1
|
Johnson TS, MacDonald TJ, Pacholczyk R, Aguilera D, Al-Basheer A, Bajaj M, Bandopadhayay P, Berrong Z, Bouffet E, Castellino RC, Dorris K, Eaton BR, Esiashvili N, Fangusaro JR, Foreman N, Fridlyand D, Giller C, Heger IM, Huang C, Kadom N, Kennedy EP, Manoharan N, Martin W, McDonough C, Parker RS, Ramaswamy V, Ring E, Rojiani A, Sadek RF, Satpathy S, Schniederjan M, Smith A, Smith C, Thomas BE, Vaizer R, Yeo KK, Bhasin MK, Munn DH. Indoximod-based chemo-immunotherapy for pediatric brain tumors: A first-in-children phase I trial. Neuro Oncol 2024; 26:348-361. [PMID: 37715730 PMCID: PMC10836763 DOI: 10.1093/neuonc/noad174] [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: 03/23/2023] [Indexed: 09/18/2023] Open
Abstract
BACKGROUND Recurrent brain tumors are the leading cause of cancer death in children. Indoleamine 2,3-dioxygenase (IDO) is a targetable metabolic checkpoint that, in preclinical models, inhibits anti-tumor immunity following chemotherapy. METHODS We conducted a phase I trial (NCT02502708) of the oral IDO-pathway inhibitor indoximod in children with recurrent brain tumors or newly diagnosed diffuse intrinsic pontine glioma (DIPG). Separate dose-finding arms were performed for indoximod in combination with oral temozolomide (200 mg/m2/day x 5 days in 28-day cycles), or with palliative conformal radiation. Blood samples were collected at baseline and monthly for single-cell RNA-sequencing with paired single-cell T cell receptor sequencing. RESULTS Eighty-one patients were treated with indoximod-based combination therapy. Median follow-up was 52 months (range 39-77 months). Maximum tolerated dose was not reached, and the pediatric dose of indoximod was determined as 19.2 mg/kg/dose, twice daily. Median overall survival was 13.3 months (n = 68, range 0.2-62.7) for all patients with recurrent disease and 14.4 months (n = 13, range 4.7-29.7) for DIPG. The subset of n = 26 patients who showed evidence of objective response (even a partial or mixed response) had over 3-fold longer median OS (25.2 months, range 5.4-61.9, p = 0.006) compared to n = 37 nonresponders (7.3 months, range 0.2-62.7). Four patients remain free of active disease longer than 36 months. Single-cell sequencing confirmed emergence of new circulating CD8 T cell clonotypes with late effector phenotype. CONCLUSIONS Indoximod was well tolerated and could be safely combined with chemotherapy and radiation. Encouraging preliminary evidence of efficacy supports advancing to Phase II/III trials for pediatric brain tumors.
Collapse
Affiliation(s)
- Theodore S Johnson
- Georgia Cancer Center, Augusta University, Augusta, Georgia, USA
- Department of Pediatrics, Augusta University, Augusta, Georgia, USA
| | - Tobey J MacDonald
- Aflac Cancer & Blood Disorders Center at Children’s Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Rafal Pacholczyk
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, Massachusetts, USA
| | - Dolly Aguilera
- Aflac Cancer & Blood Disorders Center at Children’s Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Ahmad Al-Basheer
- Georgia Cancer Center, Augusta University, Augusta, Georgia, USA
- Department of Radiation Oncology, Augusta University, Augusta, Georgia, USA
| | - Manish Bajaj
- Department of Radiology, Augusta University, Augusta, Georgia, USA
| | | | - Zuzana Berrong
- Georgia Cancer Center, Augusta University, Augusta, Georgia, USA
| | - Eric Bouffet
- Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Robert C Castellino
- Aflac Cancer & Blood Disorders Center at Children’s Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Kathleen Dorris
- Department of Pediatrics, Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Bree R Eaton
- Department of Radiation Oncology and Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Natia Esiashvili
- Department of Radiation Oncology and Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Jason R Fangusaro
- Aflac Cancer & Blood Disorders Center at Children’s Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Nicholas Foreman
- Department of Pediatrics, Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Diana Fridlyand
- Department of Pediatrics, Augusta University, Augusta, Georgia, USA
| | - Cole Giller
- Department of Neurosurgery, Augusta University, Augusta, Georgia, USA
| | - Ian M Heger
- Department of Neurosurgery, Augusta University, Augusta, Georgia, USA
| | - Chenbin Huang
- Department of Pediatrics, Emory University, Atlanta, Georgia, USA
- Department of Biomedical Informatics, Emory University, Atlanta, Georgia, USA
| | - Nadja Kadom
- Department of Radiology and Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Eugene P Kennedy
- Lumos Pharma, Inc. (formerly NewLink Genetics Corporation), Austin, Texas, USA
| | - Neevika Manoharan
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, Massachusetts, USA
| | - William Martin
- Department of Radiation Oncology, Augusta University, Augusta, Georgia, USA
| | - Colleen McDonough
- Georgia Cancer Center, Augusta University, Augusta, Georgia, USA
- Department of Pediatrics, Augusta University, Augusta, Georgia, USA
| | - Rebecca S Parker
- Georgia Cancer Center, Augusta University, Augusta, Georgia, USA
- Department of Pediatrics, Augusta University, Augusta, Georgia, USA
| | - Vijay Ramaswamy
- Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Eric Ring
- Georgia Cancer Center, Augusta University, Augusta, Georgia, USA
- Department of Pediatrics, Augusta University, Augusta, Georgia, USA
| | - Amyn Rojiani
- Georgia Cancer Center, Augusta University, Augusta, Georgia, USA
- Department of Pathology, Augusta University, Augusta, Georgia, USA
| | - Ramses F Sadek
- Georgia Cancer Center, Augusta University, Augusta, Georgia, USA
- Department of Population Health Sciences, Augusta University, Augusta, Georgia, USA
| | - Sarthak Satpathy
- Department of Pediatrics, Emory University, Atlanta, Georgia, USA
- Department of Biomedical Informatics, Emory University, Atlanta, Georgia, USA
| | - Matthew Schniederjan
- Children’s Healthcare of Atlanta and Department of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia, USA
| | - Amy Smith
- Department of Pediatrics, Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | - Christopher Smith
- Lumos Pharma, Inc. (formerly NewLink Genetics Corporation), Austin, Texas, USA
| | - Beena E Thomas
- Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Rachel Vaizer
- Department of Pediatrics, Augusta University, Augusta, Georgia, USA
| | - Kee Kiat Yeo
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, Massachusetts, USA
| | - Manoj K Bhasin
- Aflac Cancer & Blood Disorders Center at Children’s Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, Georgia, USA
- Department of Pediatrics, Emory University, Atlanta, Georgia, USA
- Department of Biomedical Informatics, Emory University, Atlanta, Georgia, USA
| | - David H Munn
- Georgia Cancer Center, Augusta University, Augusta, Georgia, USA
- Department of Pediatrics, Augusta University, Augusta, Georgia, USA
| |
Collapse
|
2
|
Shahab SW, Patil P, Fangusaro JR, Patteson B, Goldman-Yassen A, Eaton BR, Boydston W, Schniederjan M, Aguilera D. Primary Diffuse Leptomeningeal Melanomatosis in a Child with Extracranial Metastasis: Case Report. Curr Oncol 2024; 31:579-587. [PMID: 38275834 PMCID: PMC10814890 DOI: 10.3390/curroncol31010041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/14/2024] [Accepted: 01/19/2024] [Indexed: 01/27/2024] Open
Abstract
Primary meningeal melanomatosis is an extremely rare tumor with very few documented responses to treatment. A 3-year-old male with a complex past medical history, including prematurity and shunted hydrocephalus, was diagnosed with primary meningeal melanomatosis with peritoneal implants. Molecular testing revealed an NRAS Q61R mutation. The patient received proton craniospinal radiation followed by immunotherapy with nivolumab (1 mg/kg) and ipilimumab (3 mg/kg) IV every 3 weeks and, upon progression, he was switched to a higher dose of nivolumab (3 mg/kg IV every 2 weeks) and binimetinib (24 mg/m2/dose, twice a day). The patient had significant improvement of CNS disease with radiation therapy and initial immunotherapy but progression of extracranial metastatic peritoneal and abdominal disease. Radiation was not administered to the whole abdomen. After two cycles of nivolumab and treatment with the MEK inhibitor binimetinib, he had radiographic and clinical improvement in abdominal metastasis and ascitis. He ultimately died from RSV infection, Klebsiella sepsis, and subdural hemorrhage without evidence of tumor progression. This is the first report of a child with primary meningeal melanomatosis with extracranial metastatic disease with response to a combination of radiation, immunotherapy and MEK inhibitor therapy.
