorable outcomes with the addition of LT. SMARCA4 co-alterations were associated with inferior OS (HR 8.76, 1.74-44.2; p = 0.009). CONCLUSIONS Our study demonstrated that patients with ALK fusion-positive NSCLC treated with TKI + LT had larger BM and higher likelihood of pre-treatment neurologic symptoms. Despite these differences, iPFS was similar between groups. Results should be interpreted with caution as our study was limited by an underpowered sample size. SMARCA4 co-alterations were associated with inferior OS and these findings warrant further investigation.
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Affiliation(s)
- Emily Miao
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, United States; Albert Einstein College of Medicine, Bronx, NY, United States
| | - Jordan E Eichholz
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, United States; Biomarker Development Program, Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Emily S Lebow
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Jessica Flynn
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Henry Walch
- Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Harper Hubbeling
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Kathryn Beal
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Nelson S Moss
- Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Kenny K Yu
- Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Alicia Meng
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Daniel W Kelly
- Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Daniel R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, United States; Biomarker Development Program, Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Bob T Li
- Memorial Sloan Kettering Cancer Center, New York, New York, United States; Biomarker Development Program, Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, United States; Biomarker Development Program, Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Nikolaus Schultz
- Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Alexander Drilon
- Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Brandon S Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Luke R G Pike
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, United States; Biomarker Development Program, Memorial Sloan Kettering Cancer Center, New York, New York, United States.
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22
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Hubbeling H, Silverman EA, Michaud L, Tomas AA, Shouval R, Flynn J, Devlin S, Wijetunga NA, Tringale KR, Batlevi C, Dahi P, Giralt S, Lin R, Park J, Scordo M, Sauter C, Shah G, Hajj C, Salles G, Schoder H, Palomba ML, Perales MA, Yahalom J, Imber BS. Bridging Radiation Rapidly and Effectively Cytoreduces High-Risk Relapsed/Refractory Aggressive B Cell Lymphomas Prior to Chimeric Antigen Receptor T Cell Therapy. Transplant Cell Ther 2023; 29:259.e1-259.e10. [PMID: 36587744 PMCID: PMC10089652 DOI: 10.1016/j.jtct.2022.12.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/22/2022] [Accepted: 12/26/2022] [Indexed: 12/31/2022]
Abstract
Greater tumor burden before CD19-targeted chimeric antigen receptor T cell (CAR-T) therapy predicts lower complete response rate and shorter overall survival (OS) in patients with aggressive non-Hodgkin lymphoma (NHL). Recent patterns of failure studies have identified lesion characteristics, including size, standard uptake value (SUV), and extranodal location, as associated with post-CAR-T therapy failure. Here we analyzed the effect of bridging radiation-containing treatment (BRT) on pre-CAR-T therapy lesion- and patient-level characteristics and post-CAR-T therapy outcomes, including patterns of failure. Consecutive NHL patients who received radiation therapy from 30 days before leukapheresis until CAR T cell infusion were reviewed. Metabolic tumor volume (MTV) was contoured with a threshold SUV of 4. The first post-CAR-T therapy failures were categorized as preexisting/new/mixed with respect to pre-CAR-T therapy disease and in-field/marginal/distant with respect to BRT. Forty-one patients with diffuse large B cell lymphoma (DLBCL; n = 33), mantle cell lymphoma (n = 7), or Burkitt lymphoma (n = 1) were identified. BRT significantly improved established high-risk parameters of post-CAR-T therapy progression, including in-field median MTV (45.5 cc to .2 cc; P < .001), maximum SUV (18.1 to 4.4; P < .001), diameter (5.5 cm to 3.2 cm; P < .001), and lactate dehydrogenase (LDH; 312 to 232; P = .025). DLBCL patients with lower LDH levels post-BRT had improved progression-free survival (PFS; P = .001). In DLBCL, first failures were new in 7 of 19 patients, preexisting in 5 of 19, and mixed in 7 of 19; with respect to BRT, 4 of 19 were in-field and 4 of 19 were marginal. Post-CAR-T therapy survival was similar in patients with initially low MTV and those with newly low MTV post-BRT using a statistically determined threshold of 16 cc (PFS, 26 months versus 31 months; OS unreached for both). BRT produced significant cytoreductions in diameter, SUV, MTV, and LDH, all predictors of poor post-CAR-T therapy outcomes. Similar PFS and OS in patients with initially low MTV and those who achieved newly low MTV after BRT suggest that BRT may "convert" poor-risk patients to better risk. In the future, the response to BRT may allow for risk stratification and individualization of bridging strategies.
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Affiliation(s)
- Harper Hubbeling
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Emily A Silverman
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Laure Michaud
- Department of Radiology, Molecular Imaging, and Therapy Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ana Alarcon Tomas
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Roni Shouval
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jessica Flynn
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sean Devlin
- Department of Biostatistics, 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
| | - Kathryn R Tringale
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Connie Batlevi
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Parastoo Dahi
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sergio Giralt
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Richard Lin
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jae Park
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael Scordo
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Craig Sauter
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Gunjan Shah
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Carla Hajj
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Gilles Salles
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Heiko Schoder
- Department of Radiology, Molecular Imaging, and Therapy Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - M Lia Palomba
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Miguel-Angel Perales
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joachim Yahalom
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Brandon S Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York.
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23
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Qualls D, Imber BS, Okwali M, Hamlin PA, Kumar A, Lahoud OB, Matasar MJ, Noy A, Owens C, Zelenetz AD, North VS, Schöder H, Dogan A, Salles G, Yahalom J, Falchi L. Long-term outcomes of patients with limited-stage ocular adnexal DLBCL treated with combined modality therapy in the rituximab era. Br J Haematol 2023; 200:524-527. [PMID: 36484627 PMCID: PMC10407681 DOI: 10.1111/bjh.18590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 11/07/2022] [Accepted: 11/22/2022] [Indexed: 12/13/2022]
Affiliation(s)
- David Qualls
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Brandon S Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Michelle Okwali
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Paul A Hamlin
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Anita Kumar
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Oscar B Lahoud
- Department of Medicine, Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Matthew J Matasar
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ariela Noy
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Colette Owens
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andrew D Zelenetz
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Victoria S. North
- Edward S. Harkness Eye Institute, Department of Ophthalmology, Columbia University Irving Medical Center - New York-Presbyterian Hospital, USA
| | - Heiko Schöder
- Department of Radiology, Nuclear Medicine Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ahmet Dogan
- Department of Radiology, Nuclear Medicine Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Gilles Salles
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Joachim Yahalom
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Lorenzo Falchi
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY
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24
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Imber BS, O’Dwyer E, Lobaugh S, McBride SM, Hopkins M, Kollmeier M, Gorovets D, Brennan V, Pike LR, Gewanter R, Mychalczak B, Zhang Z, Schöder H, Zelefsky MJ. Failure Patterns by PSMA PET for Recurrent Prostate Cancer after Prostatectomy and Salvage Radiation. Urology 2022; 170:146-153. [PMID: 36115426 PMCID: PMC10576466 DOI: 10.1016/j.urology.2022.08.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 08/17/2022] [Accepted: 08/22/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To characterize patterns of failure using prostate-specific membrane antigen positron emission tomography (PSMA PET) after radical prostatectomy (RP) and salvage radiotherapy (SRT). METHODS Patients with rising PSA post-RP+SRT underwent 68Ga-HBED-iPSMA PET/CT on a single-arm, prospective imaging trial (NCT03204123). Scans were centrally reviewed with pattern-of-failure analysis by involved site. Positive scans were classified using 3 failure categories: pelvic nodal, extra-pelvic nodal or distant non-nodal. Associations with failure categories were analyzed using cumulative incidence and generalized logits regression. RESULTS We included 133 men who received SRT a median of 20 months post-RP; 56% received SRT to the prostatic fossa alone, while 44% received pelvic SRT. PSMA PET/CT was performed a median of 48 months post-SRT. Overall, 31% of PSMA PET/CT scans were negative, 2% equivocal and 67% had at least 1 positive site. Scan detection was significantly associated with PSA level prior to PSMA PET/CT. Analysis of 89 positive scans demonstrated pelvic nodal (53%) was the most common relapse and fossa relapse was low (9%). Overall, positive scans were pelvic (n = 35, 26%), extra-pelvic nodal (n = 26, 20%) or distant non-nodal failure (n = 28, 21%), and 70% of positive scans were oligorecurrent. We observed similar cumulative incidence for all failure categories and relatively few clinicodemographic associations. Men treated with pelvic SRT had reduced odds of pelvic failure versus exclusive fossa treatment. CONCLUSION Pelvic, extra-pelvic nodal, and distant non-nodal failures occur with similar incidence post-SRT. Regional nodal relapse is relatively common, especially with fossa-only SRT. A high oligorecurrence rate suggests a potentially important role for PSMA-guided focal therapies.