Collapse
Affiliation(s)
- Shubin W. Shahab
- Aflac Cancer and Blood Disorders Center, Atlanta, GA 30342, USA; (J.R.F.); (B.P.); (D.A.)
- Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA; (P.P.); (A.G.-Y.); (B.R.E.); (W.B.); (M.S.)
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
- Winship Cancer Institute, Atlanta, GA 30322, USA
| | - Prabhumallikarjun Patil
- Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA; (P.P.); (A.G.-Y.); (B.R.E.); (W.B.); (M.S.)
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Jason R. Fangusaro
- Aflac Cancer and Blood Disorders Center, Atlanta, GA 30342, USA; (J.R.F.); (B.P.); (D.A.)
- Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA; (P.P.); (A.G.-Y.); (B.R.E.); (W.B.); (M.S.)
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
- Winship Cancer Institute, Atlanta, GA 30322, USA
| | - Brooke Patteson
- Aflac Cancer and Blood Disorders Center, Atlanta, GA 30342, USA; (J.R.F.); (B.P.); (D.A.)
- Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA; (P.P.); (A.G.-Y.); (B.R.E.); (W.B.); (M.S.)
| | - Adam Goldman-Yassen
- Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA; (P.P.); (A.G.-Y.); (B.R.E.); (W.B.); (M.S.)
- Department of Radiology, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Bree R. Eaton
- Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA; (P.P.); (A.G.-Y.); (B.R.E.); (W.B.); (M.S.)
- Winship Cancer Institute, Atlanta, GA 30322, USA
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - William Boydston
- Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA; (P.P.); (A.G.-Y.); (B.R.E.); (W.B.); (M.S.)
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Matthew Schniederjan
- Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA; (P.P.); (A.G.-Y.); (B.R.E.); (W.B.); (M.S.)
- Department of Pathology, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Dolly Aguilera
- Aflac Cancer and Blood Disorders Center, Atlanta, GA 30342, USA; (J.R.F.); (B.P.); (D.A.)
- Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA; (P.P.); (A.G.-Y.); (B.R.E.); (W.B.); (M.S.)
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
| |
Collapse
|
3
|
Williamson C, Williamson S, Jiang R, Sudmeier L, Esiashvili N, Eaton BR. The impact of radiation therapy variables on pediatric high-grade glioma outcomes: A National Cancer Database analysis. Pediatr Blood Cancer 2024; 71:e30751. [PMID: 37937991 DOI: 10.1002/pbc.30751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 09/23/2023] [Accepted: 10/17/2023] [Indexed: 11/09/2023]
Abstract
PURPOSE The purpose of this analysis is to report patterns of care for pediatric patients with high-grade glioma (pHGG) and evaluate the impact of radiotherapy (RT) variables on outcomes using the National Cancer Database (NCDB). METHODS Eligibility criteria included age < 22 years, histologically diagnosed WHO grade III-IV gliomas treated with ≥50 Gy and < 76 Gy RT between 2004 and 2013, and RT initiation within 90 days of diagnosis. RT variables including RT dose, RT timing, and RT modality were analyzed along with baseline demographic, tumor, and treatment variables to assess the impact on overall survival. RESULTS A total of 498 pHGG patients were included. The median age was 15 years (range, 0-21), common diagnoses were astrocytoma (55%) and glioblastoma (30%), 73.5% underwent surgical resection and 90.2% received chemotherapy. The median RT dose was 59.4 Gy (SD 2.9 Gy) starting at a median of 4.4 weeks from diagnosis (SD 2.5 weeks). Fourteen patients were treated with proton therapy. Median follow-up was 19.6 months with 1- and 3-year overall survival of 78.4% and 40.4%, respectively. On multivariable analysis, female gender, older age, and RT delay of ≥6 weeks were significantly associated with a lower rate of death; glioblastoma histology, no surgical resection/biopsy only, and earlier RT initiation < 6 weeks from diagnosis were associated with a higher rate of death. There was no relationship between RT dose or proton versus photon therapy and overall survival. CONCLUSIONS Outcomes for pHGG are poor. There was no benefit to early RT timing when RT is initiated within 90 days of diagnosis or higher RT dose in this dataset.
Collapse
Affiliation(s)
- Christopher Williamson
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Shayla Williamson
- Department of Biostatistics and Bioinformatics, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Renjian Jiang
- Department of Biostatistics and Bioinformatics, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Lisa Sudmeier
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Natia Esiashvili
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Bree R Eaton
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| |
Collapse
|
4
|
Berrington de González A, Gibson TM, Lee C, Albert PS, Griffin KT, Kitahara CM, Liu D, Mille MM, Shin J, Bajaj BV, Flood TE, Gallotto SL, Paganetti H, Ahmed SK, Eaton BR, Indelicato DJ, Milgrom SA, Palmer JD, Baliga S, Poppe MM, Tsang DS, Wong K, Yock TI. The Pediatric Proton and Photon Therapy Comparison Cohort: Study Design for a Multicenter Retrospective Cohort to Investigate Subsequent Cancers After Pediatric Radiation Therapy. Adv Radiat Oncol 2023; 8:101273. [PMID: 38047226 PMCID: PMC10692298 DOI: 10.1016/j.adro.2023.101273] [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] [Received: 10/28/2022] [Accepted: 05/08/2023] [Indexed: 12/05/2023] Open
Abstract
Purpose The physical properties of protons lower doses to surrounding normal tissues compared with photons, potentially reducing acute and long-term adverse effects, including subsequent cancers. The magnitude of benefit is uncertain, however, and currently based largely on modeling studies. Despite the paucity of directly comparative data, the number of proton centers and patients are expanding exponentially. Direct studies of the potential risks and benefits are needed in children, who have the highest risk of radiation-related subsequent cancers. The Pediatric Proton and Photon Therapy Comparison Cohort aims to meet this need. Methods and Materials We are developing a record-linkage cohort of 10,000 proton and 10,000 photon therapy patients treated from 2007 to 2022 in the United States and Canada for pediatric central nervous system tumors, sarcomas, Hodgkin lymphoma, or neuroblastoma, the pediatric tumors most frequently treated with protons. Exposure assessment will be based on state-of-the-art dosimetry facilitated by collection of electronic radiation records for all eligible patients. Subsequent cancers and mortality will be ascertained by linkage to state and provincial cancer registries in the United States and Canada, respectively. The primary analysis will examine subsequent cancer risk after proton therapy compared with photon therapy, adjusting for potential confounders and accounting for competing risks. Results For the primary aim comparing overall subsequent cancer rates between proton and photon therapy, we estimated that with 10,000 patients in each treatment group there would be 80% power to detect a relative risk of 0.8 assuming a cumulative incidence of subsequent cancers of 2.5% by 15 years after diagnosis. To date, 9 institutions have joined the cohort and initiated data collection; additional centers will be added in the coming year(s). Conclusions Our findings will affect clinical practice for pediatric patients with cancer by providing the first large-scale systematic comparison of the risk of subsequent cancers from proton compared with photon therapy.
Collapse
Affiliation(s)
| | - Todd M. Gibson
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Choonsik Lee
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Paul S. Albert
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Keith T. Griffin
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Cari Meinhold Kitahara
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Danping Liu
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Matthew M. Mille
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Jungwook Shin
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Benjamin V.M. Bajaj
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Tristin E. Flood
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Sara L. Gallotto
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Harald Paganetti
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Safia K. Ahmed
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Bree R. Eaton
- Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Daniel J. Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Sarah A. Milgrom
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Joshua D. Palmer
- Department of Radiation Oncology, James Cancer Hospital at the Ohio State University Wexner Medical Center and Nationwide Children's Hospital, Columbus, Ohio
| | - Sujith Baliga
- Department of Radiation Oncology, James Cancer Hospital at the Ohio State University Wexner Medical Center and Nationwide Children's Hospital, Columbus, Ohio
| | - Matthew M. Poppe
- Department of Radiation Oncology, University of Utah–Huntsman Cancer Institute, Salt Lake City, Utah
| | - Derek S. Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Kenneth Wong
- Radiation Oncology Program, Children's Hospital Los Angeles, Los Angeles, California
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Torunn I. Yock
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
5
|
Arceo-Olaiz R, Smith EA, Stokes C, Eaton BR, Garcia-Roig M. Use of Perirectal Hyaluronic Acid Spacer Prior to Radiotherapy in a Pediatric Patient With Bladder Rhabdomyosarcoma: A Case Report. Urology 2023; 181:136-140. [PMID: 37453583 DOI: 10.1016/j.urology.2023.06.018] [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: 05/01/2023] [Revised: 06/14/2023] [Accepted: 06/19/2023] [Indexed: 07/18/2023]
Abstract
Rhabdomyosarcoma (RMS) treatment involves surgery, chemotherapy, and radiotherapy. A radioprotective space between the bladder/prostate and rectum reduces postradiation complications, as reported in adult patients. Describe pediatric preradiotherapy perirectal hyaluronic acid (HA) spacer injection for bladder/prostate RMS. We present a case of a 17-month-old male with bladder/prostate RMS. Before radiotherapy, an HA spacer was injected peri-rectally. Under general anesthesia, a transrectal ultrasound was positioned and 1mL of HA spacer was injected into the perirectal space. No complications were reported at 6-month follow-up. This is the first report of pre-radiation therapy spacer injection for pediatric bladder/prostate RMS.
Collapse
Affiliation(s)
- Ricardo Arceo-Olaiz
- Pediatric Urology Department, Emory University School of Medicine, Sandy Springs, GA; Pediatric Urology Department, Children's Healthcare of Atlanta, Atlanta, GA
| | - Edwin A Smith
- Pediatric Urology Department, Emory University School of Medicine, Sandy Springs, GA; Pediatric Urology Department, Children's Healthcare of Atlanta, Atlanta, GA
| | - Claire Stokes
- Hematology/Oncology Department, Emory University School of Medicine, Sandy Springs, GA; Hematology/Oncology Department, Children's Healthcare of Atlanta, Atlanta, GA
| | - Bree R Eaton
- Radiation Oncology Department, Emory University School of Medicine, Sandy Springs, GA
| | - Michael Garcia-Roig
- Pediatric Urology Department, Emory University School of Medicine, Sandy Springs, GA; Pediatric Urology Department, Children's Healthcare of Atlanta, Atlanta, GA.
| |
Collapse
|
6
|
Chang CW, Goette M, Kadom N, Wang Y, Wynne JF, Wang T, Liu T, Esiashvili N, Zhou J, Eaton BR, Yang X. Using Longitudinal MRI to Manage Proton Range Uncertainty for Pediatric Proton Craniospinal Irradiation. Int J Radiat Oncol Biol Phys 2023; 117:e505-e506. [PMID: 37785585 DOI: 10.1016/j.ijrobp.2023.06.1756] [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) Clinical evidence has shown that proton therapy can effectively reduce side effects for pediatric patients undergoing vertebral body-sparing craniospinal irradiation (VBS CSI), compared to conventional photon treatment modalities. However, radiation-induced growth impairment remains challenging for VBS CSI due to proton range uncertainty, compromising vertebral body sparing for growing children. Previous studies have shown that fatty marrow replacement can be observed in vertebral bodies 4-48 weeks after treatment is complete. This study aims to detect and quantify the fatty marrow replacement in vertebral bodies using longitudinal magnetic resonance (MR) to manage proton range uncertainty. MATERIALS/METHODS A prospective clinical trial of proton VBS CSI was designed, and ten pediatric patients were enrolled with prescribed doses of 15-36 Gy. The thecal sac and neural foramina were the clinical target volumes, and a Monte Carlo planning system was used to robustly optimize treatment plans with a 3.5% range margin. We analyzed patients' T1/T2 MR images acquired before, during, and after proton treatment to investigate the hematopoietic marrow transformation induced by irradiation. A metric was defined to calculate the ratio of fatty and hematopoietic marrow based on relative MR intensity histograms. We proposed a machine learning method via Gaussian fitting process (ML-GFP) to explore hidden correlations between marrow transition and radiation dose to 2 cm3 of the bone marrow (D2cc). We also leveraged this method to embed uncertainty to support potential proton range management for VBS enhancement. RESULTS The results indicated that fatty marrow replacement could be observed during inter-fractional treatment. For instance, an individual patient showed that the fatty marrow generation ratios were 0.54, 0.74, and 0.45, corresponding to 11, 18, and 65 days after the treatment started. Using ML-GFP, the fatty marrow transition was found to be quadratically correlated to treatment fractions, and the maximum transformation ranged from 40 to 50 days. Then marrow regeneration was observed due to the decrease in fatty marrow ratios. The fatty marrow ratios were also positively correlated to the D2cc doses ranging from 10 Gy to 36 Gy. Limited by insufficient low-dose data, the ML-GFP model extrapolated the data to predict the marrow transformation below 10 Gy. CONCLUSION We demonstrated the feasibility of using non-invasive longitudinal MR to quantify the fatty marrow transition from inter-fractional treatment. Based on this prospective study, the method can detect early fatty marrow generation in vertebrae caused by proton irradiation due to the conservative range margin used for robust optimization. The proposed method could be used to validate the actual proton range, allowing an accurate range margin to be defined to preserve bone marrow. Future investigation will likely focus on clinical implementation to improve life quality for pediatric CSI patients.