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Affiliation(s)
- Brandon S. Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| | - Elisabeth O’Dwyer
- Molecular Imaging and Therapeutics, Department of Radiology, Weill Cornell Medical College, New York, NY 10065
| | - Stephanie Lobaugh
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| | - Sean M. McBride
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| | - Margaret Hopkins
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| | - Marisa Kollmeier
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| | - Daniel Gorovets
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| | - Victoria Brennan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| | - Luke R.G. Pike
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| | - Richard Gewanter
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| | - Borys Mychalczak
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY 10065
| | - Heiko Schöder
- Department of Radiology, Molecular Imaging and Therapy Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michael J. Zelefsky
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065
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Moss NS, El Ahmadieh TY, Brown S, Chen J, Imber BS, Pike L, Reiner AS, Panageas KS, Brennan C, Tabar V, Beal K. Integrated Multidisciplinary Brain Metastasis Care Reduces Patient Visits and Shortens Time to Adjuvant Irradiation. JCO Oncol Pract 2022; 18:e1732-e1738. [PMID: 36037413 PMCID: PMC10166425 DOI: 10.1200/op.22.00258] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/29/2022] [Accepted: 07/28/2022] [Indexed: 01/05/2023] Open
Abstract
PURPOSE Timely surgical cavity stereotactic radiosurgery (SRS) is an important adjuvant to brain metastasis resection, with earlier treatment associated with less frequent recurrence. The logistical complexity of treatment organization, however, has resulted in suboptimal start times postsurgically. We implemented a process improvement approach to reduce the time from surgery to adjuvant irradiation of resected brain metastases. METHODS A multidisciplinary working group used process mapping to identify opportunities to reduce visits and shorten treatment times. The care delivery process was modified to streamline perioperative SRS preparation with (1) early patient identification, (2) preoperative intrateam communication, and (3) consolidation of required steps. Plan-Do-Study-Act cycles were used for process improvement. The surgery-to-SRS initiation time interval was the primary outcome. Secondary outcomes included the number of associated patient encounters. RESULTS After implementation, the median (interquartile range) interval from surgery to SRS was reduced 48% from 27 (21-34) to 14 days (13-17; P < .001). The rate of surgical cavity SRS within 30 days increased from 64% (n = 63 of 98) to 97% (n = 60 of 62; P < .001). The median (interquartile range) number of CNS-associated encounters between resection and SRS decreased from 5 (4-6) to 4 (3-5; P < .001). The proportion of patients who had > 1 magnetic resonance imaging/computed tomography between surgery and SRS decreased from 45% (44 of 98) to 13% (8 of 62; P < .001). The time from surgery to systemic therapy resumption/initiation among patients treated within 90 days postoperatively decreased from 35 (24-48) to 32 days (23-40; P = .074). There were no wound complications in either group. CONCLUSION Adjuvant SRS latency and treatment-associated encounters were significantly reduced after care-coordination implementation. This approach reduces patient and health care system burden and can be applied to other scenarios where early postoperative SRS administration is critical.
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Affiliation(s)
- Nelson S. Moss
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Tarek Y. El Ahmadieh
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Samantha Brown
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Justin Chen
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Brandon S. Imber
- Department of Radiation Oncology and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Luke Pike
- Department of Radiation Oncology and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Anne S. Reiner
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Katherine S. Panageas
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Cameron Brennan
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Viviane Tabar
- Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kathryn Beal
- Department of Radiation Oncology and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY
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Prasad K, Dauer LT, Chu BP, Aramburu‐Nunez D, Cohen G, Beal K, Imber BS, Moss NS. Patient‐specific radiological protection precautions following Cs collagen embedded Cs‐131 implantation in the brain. J Appl Clin Med Phys 2022; 23:e13776. [PMID: 36109179 PMCID: PMC9588267 DOI: 10.1002/acm2.13776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 07/25/2022] [Accepted: 08/15/2022] [Indexed: 11/17/2022] Open
Abstract
Objective Cesium‐131 brachytherapy is an adjunct for brain tumor treatment, offering potential clinical and radiation protection advantages over other isotopes including iodine‐125. We present evidence‐based radiation safety recommendations from an initial experience with Cs‐131 brachytherapy in the resection cavities of recurrent, previously irradiated brain metastases. Methods Twenty‐two recurrent brain metastases in 18 patients were resected and treated with permanent Cs‐131 brachytherapy implantation using commercially procured seed‐impregnated collagen tiles (GammaTile, GT Medical Technologies). Exposure to intraoperative staff was monitored with NVLAP‐accredited ring dosimeters. For patient release considerations, NCRP guidelines were used to develop an algorithm for modeling lifetime exposure to family and ancillary staff caring for patients based on measured dose rates. Results A median of 16 Cs‐131 seeds were implanted (range 6–46) with median cumulative strength of 58.72U (20.64‐150.42). Resulting dose rates were 1.19 mSv/h (0.28–3.3) on contact, 0.08 mSv/h (0.01–0.35) at 30 cm, and 0.01 mSv/h (0.001–0.03) at 100 cm from the patient. Modeled total caregiver exposure was 0.91 mSv (0.16–3.26), and occupational exposure was 0.06 mSv (0.02–0.23) accounting for patient self‐shielding via skull and soft tissue attenuation. Real‐time dose rate measurements were grouped into brackets to provide close contact precautions for caregivers ranging from 1–3 weeks for adults and longer for pregnant women and children, including cases with multiple implantations. Conclusions Radiological protection precautions were developed based on patient‐specific emissions and accounted for multiple implantations of Cs‐131, to maintain exposure to staff and the public in accordance with relevant regulatory dose constraints.
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Affiliation(s)
- Kavya Prasad
- Department of Medical Physics Memorial Sloan Kettering Cancer Center New York New York USA
| | - Lawrence T. Dauer
- Department of Medical Physics Memorial Sloan Kettering Cancer Center New York New York USA
| | - Bae P. Chu
- Department of Medical Physics Memorial Sloan Kettering Cancer Center New York New York USA
| | - David Aramburu‐Nunez
- Department of Medical Physics Memorial Sloan Kettering Cancer Center New York New York USA
| | - Gilad Cohen
- Department of Medical Physics Memorial Sloan Kettering Cancer Center New York New York USA
| | - Kathryn Beal
- Department of Radiation Oncology and Brain Metastasis Center Memorial Sloan Kettering Cancer Center New York New York USA
| | - Brandon S. Imber
- Department of Radiation Oncology and Brain Metastasis Center Memorial Sloan Kettering Cancer Center New York New York USA
| | - Nelson S. Moss
- Department of Neurological Surgery and Brain Metastasis Center Memorial Sloan Kettering Cancer Center New York New York USA
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Imber BS, Young RJ, Beal K, Reiner AS, Giantini-Larsen AM, Krebs S, Yang JT, Aramburu-Nunez D, Cohen GN, Brennan C, Tabar V, Moss NS. Correction to: Salvage resection plus cesium-131 brachytherapy durably controls post-SRS recurrent brain metastases. J Neurooncol 2022; 159:619. [PMID: 35997921 DOI: 10.1007/s11060-022-04121-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Brandon S Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Robert J Young
- Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Radiology, Neuroradiology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kathryn Beal
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anne S Reiner
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
| | | | - Simone Krebs
- Department of Radiology, Molecular Imaging and Therapy Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jonathan T Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David Aramburu-Nunez
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Gil'ad N Cohen
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Cameron Brennan
- Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Viviane Tabar
- Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nelson S Moss
- Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Imber BS, Beal K, Reiner AS, Giantini-Larsen A, Yang JT, Aramburu-Nunez D, Cohen G, Brennan C, Tabar V, Young RJ, Moss NS. LOCL-15 PERMANENT CARRIER-EMBEDDED CESIUM-131 BRACHYTHERAPY FOR THE SALVAGE TREATMENT OF PREVIOUSLY IRRADIATED, RECURRENT BRAIN METASTASES. Neurooncol Adv 2022. [PMCID: PMC9354192 DOI: 10.1093/noajnl/vdac078.057] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Salvage of recurrent of previously-irradiated brain metastases (rBrM) is a significant clinical challenge. High local failure rates are seen following salvage resection without adjuvant re-irradiation, while reirradiation is associated with high radionecrosis rates. Salvage surgery plus intraoperative Cs131 brachytherapy may offer dosimetric and biologic advantages including improved local control versus observation, with reduced integral brain dose versus re-irradiation.