Collapse
Affiliation(s)
| | | | - N Kadom
- Emory University, Atlanta, GA
| | - Y Wang
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - J F Wynne
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - T Wang
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - T Liu
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - N Esiashvili
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - J Zhou
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - B R Eaton
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - X Yang
- Department of Radiation Oncology, Emory University, Atlanta, GA
| |
Collapse
|
7
|
Eaton BR, Zhou J, Wang Y, Langen KM, Esiashvili N. Prospective Feasibility Trial of Vertebral Body Sparing Pencil Beam Scanning Proton Craniospinal Irradiation in Growing Children. Int J Radiat Oncol Biol Phys 2023; 117:e510-e511. [PMID: 37785599 DOI: 10.1016/j.ijrobp.2023.06.1767] [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) Advanced proton therapy techniques now allow for delivery of craniospinal irradiation (CSI) to the entire brain and thecal sac while sparing many of the anterior vertebral bodies from doses expected to inhibit growth, though this technique has not been prospectively studied. The purpose of this trial is to test the feasibility and robustness of vertebral body sparing (VBS) CSI in children with standard image guidance, to assess the dosimetric and toxicity benefits of this approach, and to report early clinical outcomes. MATERIALS/METHODS Children 3-18 years old requiring CSI treatment were eligible for this IRB approved prospective clinical trial. The CSI clinical target volume (CTV) included the brain, entire thecal sac and neural foramina with no expansion. Select anterior vertebral bodies (AVB) could be included at the physician's discretion. The spinal portion of the CTV was treated with PA beam(s) with robust optimization (+/-3.5% range, 5mm positional uncertainty). Daily image guidance included kV/kV imaging. Cone beam CT (CBCT) was acquired weekly after final positioning and a virtual CT (vCT) was created for quality assurance (QA) analysis. Acute toxicity was prospectively assessed weekly during treatment and 1 month after per CTCAE v5.0. RESULTS Ten children with a median patient age and CSI dose of 9 years (range 3-16) and 36 Gy (RBE) (range 15-36 Gy (RBE)) were enrolled. Common diagnoses were medulloblastoma (n = 4) and non-germinomatous germ cell tumor (n = 3). Seven patients received prior chemotherapy; 2 patients were treated with palliative intent. Dose statistics for the anterior vertebral body varied according to age, CSI dose and portion of the spine, with the greatest sparing in the lower thoracic and lumbar vertebrae for all patients. Nine patients completed all QA CTs; one patient required a replan due to weight gain. For all remaining patients the treatment was highly robust: CTV V95 reduction at the C-spine, T-spine, and L-spine was 0.0±0.1%, 0.6±1.3%, and 0.8±1.1%, respectively. The highest grade non-hematologic acute toxicity was grade 2 alopecia (n = 9) and grade 2 nausea/vomiting (n = 5). One patient reported transient grade 1 esophagitis during treatment. Hematologic toxicity included >/ = grade 3 lymphopenia in 7 patients, >/ = grade 3 leukopenia in 1 patient, >/ = grade 2 anemia in 6 patients, and >/ = grade 1 thrombocytopenia in 3 patients. Median follow-up is 16.6 months (range 10-36 months). Three patients experience intracranial disease progression: 2 local and 1 distant intracranial failure. There were no failures within the spine. CONCLUSION Proton vertebral body sparing CSI targeting the thecal sac only is a highly robust treatment technique and is well tolerated. Weekly CBCT to assess changes in soft tissue posterior to the spine is recommended. Further follow-up is required to assess long-term growth outcomes.
Collapse
Affiliation(s)
- B R Eaton
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - J Zhou
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Y Wang
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - K M Langen
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - N Esiashvili
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| |
Collapse
|
8
|
Hopkins B, Qian DC, Deibert C, Boulis N, Jiang X, Kahn ST, Sudmeier LJ, Shu HKG, Eaton BR, Buchwald ZS, Zhong J. Stereotactic Radiosurgery for Trigeminal Neuralgia: A Comparison of Proximal and Distal Isocenter Outcomes. Int J Radiat Oncol Biol Phys 2023; 117:e180. [PMID: 37784802 DOI: 10.1016/j.ijrobp.2023.06.1032] [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) Trigeminal neuralgia is a chronic pain condition of the trigeminal nerve affecting 12 per 100,000 people. Stereotactic radiosurgery (SRS) delivered by both a non-invasive stereotactic radiosurgery instrument and linear accelerators (LINAC) is a non-invasive alternative to surgical approaches. Although SRS in this setting is commonly performed, there lacks a consensus and comparative data on the optimal anatomical target with the two most common targets being the dorsal root entry zone (proximal) and retrogasserian zone (distal). This study aims to evaluate treatment outcomes in patients based on these two target locations. MATERIALS/METHODS This multi-center, retrospective analysis included patients treated for trigeminal neuralgia between 2017 and 2021 with GK and LINAC-based SRS who were followed for at least 1 year. All patients received a dose of 85 Gy prescribed to the isocenter, set at the dorsal root entry zone (proximal) or the retrogasserian zone (distal). Isocenter location was based on the preference of the radiation oncologist and neurosurgeon. Patient reported clinical pain relief was recorded as full, partial, or no pain relief after SRS. Among patients with full and partial pain relief duration of pain relief was recorded. Ability to achieve full or partial medication de-escalation was also recorded. Outcomes of patients in the proximal and distal target cohort were compared using time based univariate analyses using log rank hazards model. RESULTS We identified 86 eligible patients, of whom 54 patients (63%; median age 63, 72% female) were treated using a proximal target, and 32 (37%; median age 66, 71% female) were prescribed to a distal target. In the proximal and distal cohorts, patients experienced pain relief (either partial or full relief) at a rate of 74% and 90% and full pain relief at a rate of 46% and 31%, respectively (p = 0.011). The duration of pain relief was not significantly different amongst the two groups (p = 0.18). Partial medication de-escalation was more frequent in the distal target (75%) vs proximal (33%), while full medication de-escalation was more frequent with proximal (39%) vs distal (13%), p = 0.001. CONCLUSION This study contributes to the limited data evaluating the differences in outcomes between proximal and distal targeting for treatment of trigeminal neuralgia with stereotactic radiosurgery. Overall, this study confirms that both approaches achieve a high rate of response in a difficult to control disease process. Our study suggests that a distal isocenter may be associated with higher rates of any type of pain improvement while a proximal isocenter may be associated with higher rates of complete pain relief. This data is hypothesis-generating and warrants further investigation into the effectiveness/toxicity differences of two approaches.
Collapse
Affiliation(s)
- B Hopkins
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - D C Qian
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | | | | | - X Jiang
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - S T Kahn
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - L J Sudmeier
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - H K G Shu
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - B R Eaton
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Z S Buchwald
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - J Zhong
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| |
Collapse
|
9
|
Chang CW, Goette M, Kadom N, Wang Y, Wynne J, Wang T, Liu T, Esiashvili N, Zhou J, Eaton BR, Yang X. Early in vivo Radiation Damage Quantification for Pediatric Craniospinal Irradiation Using Longitudinal MRI for Intensity Modulated Proton Therapy. Adv Radiat Oncol 2023; 8:101267. [PMID: 37408668 PMCID: PMC10318210 DOI: 10.1016/j.adro.2023.101267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 04/28/2023] [Indexed: 07/07/2023] Open
Abstract
Purpose Proton vertebral body sparing craniospinal irradiation (CSI) treats the thecal sac while avoiding the anterior vertebral bodies in an effort to reduce myelosuppression and growth inhibition. However, robust treatment planning needs to compensate for proton range uncertainty, which contributes unwanted doses within the vertebral bodies. This work aimed to develop an early in vivo radiation damage quantification method using longitudinal magnetic resonance (MR) scans to quantify the dose effect during fractionated CSI. Methods and Materials Ten pediatric patients were enrolled in a prospective clinical trial of proton vertebral body sparing CSI, in which they received 23.4 to 36 Gy. Monte Carlo robust planning was used, with spinal clinical target volumes defined as the thecal sac and neural foramina. T1/T2-weighted MR scans were acquired before, during, and after treatments to detect a transition from hematopoietic to less metabolically active fatty marrow. MR signal intensity histograms at each time point were analyzed and fitted by multi-Gaussian models to quantify radiation damage. Results Fatty marrow filtration was observed in MR images as early as the fifth fraction of treatment. Maximum radiation-induced marrow damage occurred 40 to 50 days from the treatment start, followed by marrow regeneration. The mean damage ratios were 0.23, 0.41, 0.59, and 0.54, corresponding to 10, 20, 40, and 60 days from the treatment start. Conclusions We demonstrated a noninvasive method for identifying early vertebral marrow damage based on radiation-induced fatty marrow replacement. The proposed method can be potentially used to quantify the quality of CSI vertebral sparing and preserve metabolically active hematopoietic bone marrow.
Collapse
Affiliation(s)
- Chih-Wei Chang
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Matt Goette
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Nadja Kadom
- Department of Radiology and Imaging Sciences, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Yinan Wang
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Jacob Wynne
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Tonghe Wang
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Tian Liu
- Department of Radiation Oncology, Mount Sinai Medical Center, New York, New York
| | - Natia Esiashvili
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Jun Zhou
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Bree R. Eaton
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Xiaofeng Yang
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| |
Collapse
|
10
|
Roehrig A, Indelicato DJ, Paulino AC, Ermoian R, Hartsell W, Perentesis J, Hill-Kayser C, Lee JY, Laack NN, Mangona V, MacEwan I, Eaton BR, Gallotto S, Bajaj BVM, Aridgides PD, Yock TI. Correction to: Radiotherapy for Atypical Teratoid/Rhabdoid Tumor (ATRT) on the Pediatric Proton/Photon Consortium Registry (PPCR). J Neurooncol 2023; 164:269. [PMID: 37498475 DOI: 10.1007/s11060-023-04405-4] [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: 07/28/2023]
Affiliation(s)
- Andrew Roehrig
- SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY, 13210, USA
| | | | | | | | | | - John Perentesis
- Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | | | - Jae Y Lee
- ProCure Proton Therapy Center, Princeton Radiation Oncology, Somerset, NJ, USA
| | | | | | - Iain MacEwan
- University of California San Diego, San Diego, USA
| | | | | | | | - Paul D Aridgides
- SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY, 13210, USA.
| | | |
Collapse
|
11
|
Qian DC, Sykes-Martin KD, Tobillo R, Ali N, Wynne JF, Eaton BR, Paulino AC, Kalapurakal JA, Esiashvili N. Impact of Age on Overall Survival Among Children With Wilms Tumor: A Population-based Registry Analysis. Am J Clin Oncol 2023; 46:213-218. [PMID: 36856229 DOI: 10.1097/coc.0000000000000990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
OBJECTIVES International trials have reported conflicting findings on whether the association between age and worse overall survival (OS) among children with Wilms tumor (WT) is due to age as an independent prognostic factor or the observation of more advanced disease at older ages. We sought to further elucidate this relationship using a population-based registry analysis. METHODS The Surveillance, Epidemiology, and End Results database was queried for all patients diagnosed with WT under the age of 20. The association between age and OS was assessed using multivariable Cox proportional hazards regression. RESULTS In this study, 3463 patients (54% female) were diagnosed with WT between 1975 and 2016. More advanced stage, larger primary tumor size, lymph node involvement, disease requiring radiotherapy, and omission of surgery were associated with worse OS ( P <0.05). More advanced stage, larger primary tumor size, and disease requiring radiotherapy were also associated with older age, whereas bilateral disease was associated with younger age ( P <0.001). On average, each year of age conferred an incremental hazard ratio (HR) of 1.07 (95% CI, 1.01 to 1.12, P =0.018) independent of relevant covariates. The rise in adjusted OS HR was most pronounced after the transitions in diagnosis age from 2 to 3 (HR age 3-15 vs. 0-2 1.77, 95% CI, 1.11 to 2.82, P =0.016) and from 15 to 16 (HR age 16-19 vs. 3-15 2.58, 95% CI, 1.06 to 6.25, P =0.036). CONCLUSIONS Diagnosis of pediatric WT at an older age was found to be independently associated with worse OS. Although additional prospective studies are warranted to examine tumor biology and other potential correlates, more aggressive treatment of older children based on age, especially as they approach early adulthood, may be considered in the multidisciplinary management of WT.
Collapse
Affiliation(s)
- David C Qian
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | | | - Rachel Tobillo
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Naba Ali
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Jacob F Wynne
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Bree R Eaton
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Arnold C Paulino
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - John A Kalapurakal
- Department of Radiation Oncology, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL
| | - Natia Esiashvili
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| |
Collapse
|
12
|
Sudmeier LJ, Madden N, Zhang C, Brock K, Esiashvili N, Eaton BR. Palliative radiotherapy for children: Symptom response and treatment-associated toxicity according to radiation therapy dose and fractionation. Pediatr Blood Cancer 2023; 70:e30195. [PMID: 36642970 PMCID: PMC10430237 DOI: 10.1002/pbc.30195] [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: 06/10/2022] [Revised: 11/08/2022] [Accepted: 12/19/2022] [Indexed: 01/17/2023]
Abstract
BACKGROUND/OBJECTIVES Radiotherapy is an effective palliative treatment in advanced cancer. Shorter palliative treatment courses are recommended for adults, though pediatric data addressing treatment efficacy and toxicity according to radiation therapy (RT) dose and fractionation are limited. DESIGN/METHODS Total 213 patients aged 21 years or younger receiving 422 palliative radiotherapy treatment courses from 2003 to 2016 were included. Symptom response and treatment-associated toxicity were recorded and analyzed in relationship to demographic and treatment variables. RESULTS Common diagnoses included sarcoma (32.5%), neuroblastoma (24.9%), leukemia/lymphoma (14.9%), and central nervous system tumors (10.9%). The most common indication for treatment was pain (46.7%). Patients received a median of 10 fractions, 2.5 Gy dose per fraction, and 21 Gy total dose. Number of RT fractions was five or less in 166 (39.3%), six to 10 fractions in 117 (27.2%), and 10 or more fractions in 139 (32.9%) of courses. Complete or partial pain relief was achieved in 85% (151 of 178 evaluable patients), including 77.8% receiving five or less fractions and 89.6% receiving more than five fractions. Highest toxicity was grade 1 in 159 (38.9%), grade 2 in 26 (6.4%), and grade 3 in two (0.5%) treatments. On multivariable analysis, RT delivered 30 or more days from death (OR 12.13, 95% CI: 2.13-69.2, p = .005) and no adjuvant chemotherapy (OR 0.14, 95% CI: 0.03-0.54, p = .005) were significantly associated with pain response, and five or less fractions were significantly associated with lower toxicity (OR 0.24, 95% CI: 0.06-0.97, p = .045). CONCLUSIONS Palliative RT courses of five or less fractions result in high rates of pain control and are associated with low toxicity in pediatric patients with cancer.