METHODS
A prospective registry of consecutively treated patients with rBrM after prior stereotactic radiosurgery (SRS) was analyzed. Following maximal-safe resection and intraoperative viable-disease confirmation, cavities were implanted with commercially-available, collagen-matrix embedded Cs131 seeds (GammaTile, GT Medical Technologies). Prescribed dose was 60Gy at 5mm from the cavity.
RESULTS
Twenty patients underwent 24 operations with Cs131 implantation in 25 cavities. Previous SRS occurred a median of 358d preoperatively (range=56-1334). Median maximum preoperative diameter was 3.0cm (range=1.1-6.3) and enhancing volume was 9.5cm3 (range=0.6-69.7). Gross- or near-total resection was achieved in 60% of lesions. A median of 16 Cs131 seeds (range=6-30), with a median activity of 3.5U/seed were implanted. Maximal preoperative diameter and enhancing volume were weakly associated with the number of implanted seeds (correlation coefficients=0.50, 0.41, respectively). There was one postoperative wound dehiscence in a multiply resected and irradiated patient with hydrocephalus. With median follow-up of 12.5 months, 2 tumors recurred (one in-field, one marginal) resulting in a 1-year progression incidence of 9.8% (95%CI=0.0-23.2). Radiographic seed migration was identified in 7/25 cavities (28%) on surveillance scans ranging from 1.9-11.7 months post-implantation, without clinical sequelae.
CONCLUSIONS
With >1 year of follow-up, intraoperative brachytherapy with commercially-available Cs131 implants was associated with a high rate of local control and a favorable toxicity profile. Modest correlation between preoperative tumor geometry and implanted tiles in the context of high associated cost suggests a need to optimize planning criteria. A randomized trial of salvage resection with or without Cs131 is ongoing (NCT04690348) to assess the incremental benefit of brachytherapy.
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Affiliation(s)
| | - Kathryn Beal
- Memorial Sloan Kettering Cancer Center , New York , USA
| | - Anne S Reiner
- Memorial Sloan Kettering Cancer Center , New York , USA
| | | | | | | | - Gilad Cohen
- Memorial Sloan Kettering Cancer Center , New York , USA
| | | | - Viviane Tabar
- Memorial Sloan Kettering Cancer Center , New York , USA
| | | | - Nelson S Moss
- Memorial Sloan Kettering Cancer Center , New York , USA
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Moss NS, El Ahmadieh TY, Brown S, Chen J, Imber BS, Pike L, Reiner AS, Panageas KS, Brennan C, Tabar V, Beal K. MMAP-06 INTEGRATED TEAM-BASED BRAIN METASTASIS CARE REDUCES PATIENT VISITS AND SHORTENS TIME TO ADJUVANT IRRADIATION. Neurooncol Adv 2022. [PMCID: PMC9354193 DOI: 10.1093/noajnl/vdac078.062] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
PURPOSE
Timely surgical cavity stereotactic radiosurgery (SRS) is an important adjuvant to brain metastasis resection, with earlier treatment associated with less frequent recurrence. The logistical complexity of treatment organization, however, has resulted in suboptimal start times post-surgically. We implemented a team-based process improvement approach to reduce the time from surgery to adjuvant irradiation of resected brain metastases.
METHODS
A multidisciplinary working group used process-mapping to identify opportunities to reduce visits and shorten treatment times. The care delivery process was modified to streamline perioperative SRS preparation with (1) early patient identification, (2) preoperative intra-team communication, and (3) consolidation of required steps. Plan-Do-Study-Act cycles were used for process improvement. The surgery-to-SRS initiation time interval was the primary outcome. Secondary outcomes included the number of associated patient encounters.
RESULTS
Following implementation, the median (IQR) interval from surgery to SRS was reduced 48% from 27 (21,34) to 14 (13,17) days (p<0.001). The rate of surgical-cavity SRS within 30 days increased from 64% (n=63/98) to 97% (n=60/62; p<0.001). The median (IQR) number of CNS-associated encounters between resection and SRS decreased from 5 (4,6) to 4 (3,5; p<0.001). The proportion of patients who had >1 MRI/CT between surgery and SRS decreased from 45% (44/98) to 13% (8/62; p<0.001). The time from surgery to systemic therapy resumption/initiation among patients treated within 90 days post-operatively decreased from 35 (24,48) to 32 days (23,40; p=0.074). There were no wound complications in either group.
CONCLUSION
Adjuvant SRS latency and treatment-associated encounters were significantly reduced after care-coordination implementation. This approach reduces patient and healthcare system burden and can be applied to other scenarios where early post-operative SRS administration is critical.
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Affiliation(s)
- Nelson S Moss
- Memorial Sloan Kettering Cancer Center , New York, NY , USA
| | | | - Samantha Brown
- Memorial Sloan Kettering Cancer Center , New York, NY , USA
| | - Justin Chen
- Memorial Sloan Kettering Cancer Center , New York, NY , USA
| | | | - Luke Pike
- Memorial Sloan Kettering Cancer Center , New York, NY , USA
| | - Anne S Reiner
- Memorial Sloan Kettering Cancer Center , New York, NY , USA
| | | | | | - Viviane Tabar
- Memorial Sloan Kettering Cancer Center , New York, NY , USA
| | - Kathryn Beal
- Memorial Sloan Kettering Cancer Center , New York, NY , USA
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30
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Imber BS, Young RJ, Beal K, Reiner AS, Giantini-Larsen AM, Yang JT, Aramburu-Nunez D, Cohen GN, Brennan C, Tabar V, Moss NS. Salvage resection plus cesium-131 brachytherapy durably controls post-SRS recurrent brain metastases. J Neurooncol 2022; 159:609-618. [PMID: 35896906 PMCID: PMC9328626 DOI: 10.1007/s11060-022-04101-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 07/16/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Salvage of recurrent previously irradiated brain metastases (rBrM) is a significant challenge. Resection without adjuvant re-irradiation is associated with a high local failure rate, while reirradiation only partially reduces failure but is associated with greater radiation necrosis risk. Salvage resection plus Cs131 brachytherapy may offer dosimetric and biologic advantages including improved local control versus observation, with reduced normal brain dose versus re-irradiation, however data are limited. METHODS A prospective registry of consecutive patients with post-stereotactic radiosurgery (SRS) rBrM undergoing resection plus implantation of collagen-matrix embedded Cs131 seeds (GammaTile, GT Medical Technologies) prescribed to 60 Gy at 5 mm from the cavity was analyzed. RESULTS Twenty patients underwent 24 operations with Cs131 implantation in 25 tumor cavities. Median maximum preoperative diameter was 3.0 cm (range 1.1-6.3). Gross- or near-total resection was achieved in 80% of lesions. A median of 16 Cs131 seeds (range 6-30), with a median air-kerma strength of 3.5 U/seed were implanted. There was one postoperative wound dehiscence. With median follow-up of 1.6 years for survivors, two tumors recurred (one in-field, one marginal) resulting in 8.4% 1-year progression incidence (95%CI = 0.0-19.9). Radiographic seed settling was identified in 7/25 cavities (28%) 1.9-11.7 months post-implantation, with 1 case of distant migration (4%), without clinical sequelae. There were 8 cases of radiation necrosis, of which 4 were symptomatic. CONCLUSIONS With > 1.5 years of follow-up, intraoperative brachytherapy with commercially available Cs131 implants was associated with favorable local control and toxicity profiles. Weak correlation between preoperative tumor geometry and implanted tiles highlights a need to optimize planning criteria.