Collapse
Affiliation(s)
- Lisa J Sudmeier
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Nicholas Madden
- Hulston Cancer Center, CoxHealth, Springfield, Missouri, USA
| | - Chao Zhang
- Department of Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Katharine Brock
- Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Natia Esiashvili
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Bree R Eaton
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
- Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| |
Collapse
|
13
|
Roehrig A, Indelicato DJ, Paulino AC, Ermoian R, Hartsell W, Perentesis J, Hill-Kayser C, Lee JY, Laack NN, Mangona V, MacEwan I, Eaton BR, Gallotto S, Bajaj BVM, Aridgides PD, Yock TI. Radiotherapy for Atypical Teratoid/=Rhabdoid Tumor (ATRT) on the Pediatric Proton/Photon Consortium Registry (PPCR). J Neurooncol 2023; 162:353-362. [PMID: 36951945 DOI: 10.1007/s11060-023-04296-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 03/11/2023] [Indexed: 03/24/2023]
Abstract
PURPOSE Atypical teratoid/rhabdoid tumors (ATRT) of the central nervous system (CNS) are rare tumors with a poor prognosis and variable use of either focal or craniospinal (CSI) radiotherapy (RT). Outcomes on the prospective Pediatric Proton/Photon Consortium Registry (PPCR) were evaluated according to RT delivered. METHODS Pediatric patients receiving RT were prospectively enrolled on PPCR to collect initial patient, disease, and treatment factors as well as provide follow-up for patient outcomes. All ATRT patients with evaluable data were included. Kaplan-Meier analyses with log-rank p-values and cox proportional hazards regression were performed. RESULTS The PPCR ATRT cohort includes 68 evaluable ATRT patients (median age 2.6 years, range 0.71-15.40) from 2012 to 2021. Median follow-up was 40.8 months (range 3.4-107.7). Treatment included surgery (65% initial gross total resection or GTR), chemotherapy (60% with myeloablative therapy including stem cell rescue) and RT. For patients with M0 stage (n = 60), 50 (83%) had focal RT and 10 (17%) had CSI. Among patients with M + stage (n = 8), 3 had focal RT and 5 had CSI. Four-year overall survival (OS, n = 68) was 56% with no differences observed between M0 and M + stage patients (p = 0.848). Local Control (LC) at 4 years did not show a difference for lower primary dose (50-53.9 Gy) compared to ≥ 54 Gy (73.3% vs 74.7%, p = 0.83). For patients with M0 disease, four-year OS for focal RT was 54.6% and for CSI was 60% (Hazard Ratio 1.04, p = 0.95. Four-year event free survival (EFS) among M0 patients for focal RT was 45.6% and for CSI was 60% (Hazard Ratio 0.71, p = 0.519). For all patients, the 4-year OS comparing focal RT with CSI was 54.4% vs 60% respectively (p = 0.944), and the 4-year EFS for focal RT or CSI was 42.8% vs 51.4% respectively (p = 0.610). CONCLUSION The PPCR ATRT cohort found no differences in outcomes according to receipt of either higher primary dose or larger RT field (CSI). However, most patients were M0 and received focal RT. A lower primary dose (50.4 Gy), regardless of patient age, is appealing for further study as part of multi-modality therapy.
Collapse
Affiliation(s)
- Andrew Roehrig
- SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY, 13210, USA
| | | | | | | | | | - John Perentesis
- Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | | | - Jae Y Lee
- ProCure Proton Therapy Center, Princeton Radiation Oncology, Somerset NJ, USA
| | | | | | - Iain MacEwan
- University of California San Diego, San Diego, USA
| | | | | | | | - Paul D Aridgides
- SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY, 13210, USA.
| | | |
Collapse
|
14
|
Huang V, Rejimon A, Reddy K, Trivedi AG, Ramesh KK, Giuffrida AS, Muiruri R, Shim H, Eaton BR. Spectroscopic MRI-Guided Proton Therapy in Non-Enhancing Pediatric High-Grade Glioma. Tomography 2023; 9:633-646. [PMID: 36961010 PMCID: PMC10037577 DOI: 10.3390/tomography9020051] [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: 12/28/2022] [Revised: 02/24/2023] [Accepted: 03/06/2023] [Indexed: 03/12/2023] Open
Abstract
Radiation therapy (RT) is a critical part of definitive therapy for pediatric high-grade glioma (pHGG). RT is designed to treat residual tumor defined on conventional MRI (cMRI), though pHGG lesions may be ill-characterized on standard imaging. Spectroscopic MRI (sMRI) measures endogenous metabolite concentrations in the brain, and Choline (Cho)/N-acetylaspartate (NAA) ratio is a highly sensitive biomarker for metabolically active tumor. We provide a preliminary report of our study introducing a novel treatment approach of whole brain sMRI-guided proton therapy for pHGG. An observational cohort (c1 = 10 patients) receives standard of care RT; a therapeutic cohort (c2 = 15 patients) receives sMRI-guided proton RT. All patients undergo cMRI and sMRI, a high-resolution 3D whole-brain echo-planar spectroscopic imaging (EPSI) sequence (interpolated resolution of 12 µL) prior to RT and at several follow-up timepoints integrated into diagnostic scans. Treatment volumes are defined by cMRI for c1 and by cMRI and Cho/NAA ≥ 2x for c2. A longitudinal imaging database is used to quantify changes in lesion and metabolite volumes. Four subjects have been enrolled (c1 = 1/c2 = 3) with sMRI imaging follow-up of 4-18 months. Preliminary data suggest sMRI improves identification of pHGG infiltration based on abnormal metabolic activity, and using proton therapy to target sMRI-defined high-risk regions is safe and feasible.
Collapse
Affiliation(s)
- Vicki Huang
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA 30322, USA
- Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, GA 30332, USA
| | - Abinand Rejimon
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA 30322, USA
- Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, GA 30332, USA
| | - Kartik Reddy
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA 30322, USA
- Department of Radiology, Children’s Healthcare of Atlanta, Atlanta, GA 30342, USA
| | - Anuradha G. Trivedi
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA 30322, USA
- Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, GA 30332, USA
| | - Karthik K. Ramesh
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA 30322, USA
- Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, GA 30332, USA
| | - Alexander S. Giuffrida
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA 30322, USA
- Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, GA 30332, USA
| | - Robert Muiruri
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Hyunsuk Shim
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA 30322, USA
- Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, GA 30332, USA
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA 30322, USA
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Bree R. Eaton
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA 30322, USA
- Department of Radiology, Children’s Healthcare of Atlanta, Atlanta, GA 30342, USA
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA 30322, USA
| |
Collapse
|
15
|
Gondi V, Bauman G, Bradfield L, Burri SH, Cabrera AR, Cunningham DA, Eaton BR, Hattangadi-Gluth JA, Kim MM, Kotecha R, Kraemer L, Li J, Nagpal S, Rusthoven CG, Suh JH, Tomé WA, Wang TJC, Zimmer AS, Ziu M, Brown PD. Radiation Therapy for Brain Metastases: An ASTRO Clinical Practice Guideline. Pract Radiat Oncol 2022; 12:265-282. [PMID: 35534352 DOI: 10.1016/j.prro.2022.02.003] [Citation(s) in RCA: 77] [Impact Index Per Article: 38.5] [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: 02/02/2022] [Accepted: 02/07/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE This guideline provides updated evidence-based recommendations addressing recent developments in the management of patients with brain metastases, including advanced radiation therapy techniques such as stereotactic radiosurgery (SRS) and hippocampal avoidance whole brain radiation therapy and the emergence of systemic therapies with central nervous system activity. METHODS The American Society for Radiation Oncology convened a task force to address 4 key questions focused on the radiotherapeutic management of intact and resected brain metastases from nonhematologic solid tumors. The guideline is based on a systematic review provided by the Agency for Healthcare Research and Quality. Recommendations were created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength. RESULTS Strong recommendations are made for SRS for patients with limited brain metastases and Eastern Cooperative Oncology Group performance status 0 to 2. Multidisciplinary discussion with neurosurgery is conditionally recommended to consider surgical resection for all tumors causing mass effect and/or that are greater than 4 cm. For patients with symptomatic brain metastases, upfront local therapy is strongly recommended. For patients with asymptomatic brain metastases eligible for central nervous system-active systemic therapy, multidisciplinary and patient-centered decision-making to determine whether local therapy may be safely deferred is conditionally recommended. For patients with resected brain metastases, SRS is strongly recommended to improve local control. For patients with favorable prognosis and brain metastases receiving whole brain radiation therapy, hippocampal avoidance and memantine are strongly recommended. For patients with poor prognosis, early introduction of palliative care for symptom management and caregiver support are strongly recommended. CONCLUSIONS The task force has proposed recommendations to inform best clinical practices on the use of radiation therapy for brain metastases with strong emphasis on multidisciplinary care.
Collapse
Affiliation(s)
- Vinai Gondi
- Department of Radiation Oncology, Northwestern Medicine Cancer Center and Proton Center, Warrenville, Illinois.
| | - Glenn Bauman
- Division of Radiation Oncology, Department of Oncology, London Health Sciences Centre & Western University, London, Ontario, Canada
| | - Lisa Bradfield
- American Society for Radiation Oncology, Arlington, Virginia
| | - Stuart H Burri
- Department of Radiation Oncology, Atrium Health, Charlotte, North Carolina
| | - Alvin R Cabrera
- Department of Radiation Oncology, Kaiser Permanente, Seattle, Washington
| | | | - Bree R Eaton
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | | | - Michelle M Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | | | - Jing Li
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Seema Nagpal
- Division of Neuro-oncology, Department of Neurology, Stanford University, Stanford, California
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado, Aurora, Colorado
| | - John H Suh
- Department of Radiation Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio
| | - Wolfgang A Tomé
- Department of Radiation Oncology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Tony J C Wang
- Department of Radiation Oncology, Columbia University, New York, New York
| | - Alexandra S Zimmer
- Women's Malignancies Branch, National Institutes of Health/National Cancer Institute, Bethesda, Maryland
| | - Mateo Ziu
- Department of Neurosciences, INOVA Neuroscience and INOVA Schar Cancer Institute, Falls Church, Virginia
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
16
|
Janopaul-Naylor J, Voloschin AD, Patel JS, Rupji M, Hoang KB, Olson JJ, Shu HKG, Zhong J, Neill SG, Eaton BR. Impact of systemic therapy regimen on survival of PCNSL. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.2070] [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
2070 Background: Primary CNS Lymphoma (PCNSL) is a rare and often fatal disease. Treatment includes multi-agent systemic therapy with a backbone of high-dose methotrexate (HD-MTX). Despite multiple drug and radiotherapy combinations for induction and consolidation treatment there remains no clear standard of care. The purpose of this analysis is to evaluate how varying treatment approaches impacted clinical outcomes at our institution. Methods: Data retrospectively collected for 95 consecutive patients with PCNSL pathologically confirmed from 2002 to 2021. Primary endpoint was OS with secondary endpoints of PFS and LC. Progression based on RANO criteria. Kaplan-Meier analyses, Log-rank test and Cox proportional hazard models used for time to event endpoints. MVA by backward selection applying an alpha of 0.2 for associations with 1st line chemo agents, number of cycles of HD-MTX (>6 or 0-5), size of enhancing tumor at presentation, CSF cytology, type of surgery (biopsy, STR, or GTR), and use of WBRT. Results: Most patients had KPS >70 (64.2%), were HIV negative (89.5%), and had no history of solid organ transplant (95.8%). Diagnosis was made by biopsy (73.7%) or resection (GTR 13.7%, STR 12.6%). 54.3% had <14 cc contrast-enhancing tumor volume (median 12.6 cc, range 0.5 - 67.8 cc) and 48.6% had single enhancing lesion. Of the 62 patients treated first line with at least 1 cycle of HD-MTX, 61.3% were treated with HD-MTX + Rituximab (R) and 33.9% with HD-MTX + R + temozolomide (TMZ). With or after induction HD-MTX, 1-3 patients received one or a combination of cytarabine, thiotepa, procarbazine, vincristine, carmustine, or ASCT. Of the 60 patients with evaluable CSF, 30.0% had positive cytology. IT chemotherapy (ITc) was administered to 12 patients (5 with + cytology, 4 with - cytology, 3 with unknown cytology). WBRT for consolidation after chemotherapy used for 3 patients and as monotherapy for 9 patients. 2-year OS and PFS rate was 50.1% (95% CI 38.6%-60.5%) and 38.5% (95% CI 27.9%-49.0%). On MVA, > 6 cycles of MTX was associated with superior OS, PFS, and LC. For patients receiving any chemotherapy, addition of R was associated with inferior OS while ITc was associated with improved OS, PFS, and LC (Table). There was no OS association on MVA with TMZ, GTR, consolidation WBRT, or size or number of initial lesions (p>0.05). Conclusions: Completion of induction HD-MTX and use of ITc was associated with better outcomes in this population. Incorporation of R into 1st line therapy was associated with worse OS. Survival remained poor throughout the study period, underscoring importance of further innovation. [Table: see text]
Collapse
Affiliation(s)
- James Janopaul-Naylor
- Department of Radiation Oncology at Winship Cancer Institute at Emory University, Atlanta, GA
| | | | - Jimmy S Patel
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA
| | - Manali Rupji
- Winship Cancer Institute, Emory University, Atlanta, GA
| | - Kimberly B. Hoang
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA
| | - Jeffrey J. Olson
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA
| | - Hui-Kuo George Shu
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Jim Zhong
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Stewart G. Neill
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | - Bree R. Eaton
- Winship Cancer Institute of Emory University, Atlanta, GA
| |
Collapse
|
17
|
Ramesh K, Mellon EA, Gurbani SS, Weinberg BD, Schreibmann E, Sheriff SA, Goryawala M, de le Fuente M, Eaton BR, Zhong J, Voloschin AD, Sengupta S, Dunbar EM, Holdhoff M, Barker PB, Maudsley AA, Kleinberg LR, Shim H, Shu HKG. A multi-institutional pilot clinical trial of spectroscopic MRI-guided radiation dose escalation for newly diagnosed glioblastoma. Neurooncol Adv 2022; 4:vdac006. [PMID: 35382436 PMCID: PMC8976280 DOI: 10.1093/noajnl/vdac006] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background Glioblastomas (GBMs) are aggressive brain tumors despite radiation therapy (RT) to 60 Gy and temozolomide (TMZ). Spectroscopic magnetic resonance imaging (sMRI), which measures levels of specific brain metabolites, can delineate regions at high risk for GBM recurrence not visualized on contrast-enhanced (CE) MRI. We conducted a clinical trial to assess the feasibility, safety, and efficacy of sMRI-guided RT dose escalation to 75 Gy for newly diagnosed GBMs. Methods Our pilot trial (NCT03137888) enrolled patients at 3 institutions (Emory University, University of Miami, Johns Hopkins University) from September 2017 to June 2019. For RT, standard tumor volumes based on T2-FLAIR and T1w-CE MRIs with margins were treated in 30 fractions to 50.1 and 60 Gy, respectively. An additional high-risk volume based on residual CE tumor and Cho/NAA (on sMRI) ≥2× normal was treated to 75 Gy. Survival curves were generated by the Kaplan-Meier method. Toxicities were assessed according to CTCAE v4.0. Results Thirty patients were treated in the study. The median age was 59 years. 30% were MGMT promoter hypermethylated; 7% harbored IDH1 mutation. With a median follow-up of 21.4 months for censored patients, median overall survival (OS) and progression-free survival were 23.0 and 16.6 months, respectively. This regimen appeared well-tolerated with 70% of grade 3 or greater toxicity ascribed to TMZ and 23% occurring at least 1 year after RT. Conclusion Dose-escalated RT to 75 Gy guided by sMRI appears feasible and safe for patients with newly diagnosed GBMs. OS outcome is promising and warrants additional testing. Based on these results, a randomized phase II trial is in development.