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Affiliation(s)
- Brandon S Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Robert J Young
- Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Radiology, Neuroradiology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kathryn Beal
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anne S Reiner
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
| | | | - Jonathan T Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David Aramburu-Nunez
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Gil'ad N Cohen
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Cameron Brennan
- Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Viviane Tabar
- Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nelson S Moss
- Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA. .,Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Tringale KR, Hubbeling H, Chino F, Hajj C, Yahalom J, Imber BS. Trends in Use of and Medicare Spending on Short-Course Radiotherapy for Lymphomas From 2015 to 2019. JAMA Health Forum 2022; 3:e221815. [PMID: 35977221 PMCID: PMC9250056 DOI: 10.1001/jamahealthforum.2022.1815] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 04/28/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Kathryn R. Tringale
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Harper Hubbeling
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Carla Hajj
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joachim Yahalom
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Brandon S. Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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Wu Y, Liu X, Imber BS, Zhong QZ, Yang Y, Wu T, Chen SY, Chen B, Song YW, Fang H, Jin J, Liu YP, Jing H, Tang Y, Li N, Lu NN, Wang SL, Chen F, Yin L, Zhang XM, Zhu J, Tsang RW, Yahalom J, Hu C, Men K, Deng M, Xia C, Li YX, Qi SN. Influence of age on long-term net survival benefit for early-stage MALT lymphomas treated with radiotherapy: A SEER database analysis (2000-2015). Radiother Oncol 2022; 173:179-187. [PMID: 35667572 DOI: 10.1016/j.radonc.2022.05.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 04/11/2022] [Revised: 05/24/2022] [Accepted: 05/29/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Given the lower incidence of lymphoma-related death but higher background mortality in patients with early-stage mucosa-associated lymphoid tissue (MALT) lymphoma, it is critically important to examine how age affects a treatment's survival benefit. METHODS 9,467 patients with early-stage MALT lymphoma in the Surveillance, Epidemiology, and End Results (SEER) database treated between 2000-2015 were extracted and analyzed. Primary therapy was classified as radiotherapy (n = 3,407), chemotherapy (n = 1,294), and other/unknown treatments including observation (n = 4,766). Inverse probability of treatment weighting (IPTW) was conducted to balance baseline characteristics between groups. Relative survival (RS), standardized mortality ratio (SMR), and transformed Cox regression were conducted to compare survival differences between treatment modalities by controlling for the background mortality. Radiotherapy-age interaction was examined. RESULTS Across age-groups, early-stage MALT lymphoma patients were at lower risk of lymphoma-related death than death due to other causes. The 10-year overall survival (OS, 73.8%) and RS (96.6%) rates were significantly higher, and the SMR (1.14) significantly lower, with radiotherapy than with chemotherapy (OS, 61.7%; RS, 86.4%; SMR, 1.54; P < 0.001) or other/unknown treatments (OS, 61.1%; RS, 87.2%; SMR, 1.41; P < 0.001). By multivariable analysis and IPTW, radiotherapy remained an independent predictor of better RS (HR 0.81, 95%CI, 0.73-0.89; P < 0.001). A significant interaction between age and radiotherapy was identified for both RS (Pinteraction = 0.016) and OS (Pinteraction = 0.024), indicating greater benefit in young adults. CONCLUSION Radiotherapy was associated with significant better survival in early-stage MALT lymphoma, especially in young adults.
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Affiliation(s)
- Yunpeng Wu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, PR China
| | - Xin Liu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, PR China
| | - Brandon S Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, United States
| | - Qiu-Zi Zhong
- Department of Radiation Oncology, Beijing Hospital, National Geriatric Medical Center, Beijing, PR China
| | - Yong Yang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, PR China; Department of Radiation Oncology, Fujian Medical University Union Hospital, Fuzhou, PR China
| | - Tao Wu
- Affiliated Hospital of Guizhou Medical University, Guizhou Cancer Hospital, Guiyang, PR China
| | - Si-Ye Chen
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, PR China
| | - Bo Chen
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, PR China
| | - Yong-Wen Song
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, PR China
| | - Hui Fang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, PR China
| | - Jing Jin
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, PR China
| | - Yue-Ping Liu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, PR China
| | - Hao Jing
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, PR China
| | - Yuan Tang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, PR China
| | - Ning Li
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, PR China
| | - Ning-Ning Lu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, PR China
| | - Shu-Lian Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, PR China
| | - Fan Chen
- Department of Radiation Oncology, Affiliated Hospital of Qinghai University, PR China
| | - Lin Yin
- Department of Radiation Oncology, Affiliated Hospital of Qinghai University, PR China
| | - Xi-Mei Zhang
- Tianjin Medical University Cancer Institute & Hospital, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Center for Cancer, PR China
| | - Jingru Zhu
- Department of Radiation Oncology, Xiangya Hospital, Central South University (CSU), Changsha, PR China
| | - Richard W Tsang
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Canada
| | - Joachim Yahalom
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, United States
| | - Chen Hu
- Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, United States
| | - Kuo Men
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, PR China
| | - Min Deng
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, PR China
| | - Changfa Xia
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, PR China
| | - Ye-Xiong Li
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, PR China.
| | - Shu-Nan Qi
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, PR China.
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Ma J, del Balzo L, Khaleel SS, Flynn J, Zhang Z, Voss MH, Freeman B, Hakimi AA, Lee CH, Eichholz J, Kelly DW, Yang JT, Mueller B, Carlo MI, Motzer RJ, Imber BS, Beal K, Moss NS, Kotecha R, Pike LRG. Molecular profile and clinical outcomes of renal cell carcinoma brain metastases treated with stereotactic radiosurgery. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.4526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
4526 Background: Molecular profiles of renal cell carcinoma (RCC) tumors are associated with systemic treatment (ST) responses and clinical outcomes. However, the molecular profiles of RCC brain metastases (BM) and their correlation with ST response and clinical outcomes are not well characterized. Effective management of BM with locoregional therapies including stereotactic radiosurgery (SRS) is critical as ST advances have improved overall survival (OS). Therefore, we sought to identify the clinical and genomic features of RCC BM in a large cohort of patients treated with SRS. Methods: We performed an institutional retrospective analysis of RCC BM patients treated with SRS and evaluated corresponding genomic next generation sequencing (NGS) data via a targeted sequencing panel (MSK-IMPACT). A comparison cohort of all institutional patients with available NGS data was utilized to investigate genes enriched in our BM cohort using Fisher exact testing. Kaplan Meier analyses were performed for OS and intracranial progression-free survival (iPFS). Clinical factors and genes mutated in ≥ 10% of samples were assessed per patient using Cox proportional hazards models, and per individual BMs using clustered competing risks regression with a competing risk of death. Results: From 2010-2021, 91 RCC BM patients underwent SRS for 212 BMs, including 86% clear cell and 14% non-clear cell RCC. NGS data was available for 76 patients (84%), including 18 resected BMs, 26 extra-cranial metastatic lesions (EM), and 32 primary kidney tumors (Table 1). Median follow-up was 3.2 years with median OS of 21 months (m) and median iPFS of 7.8m. Karnofsky performance status ≥80 and extracranial disease control were significantly associated with improved OS on multivariable analyses (MVA; p=0.049 and 0.01, respectively). No clinical variables were significantly associated with iPFS on MVA. At the BM level, SETD2 alterations approached significance for improved iPFS (HR=0.35; 95%CI 0.11, 1.05; p=0.06). Enrichment in SMARCA4 alterations was seen in the BM cohort as compared to primary kidney and EM samples from patients without BM (17% vs 1% vs 2%, p<0.05). Conclusions: To our knowledge, this is the largest study investigating mutational profiles of RCC BM. SMARCA4 alterations were enriched in BM samples and a trend towards improved iPFS was seen in SETD2 variant BMs, warranting further investigation.[Table: see text]
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Affiliation(s)
- Jennifer Ma
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Sari Safaa Khaleel
- Memorial Sloan-Kettering Cancer Center-Fellowship (GME Office), New York, NY
| | - Jessica Flynn
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Zhigang Zhang
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Martin H Voss
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - A. Ari Hakimi
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Chung-Han Lee
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | - Boris Mueller
- Memorial Sloan-Kettering Cancer Center, Tarrytown, NY
| | | | | | | | - Kathryn Beal
- Memorial Sloan Kettering Cancer Center, New York, NY
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Skakodub A, Tringale KR, Walch HS, Vasudevan H, Eichholz J, Kelly DW, Moss NS, Yu KKH, Li BT, Mueller B, Yang JT, Beal K, Imber BS, Gomez DR, Schultz N, Pike LRG. Genomic analysis and clinical correlations of non-small cell lung cancer (NSCLC) brain metastasis (BM). J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.2008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
2008 Background: Approximately 30% of patients with NSCLC present with BM, and up to 50% of patients ultimately develop BM. While modern NSCLC-directed agents yield excellent systemic response, most patients require focal treatment. Prior reports of BM genomics have been limited by low numbers, missing clinical data, and lack of matched specimens. Here, we report the largest cohort to date of molecularly profiled NSCLC BM samples with clinical correlates. Methods: Clinical data and outcomes for 244 patients with NSCLC and resected BM were identified, and BM samples were assessed with one of four versions (341, 410, 468, 505) of MSK-IMPACT, a custom FDA-approved next generation sequencing-based tumor sequencing assay. 51 (20.9%) patients had matched primary site tissue, and 44 (18%) patients had matched tissue from another metastatic site or CSF. Genomic alterations were filtered for driver variants using OncoKB. Results: Median age was 66 years (range 31-91), and median follow-up was 2.3 years (IQR 1.3-4.3). Adenocarcinoma was the most common histology (183, 78%). Half presented with a single BM, and 121 (51%) patients were treatment naive. Most (197, 83%) received adjuvant stereotactic radiosurgery (SRS) to the resection site and 28% received SRS to additional BM. After resection, 130 (55.1%) had CNS progression, often regional (54, 42%). SRS to new BMs (32%) was the most common salvage treatment. Median overall survival from BM diagnosis was 2.5 years (95%CI 2.1-3.2). Median CNS-progression-free survival was 1.2 years (95%CI 0.9-1.4). The most frequently altered genes in BM samples were TP53 (72%), CDKN2A (34%), KRAS (31%), KEAP1 (26%), and EGFR (21%). CDKN2A was more frequently altered in BM samples when compared to NSCLC primary samples (34% vs 14%, p = 0.003, q = 0.034). With regard to overrepresented gene sets, cell cycle pathway alterations were enriched in BM (56% vs 31%, p = 0.002, q = 0.022). BM samples had a significantly higher fraction of genome altered relative to the primary samples (p < 0.0001, q < 0.0001). After grouping patients based on type of CNS progression, we found that EGFR alterations were enriched in patients with leptomeningeal failures when compared to both patients without progression (42% vs 18%, p = 0.03, q = 0.93) and to patients with either local or regional progression (42% vs 19%, p = 0.03, q = 0.9). Conclusions: In the largest-ever assembled cohort of genomically-profiled NSCLC BM, we found significant enrichment for CDKN2A and cell cycle pathway alterations in BM compared to extracranial disease, as well as a higher fraction of genome altered, in BMs compared to matched primary tumor controls. We also observed EGFR alteration enrichment in patients who develop LMD, suggesting specific biologic underpinnings driving patterns of CNS failure. Further investigation into the role of systemic therapy and time course will elucidate potential mechanisms for CNS failure in patients with NSCLC.
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Affiliation(s)
- Anna Skakodub
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | | | | | | | | | - Bob T. Li
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Boris Mueller
- Memorial Sloan-Kettering Cancer Center, Tarrytown, NY
| | | | - Kathryn Beal
- Memorial Sloan Kettering Cancer Center, New York, NY
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Hubbeling H, Silverman E, Wijetunga NA, Palomba ML, Tomas AA, Shouval R, Batlevi CW, Dahi PB, Giralt SA, Lin RJ, Park JH, Scordo M, Sauter CS, Shah G, Perales MA, Hajj C, Yahalom J, Imber BS. Lesion Characteristics and Patterns of Failure in Diffuse Large B Cell Lymphoma Patients Treated with Bridging Radiotherapy Prior to Chimeric Antigen Receptor T Cell Therapy. Transplant Cell Ther 2022. [DOI: 10.1016/s2666-6367(22)00703-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Imber BS, Hubbeling H, Silverman E, Wijetunga NA, Palomba ML, Tomas AA, Shouval R, Batlevi CW, Dahi PB, Giralt SA, Lin RJ, Park JH, Scordo M, Sauter CS, Shah G, Perales MA, Hajj C, Yahalom J. Five-Year Experience Using Bridging Radiotherapy Prior to Chimeric Antigen Receptor (CAR) T-Cell Therapies for B-Cell Malignancies. Transplant Cell Ther 2022. [DOI: 10.1016/s2666-6367(22)00423-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Mathis NJ, Wijetunga NA, Imber BS, Pike LRG, Yang JT. Recent Advances and Applications of Radiation Therapy for Brain Metastases. Curr Oncol Rep 2022; 24:335-342. [PMID: 35133614 DOI: 10.1007/s11912-022-01209-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW Radiation therapy (RT) is a mainstay of treatment for brain metastases from solid tumors. Treatment of these patients is complex and should focus on minimizing symptoms, preserving functional status, and prolonging survival. RECENT FINDINGS Whole-brain radiotherapy (WBRT) can lead to toxicity, and while it does reduce recurrence in the CNS, this has not been shown to provide a survival benefit. Recent advances focus on reducing the toxicity of WBRT or using more targeted radiation therapy. New paradigms including the use of proton RT for leptomeningeal metastases (LM) and stereotactic radiosurgery (SRS) before craniotomy hold promise in improving treatment efficacy and reducing toxicity. Omission or replacement of WBRT is often safe and the use of SRS is expanding to include patients with more lesions and preoperative RT. Proton RT holds promise for LM. Progress is being made in improving patient-centered outcomes and reducing toxicity for patients with brain metastases.
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Affiliation(s)
- Noah J Mathis
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - N Ari Wijetunga
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - Brandon S Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - Luke R G Pike
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - Jonathan T Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA.
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Yu KKH, Imber BS, Moss NS. Multimodality durable salvage of recurrent brain metastases refractory to LITT, SRS and immunotherapy with resection and cesium-131 brachytherapy: case report and literature review. BMJ Case Rep 2021; 14:e245369. [PMID: 34920997 PMCID: PMC8685948 DOI: 10.1136/bcr-2021-245369] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2021] [Indexed: 01/10/2023] Open
Abstract
Brain metastases (BrM) are treated with multimodality therapy, however the optimal combination and timing of modalities in the setting of recurrent tumours that have failed prior treatments remain poorly defined. We present a case of a patient with biopsy-confirmed renal cell carcinoma BrM with good performance status initially treated with laser interstitial thermal ablation therapy (LITT) followed by stereotactic radiosurgery and dual checkpoint inhibitor immunotherapy. He subsequently developed rapid in-field recurrence which was treated with salvage surgical resection and implantation of intracavitary cesium-131 brachytherapy. The patient's disease remained stable through 18 months postoperatively. This case illustrates the range of options available and provides a combination salvage therapy strategy in a select group of locally recurrent patients who have exhausted conventional treatment options.
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Affiliation(s)
- Kenny Kwok Hei Yu
- Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Brandon S Imber
- Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Nelson S Moss
- Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Shepherd AF, Yu AF, Iocolano M, Leeman JE, Wild AT, Imber BS, Chaft JE, Offin M, Huang J, Isbell JM, Wu AJ, Gelblum DY, Shaverdian N, Simone CB, Gomez D, Yorke E, Jackson A, Rimner A. Increasing Heart Dose Reduces Overall Survival in Patients Undergoing Postoperative Radiation Therapy for NSCLC. JTO Clin Res Rep 2021; 2:100209. [PMID: 34590050 PMCID: PMC8474215 DOI: 10.1016/j.jtocrr.2021.100209] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 05/07/2021] [Revised: 06/30/2021] [Accepted: 07/04/2021] [Indexed: 12/25/2022] Open
Abstract
Introduction Given the concern for cardiopulmonary toxicity in patients with NSCLC undergoing postoperative radiation therapy (PORT), the purpose of this study was to evaluate the association between heart dose and overall survival (OS) in patients undergoing PORT with modern techniques. Methods This is a retrospective study of consecutive patients with NSCLC treated with PORT between May 2004 and January 2017. Clinical records were reviewed and radiation dose distributions were analyzed for association with OS. Results A total of 284 patients were analyzed. At the time of surgery, most patients had pathologic American Joint Committee on Cancer seventh edition stage III disease (91.2 %) and received either preoperative or adjuvant chemotherapy (92.3 %). Most patients underwent a lobectomy (81.3 %) and had R0 (80.6 %) or R1 (19.4 %) resection. PORT was delivered with a median radiation dose of 54 Gy, and 70.4 % of patients were treated with intensity-modulated radiation therapy. Dosimetric variables across a large range of doses to the heart were highly significant (p < 0.05) for OS. The volume of the heart receiving 8 Gy (HV8) was the most significant dosimetric variable (p < 0.001), and the median HV8 was 35.5 %. The median OS was 33.2 versus 53.6 months (p < 0.005) for patients with HV8 above or below 35.5 %, respectively. On multivariable analysis accounting for other potential prognostic confounders, HV8 remained highly significant (p < 0.001). Conclusions The data reveal a strong correlation between increasing heart dose and OS in patients with NSCLC undergoing PORT. Taken together with the recently presented LungART trial, lowering heart dose in PORT patients may help to decrease the risk of morbidity and mortality and improve the therapeutic ratio of PORT.
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Affiliation(s)
- Annemarie F Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Anthony F Yu
- Department of Medicine, Cardiology, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Michelle Iocolano
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jonathan E Leeman
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Aaron T Wild
- Southeast Radiation Oncology Group, Levine Cancer Institute, Charlotte, North Carolina
| | - Brandon S Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Jamie E Chaft
- Department of Medical Oncology, Thoracic Oncology Service, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Michael Offin
- Department of Medical Oncology, Thoracic Oncology Service, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - James Huang
- Department of Surgery, Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - James M Isbell
- Department of Surgery, Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Daphna Y Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Narek Shaverdian
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Daniel Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Andrew Jackson
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York City, New York
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Carnevale JA, Imber BS, Winston GM, Goldberg JL, Ballangrud A, Brennan CW, Beal K, Tabar V, Moss NS. Risk of tract recurrence with stereotactic biopsy of brain metastases: an 18-year cancer center experience. J Neurosurg 2021; 136:1045-1051. [PMID: 34507279 DOI: 10.3171/2021.3.jns204347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 03/15/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Stereotactic biopsy is increasingly performed on brain metastases (BrMs) as improving cancer outcomes drive aggressive multimodality treatment, including laser interstitial thermal therapy (LITT). However, the tract recurrence (TR) risk is poorly defined in an era defined by focused-irradiation paradigms. As such, the authors aimed to define indications and adjuvant therapies for this procedure and evaluate the BrM-biopsy TR rate. METHODS In a single-center retrospective review, the authors identified stereotactic BrM biopsies performed from 2002 to 2020. Surgical indications, radiographic characteristics, stereotactic planning, dosimetry, pre- and postoperative CNS-directed and systemic treatments, and clinical courses were collected. Recurrence was evaluated using RANO-BM (Response Assessment in Neuro-Oncology Brain Metastases) criteria. RESULTS In total, 499 patients underwent stereotactic intracranial biopsy for any diagnosis, of whom 25 patients (5.0%) underwent biopsy for pathologically confirmed viable BrM, a proportion that increased over the time period studied. Twelve of the 25 BrM patients had ≥ 3 months of radiographic follow-up, of whom 6 patients (50%) developed new metastatic growth along the tract at a median of 5.0 months post-biopsy (range 2.3-17.1 months). All of the TR cases had undergone pre- or early post-biopsy stereotactic radiosurgery (SRS), and 3 had also undergone LITT at the time of initial biopsy. TRs were treated with resection, reirradiation, or observation/systemic therapy. CONCLUSIONS In this study the authors identified a nontrivial, higher than previously described rate of BrM-biopsy tract recurrence, which often required additional surgery or radiation and justified close radiographic surveillance. As BrMs are commonly treated with SRS limited to enhancing tumor margins, consideration should be made, in cases lacking CNS-active systemic treatments, to include biopsy tracts in adjuvant radiation plans where feasible.
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Affiliation(s)
- Joseph A Carnevale
- 1Department of Neurological Surgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center.,2Department of Neurological Surgery, NewYork-Presbyterian Hospital, Weill Cornell Medical Center; and
| | | | - Graham M Winston
- 1Department of Neurological Surgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center.,2Department of Neurological Surgery, NewYork-Presbyterian Hospital, Weill Cornell Medical Center; and
| | - Jacob L Goldberg
- 1Department of Neurological Surgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center.,2Department of Neurological Surgery, NewYork-Presbyterian Hospital, Weill Cornell Medical Center; and
| | - Ase Ballangrud
- 4Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Cameron W Brennan
- 1Department of Neurological Surgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center
| | | | - Viviane Tabar
- 1Department of Neurological Surgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center
| | - Nelson S Moss
- 1Department of Neurological Surgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center
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Moss NS, Imber BS, Cohen G, Prasad K, Nunez DA, Brennan CW, Tabar V, Beal KP. TRLS-07. Intracavitary carrier-embedded Cs131 brachytherapy for recurrent brain metastases: A randomized phase II study. Neurooncol Adv 2021. [PMCID: PMC8351308 DOI: 10.1093/noajnl/vdab071.025] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background The salvage treatment of recurrent brain metastases after failed irradiation is a clinical challenge. Adjuvant SRS is standard of care for resected brain metastases in the upfront post-resection setting given a significant local control advantage over surgery alone. However, the role of reirradiation following salvage resection of recurrent post-irradiation metastases is unclear owing to both reduced efficacy of subsequent courses of external beam radiation, and likely increased risk of radiation injury. Intracavitary cesium 131 (Cs131) brachytherapy offers a highly conformal adjunct radiation option that we hypothesize may allow for improved local control while also theoretically conveying a low risk of radiation necrosis. In this randomized controlled study, we aim to define the potential benefits and risks of resection plus permanently implanted, carrier-embedded intracavitary Cs131 brachytherapy versus conventional care (surgery alone). Methods This is a single-center randomized controlled study of patients undergoing resection of recurrent, previously-irradiated brain metastases. Exclusion criteria include prior in-field infection, prior radiation >100Gy (in 2Gy fraction equivalents), >5 additional active or untreated CNS lesions, or leptomeningeal carcinomatosis. Subjects are randomized 1:1 to undergo either surgery with placement of Cs131 brachytherapy or surgery alone. The primary endpoint is freedom from treated-site progression at 9 months. Secondary endpoints include wound complications at 3 months and time to local retreatment at the index site, and exploratory objectives include neurocognitive function prior to surgery and at 3 and 12 months postoperatively, with correlative analyses of the previously irradiated brain metastasis tissue. Accrual began on December 24, 2020 and 5 of a planned 76 patients have enrolled. This is the first randomized controlled trial of surgery plus permanently implanted intracavitary Cs131 brachytherapy versus surgery alone for recurrent brain metastases. ClinicalTrials.gov Identifier: NCT04690348
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Affiliation(s)
- Nelson S Moss
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Gilad Cohen
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kavya Prasad
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | - Viviane Tabar
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kathryn P Beal
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Imber BS, Tin AL, Vickers A, Eastham JA, Zelefsky MJ, Ehdaie B, Gorovets D. Patient-reported financial toxicity following management of localized prostate cancer. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.e17053] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e17053 Background: Cancer patients’ potential for severe financial toxicity (FT) is well-established, however there is limited data on the magnitude of this challenge associated with treatment of localized prostate cancer (PC). The extent to which men consider potential financial implications prior to selection of a treatment strategy remains poorly understood. Methods: Between 5/2020-10/2020, 1233 insured PC patients treated at a comprehensive cancer center completed a one-time FT survey which included the COmprehensive Score for financial Toxicity (COST) instrument, impressions of PC costs and financial coping strategies. Inclusion criteria was localized disease and treatment with either radical prostatectomy (RP) or definitive radiotherapy (RT) in the previous 4-26 months (mo) or at least 6mo of active surveillance (AS) prior to survey. To assess possible temporal differences in FT, responses were grouped into 6, 12, 18 and 24 months after treatment start, and we plotted COST against time, using generalized additive models to allow for non-linearity. Results: Overall, 988 men were eligible for analysis: 347 (35%) underwent RP, 384 (39%) underwent RT, and 257 (26%) were on AS. The median age at survey completion was 67 years (quartiles 62, 72). Men were predominantly white (89%), English-speakers (99%) and married (84%). The median (quartiles) COST score for all patients was 33 (26, 38) with possible range of 0-44 with lower scores indicating greater FT; median values were identical with similar quartiles (+/- 1 point) when stratified by treatment type. There were no significant changes in median COST between men surveyed at the four time points for any treatment subgroup. In total, 66 men (7.1%) reported spending > 20% of annual income on treatment and 10% felt that PC has created at least somewhat of a financial hardship for their family. Top drivers of burdensome cost included medical bills (37%) and transportation costs (21%). Most (83%) reported giving little or no consideration to possible costs prior to making a PC treatment decision, yet the majority (77%) felt that out of pocket costs should be communicated to a patient prior to decision making. Most believed patients should definitely (46%) or possibly (33%) have the opportunity to discuss financial concerns with the radiation oncologist or urologist. Conclusions: Our study is the first reported use of the COST instrument to assess subjective financial distress in localized PC patients. Our results demonstrate that the overall degree of FT in this cohort of insured patients treated at a specialized cancer center is low. While potential financial burden does not strongly influence treatment decision making in this cohort, most want this information and an opportunity to discuss financial concerns with their oncologist. Next steps include identification of predictors for high FT risk and extension of our survey to hospital systems with differing demographic profiles.
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Affiliation(s)
| | - Amy L. Tin
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | - Behfar Ehdaie
- Memorial Sloan Kettering Cancer Center, New York, NY
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Lumish M, Falchi L, Imber BS, Scordo M, von Keudell G, Joffe E. How we treat mature B-cell neoplasms (indolent B-cell lymphomas). J Hematol Oncol 2021; 14:5. [PMID: 33407745 PMCID: PMC7789477 DOI: 10.1186/s13045-020-01018-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 12/02/2020] [Indexed: 12/30/2022] Open
Abstract
Mature B cell neoplasms, previously indolent non-Hodgkin lymphomas (iNHLs), are a heterogeneous group of malignancies sharing similar disease courses and treatment paradigms. Most patients with iNHL have an excellent prognosis, and in many, treatment can be deferred for years. However, some patients will have an accelerated course and may experience transformation into aggressive lymphomas. In this review, we focus on management concepts shared across iNHLs, as well as histology-specific strategies. We address open questions in the field, including the influence of genomics and molecular pathway alterations on treatment decisions. In addition, we review the management of uncommon clinical entities including nodular lymphocyte-predominant Hodgkin lymphoma, hairy cell leukemia, splenic lymphoma and primary lymphoma of extranodal sites. Finally, we include a perspective on novel targeted therapies, antibodies, antibody-drug conjugates, bispecific T cell engagers and chimeric antigen receptor T cell therapy.
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Affiliation(s)
- Melissa Lumish
- Lymphoma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-441B, New York, NY, 10065, USA
| | - Lorenzo Falchi
- Lymphoma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-441B, New York, NY, 10065, USA
| | - Brandon S Imber
- Lymphoma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-441B, New York, NY, 10065, USA
| | - Michael Scordo
- Lymphoma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-441B, New York, NY, 10065, USA
| | - Gottfried von Keudell
- Lymphoma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-441B, New York, NY, 10065, USA
| | - Erel Joffe
- Lymphoma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-441B, New York, NY, 10065, USA.
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Kanungo I, Skrehot HC, Chandra A, Imber BS, Nguyen AT, Wadhwa H, Jahangiri A, Aghi MK. Diagnostic and Therapeutic Features Associated with Time to Malignant Transformation in Supratentorial Low-Grade Oligodendroglioma. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Imber BS, Varghese M, Goldman DA, Zhang Z, Gewanter R, Marciscano AE, Mychalczak B, Gorovets D, Kollmeier M, McBride SM, Zelefsky MJ. Clinical Outcomes of Combined Prostate- and Metastasis-Directed Radiation Therapy for the Treatment of De Novo Oligometastatic Prostate Cancer. Adv Radiat Oncol 2020; 5:1213-1224. [PMID: 33305082 PMCID: PMC7718501 DOI: 10.1016/j.adro.2020.06.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 06/02/2020] [Accepted: 06/14/2020] [Indexed: 01/20/2023] Open
Abstract
PURPOSE The Systemic Therapy in Advancing or Metastatic Prostate Cancer: Evaluation of Drug Efficacy (STAMPEDE) trial reported overall survival benefits for prostate-directed radiation therapy (PDRT) in low-burden metastatic prostate cancer. Oligometastasis-directed radiation therapy (ORT) improves androgen deprivation therapy (ADT)-free and progression-free survivals. Comprehensive PDRT + ORT to all detectable metastases may offer benefit for de novo oligometastatic prostate cancer (DNOPC) and is under prospective study; given few available benchmarks, we reviewed our institutional experience. METHODS AND MATERIALS Forty-seven patients with DNOPC with predominantly M1b disease received neoadjuvant, concurrent, and adjuvant ADT plus PDRT + ORT to 1 to 6 oligometastases. Gross pelvic (N1) nodes were not considered oligometastases unless focally targeted without broader nodal coverage. Outcomes were analyzed from radiation therapy (RT) start using Kaplan-Meier, competing risks, and Cox regression. Median follow-up was 27 (95% confidence interval, 16-42) months. RESULTS At 1- and 2-years post-RT, cumulative incidence of distant metastatic progression (DMP) was 21% and 32%, whereas overall survival was 90% and 87%, respectively. Neuroendocrine/intraductal histology, prostate-specific antigen (PSA) < 20, and detectable PSA after PDRT + ORT were associated with increased DMP risk; number and location of oligometastases were not. Local failure was rare, with 3 prostate recurrences and progression of 10 treated oligometastases during follow-up. After neoadjuvant ADT, 9 (19%) patients had undetectable PSA (<0.05 ng/mL), which increased to 32 (68%) after PDRT + ORT. Overall 2-year incidence of biochemical recurrence (BCR) and development of castrate resistance were 23% and 36%, respectively. Undetectable PSA post-RT was associated with lower risk of BCR (hazard ratio, 0.19; P = .004) and DMP (hazard ratio, 0.26; P = .025). Overall, 23 (49%) patients were trialed off ADT; 16 (70%) had testosterone recovery (>150 ng/dL) and, of these, 5 had subsequent PSA rise and restarted ADT 2 to 21 months postrecovery. The remaining 11 were maintained off ADT without BCR. Median noncastrate duration was 8 months; 7 patients had normalized testosterone for >1 year. CONCLUSIONS A comprehensive, radiotherapeutic-based treatment strategy has favorable clinical outcomes and can produce prolonged noncastrate remissions in a subset with DNOPC.
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Affiliation(s)
- Brandon S. Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Melissa Varghese
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Debra A. Goldman
- 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
| | - Richard Gewanter
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ariel E. Marciscano
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Borys Mychalczak
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel Gorovets
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marisa Kollmeier
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sean M. McBride
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael J. Zelefsky
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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Shepherd AF, Iocolano M, Leeman J, Imber BS, Wild AT, Offin M, Chaft JE, Huang J, Rimner A, Wu AJ, Gelblum DY, Shaverdian N, Simone CB, Gomez DR, Yorke ED, Jackson A. Clinical and Dosimetric Predictors of Radiation Pneumonitis in Patients With Non-Small Cell Lung Cancer Undergoing Postoperative Radiation Therapy. Pract Radiat Oncol 2020; 11:e52-e62. [PMID: 33068790 DOI: 10.1016/j.prro.2020.09.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 08/03/2020] [Accepted: 09/28/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE Radiation pneumonitis (RP) is a common and potentially life-threatening toxicity from lung cancer radiation therapy. Data sets reporting RP rates after postoperative radiation therapy (PORT) have historically been small and with predominantly outdated field designs and radiation techniques. We examined a large cohort of patients in this context to assess the incidence and causes of RP in the modern era. METHODS AND MATERIALS We reviewed 285 patients with non-small cell lung cancer treated with PORT at our institution from May 2004 to January 2017. Complete dosimetric data and clinical records were reviewed and analyzed with grade 2 or higher RP as the endpoint (RP2+) (Common Terminology Criteria for Adverse Events v4.0). Patients were a median of 67 years old (range, 28-87), and most had pathologic stage III non-small cell lung cancer (91%) and received trimodality therapy (90%). Systematic dosimetric analyses using Dx increments of 5% and Vx increments of 2 Gy were performed to robustly evaluate dosimetric variables. Lung V5 was also evaluated. RESULTS The incidence of RP2+ after PORT was 12.6%. Dosimetric factors most associated with RP2+ were total lungV4 (hazard ratio [HR] 1.04, P < .001) and heart V16 (HR 1.03, P = .001). On univariate analysis, the clinical factors of age (HR 1.05, P = .006) and carboplatin chemotherapy (HR 2.32, P = .012) were correlated with RP2+. On step-up multivariate analysis, only bivariate models remained significant, including lungV5 (HR 1.037, P < .001) and age (HR 1.052, P = .011). CONCLUSIONS The incidence of RP after PORT is consistent with the literature. Factors correlated with RP include lung and heart doses, age, and carboplatin chemotherapy. These data also suggest that elderly patients may be more susceptible to lower doses of radiation to the lung. Based on these data, dose constraints to limit the risk of RP2+ to <5% in the setting of PORT include lungV5 ≤65% in patients <65 years old and lungV5 ≤36% in patients 65 years or older.
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Affiliation(s)
- Annemarie F Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Michelle Iocolano
- Department of Radiation Oncology, The Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jonathan Leeman
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts
| | - Brandon S Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Aaron T Wild
- Southeast Radiation Oncology Group, Charlotte, North Carolina
| | - Michael Offin
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jamie E Chaft
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - James Huang
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daphna Y Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Narek Shaverdian
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ellen D Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew Jackson
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
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Ghione P, Qi S, Imber BS, Seshan V, Moskowitz A, Galasso N, Lunning M, Straus D, Sauter C, Dahi P, Dogan A, Yahalom J, Horwitz S. Modified SMILE (mSMILE) and intensity-modulated radiotherapy (IMRT) for extranodal NK-T lymphoma nasal type in a single-center population. Leuk Lymphoma 2020; 61:3331-3341. [PMID: 32844695 DOI: 10.1080/10428194.2020.1811864] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
A modification of the SMILE regimen with dexamethasone, methotrexate, ifosfamide, L-asparaginase, etoposide (mSMILE) followed by Intensity-Modulated Radiotherapy (IMRT) at lower than usual dose, has been adopted as standard of care for extranodal NK-/T-cell lymphoma (ENKL) at our institution. mSMILE is a short course, intensive regimen incorporating pegylated asparaginase. Here, we describe clinical details, outcome and safety of patients receiving mSMILE. Among 28 patients with ENKL treated, response post-mSMILE was 93% (CR 68%), response post IMRT was 95% (CR 87.5%). Among early-stage patients/low PINK-E (n = 13), overall survival (OS) was 100% at the median follow-up of 31 months; progression-free survival (PFS) was 92%. Advanced-stage and intermediate/high PINK-E patients fared similarly (OS 43%, PFS 33.3% at the median follow-up). Thirty-two percent of the patients experienced G3-4 non-hematologic toxicity, all experienced hematologic toxicity. Most localized-stage patients achieved long-term disease control. Despite high response rates, most of the advanced stage patients relapsed quickly.
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Affiliation(s)
- Paola Ghione
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Shunan Qi
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Radiation Oncology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Brandon S Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Venkatraman Seshan
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alison Moskowitz
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Natasha Galasso
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Matthew Lunning
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David Straus
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Craig Sauter
- Department of Medicine, Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Parastoo Dahi
- Department of Medicine, Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ahmet Dogan
- Hematopathology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joachim Yahalom
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Steven Horwitz
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Moss NS, Imber BS, Prasad K, Chu BP, Goel A, Aramburu-Nunez D, Bellamy M, Yang TJ, Khan AJ, Dauer LT, Cohen GN, Beal K, Tabar V. 69. PERMANENT INTRACAVITARY Cs131 BRACHYTHERAPY FOR PREVIOUSLY-IRRADIATED RECURRENT BRAIN METASTASES: INITIAL CLINICAL AND RADIATION SAFETY EXPERIENCE. Neurooncol Adv 2020. [PMCID: PMC7401341 DOI: 10.1093/noajnl/vdaa073.056] [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] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE Recurrence of previously-irradiated brain metastases (BrM) presents a significant challenge. We describe our initial experience using salvage resection with Cs131 brachytherapy in previously-irradiated BrM. METHODS Between September 2019 and April 2020, 9 patients with recurrent BrM underwent maximally-safe metastatectomy. Following pathological confirmation of viable recurrence, cavities were implanted with permanent Cs131 brachytherapy (GammaTile, GT Medical Technologies). Prescribed dose was 60Gy at 5mm from the cavity. Postimplant dosimetry (V100) was calculated on postoperative day 1 fused CT/MRI. Intraoperative team exposure was recorded using intraoperative ring dosimetry, and patient dose-rates measured postoperatively informed patient, family and medical-staff exposure modeling. RESULTS Nine patients (55% female, median age 54) underwent 10 implantations (6 supratentorial, 4 infratentorial). Median preoperative maximum diameter was 3.5cm (2.3–6.3) and histologies included breast, gastrointestinal, lung, kidney and oral cavity squamous cell carcinomas. Five had undergone prior resection or laser ablation. All lesions received >/=1 prior course of stereotactic irradiation a median of 10.1 months (3.7–15.9) earlier. Eight lesions were gross-totally resected. Median number of implanted Cs131 seeds was 16 (12–28) with median seed strength of 61.8U (42.4–98.0). Median postoperative cavity size was well-correlated with the number of implanted seeds (Pearson R=0.75, p=0.03). Median V100 dose coverage of the cavities and uniform 5mm expansion of the cavities were 99% (79–100%) and 79% (51–95%), respectively. Median measured exposure rates were 90mR/hr (28–152) on contact, 9.15mR/hr (2.7–13.9) at 30cm and 1.4mR/hr (0.6–2.3) at 1 meter from the patient. Mean ring dose was 6.83mrem (0–18) for the radiation oncologist and 9.17mrem (0–15) for the neurosurgeon. Modeled lifetime family-member and visitor exposure was 116mrem (52-193mrem), and healthcare worker exposure was 39mrem (17-64mrem), all well below regulatory limits. There were no immediate wound complications or unanticipated neurologic injuries. CONCLUSION In our early experience, salvage interstitial Cs131 implantation was safely employed for recurrent brain metastases.
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Affiliation(s)
- Nelson S Moss
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Kavya Prasad
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Bae P Chu
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Arun Goel
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | | | - Atif J Khan
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Gilad N Cohen
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kathryn Beal
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Viviane Tabar
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Imber BS, Chau K, Goldberg E, Joffe E, Yahalom J. Grade 3A follicular lymphoma can be effectively controlled with very low-dose radiation therapy. Leuk Lymphoma 2020; 61:1500-1503. [PMID: 32037915 PMCID: PMC7269818 DOI: 10.1080/10428194.2020.1716222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 01/08/2020] [Indexed: 10/25/2022]
Affiliation(s)
- Brandon S. Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center; 1275 York Ave., New York, NY 10065
| | - Karen Chau
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center; 1275 York Ave., New York, NY 10065
| | - Eliana Goldberg
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center; 1275 York Ave., New York, NY 10065
| | - Erel Joffe
- Lymphoma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center; 1275 York Ave., New York, NY 10065
| | - Joachim Yahalom
- Corresponding Author: Joachim Yahalom, MD, FACR, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY 10065, 212-639-5999,
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50
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Imber BS, Sadelain M, DeSelm C, Batlevi C, Brentjens RJ, Dahi PB, Giralt S, Park JH, Sauter C, Scordo M, Shah G, Perales MA, Palomba ML, Yahalom J. Early experience using salvage radiotherapy for relapsed/refractory non-Hodgkin lymphomas after CD19 chimeric antigen receptor (CAR) T cell therapy. Br J Haematol 2020; 190:45-51. [PMID: 32135029 DOI: 10.1111/bjh.16541] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/20/2020] [Accepted: 01/24/2020] [Indexed: 01/01/2023]
Abstract
Radiotherapy is potentially an important salvage strategy post-chimeric antigen receptor T cell therapy (CART), but limited data exist. We reviewed 14 patients treated with salvage radiation post-CART progression (SRT). Most received SRT for first post-CART relapse (71%) to sites previously PET-avid pre-CART (79%). Median overall survival (OS) post-SRT was 10 months. Post-SRT, six localized relapses achieved 100% response (3 = complete, 3 = partial), with improved freedom from subsequent relapse (P = 0·001) and OS (P = 0·004) compared to advanced stage relapses. Three were bridged to allogeneic transplantation; at analysis, all were alive/NED. SRT has diverse utility and can integrate with novel agents or transplantation to attempt durable remissions.
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Affiliation(s)
- Brandon S Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michel Sadelain
- Center for Cell Engineering and Immunology Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Carl DeSelm
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Connie Batlevi
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Medicine, Center for Cellular Therapeutics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Renier J Brentjens
- Department of Medicine, Center for Cellular Therapeutics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Parastoo B Dahi
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sergio Giralt
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jae H Park
- Department of Medicine, Center for Cellular Therapeutics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Craig Sauter
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michael Scordo
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Gunjan Shah
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Miguel-Angel Perales
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - M Lia Palomba
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Medicine, Center for Cellular Therapeutics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joachim Yahalom
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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