Collapse
Affiliation(s)
- Karthik Ramesh
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia, USA,Department of Biomedical Engineering, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Eric A Mellon
- Department of Radiation Oncology, University of Miami, Miami, Florida, USA
| | - Saumya S Gurbani
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia, USA,Department of Biomedical Engineering, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Brent D Weinberg
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA,Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Eduard Schreibmann
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | | | | | - Bree R Eaton
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jim Zhong
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Alfredo D Voloschin
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Soma Sengupta
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia, USA,Present affiliation: Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | | | - Matthias Holdhoff
- Department of Oncology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Peter B Barker
- Department of Radiology and Radiological Science, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Lawrence R Kleinberg
- Department of Radiation Oncology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Hyunsuk Shim
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia, USA,Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA,Department of Biomedical Engineering, Emory University School of Medicine, Atlanta, Georgia, USA,Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia, USA,Corresponding Authors: Hyunsuk Shim, PhD and Hui-Kuo G. Shu, MD, PhD, Department of Radiation Oncology, Winship Cancer Institute of Emory University, 1701 Uppergate Drive, Atlanta, GA 30322, USA (. )
| | - Hui-Kuo G Shu
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia, USA,Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| |
Collapse
|
18
|
Bray DP, Quillin JW, Press RH, Yang Y, Chen Z, Eaton BR, Olson JJ. Adjuvant Radiotherapy Versus Watchful Waiting for World Health Organization Grade II Atypical Meningioma: A Single-Institution Experience. Neurosurgery 2021. [DOI: 10.1093/neuros/nyaa580_s124] [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: 11/13/2022] Open
|
19
|
Janopaul-Naylor J, Kanter KR, Flampouri S, Nguyen V, Olson TA, Eaton BR. Adjuvant chemoradiation for high-grade cardiac leiomyosarcoma in a child: Case report and review of literature. Pediatr Blood Cancer 2021; 68:e29241. [PMID: 34260156 DOI: 10.1002/pbc.29241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/02/2021] [Accepted: 07/05/2021] [Indexed: 11/09/2022]
Abstract
A 13-year-old healthy girl presented with dizziness and palpitations, found to have a left atrial mass. An 8-cm tumor was removed en bloc. Pathology confirmed grade 3 leiomyosarcoma with multifocal positive margins. She received adjuvant ifosfamide and doxorubicin, followed by concurrent proton radiotherapy and ifosfamide. Radiotherapy included 66 Gy (RBE) in 33 fractions to the operative bed. Prospectively graded toxicities included Grade 2 esophagitis and Grade 1 anorexia, dermatitis, and fatigue. She completed six cycles of ifosfamide. Two years post operation, she had no evidence of disease, intermittent palpitations with normal cardiac function, and no other cardiopulmonary or esophageal symptoms.
Collapse
Affiliation(s)
- James Janopaul-Naylor
- Department of Radiation Oncology, Winship Cancer Institute at Emory University, Atlanta, Georgia, USA
| | - Kirk R Kanter
- Pediatric Cardiac Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Stella Flampouri
- Department of Radiation Oncology, Winship Cancer Institute at Emory University, Atlanta, Georgia, USA
| | - Vivi Nguyen
- Department of Radiation Oncology, Winship Cancer Institute at Emory University, Atlanta, Georgia, USA
| | - Thomas A Olson
- Department of Pediatric Hematology and Oncology, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Bree R Eaton
- Department of Radiation Oncology, Winship Cancer Institute at Emory University, Atlanta, Georgia, USA
| |
Collapse
|
20
|
Bray DP, Buster BE, Quillin JW, Press RH, Eaton BR, Olson JJ. Adjuvant Radiotherapy in Grade II, Atypical Meningioma of the Skull Base. J Neurol Surg B Skull Base 2021; 83:418-422. [DOI: 10.1055/s-0041-1735879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 08/12/2021] [Indexed: 10/20/2022] Open
Abstract
Abstract
Introduction Atypical meningiomas (AM) are meningiomas that are more aggressive than their grade-I counterparts and have a higher rate of recurrence. The effect of adjuvant radiotherapy (ART) on AM of the skull base is not defined.
Methods A retrospective review of all AM's of the skull base primarily resected at our institution from 1996 to 2018 was completed. ART was defined as radiotherapy (RT) that occurred within 6 months of initial resection, regardless of Simpson's grade. Minimum time length of follow-up after resection was 2 years. Statistical analysis was performed using SAS.
Results There were a total of 59 skull base–located (SBL) AMs resected at our institution from 1996 to 2018. The average age of our cohort was 53.2 years. Gross total resection, defined as Simpson's grades I to III resection, was achieved in 36 (61%) of cases. Thirty-five of 59 (59%) patients received ART. Recurrence was observed in 14 patients (24%), and mean time to recurrence was 63.8 months. Patients who received ART had a lower observed rate of recurrence (8 vs. 46%); however, time to recurrence was not significantly different between the two populations.
Conclusion We observe that AM in the skull base location have higher recurrence rates than we would expect from grade-I meningioma. These data suggest that ART may offer benefit to the overall observed frequency of recurrence of SBL AM; however, the time to recurrence between patients who received ART and those who did not was not statistically significant in survival analysis.
Collapse
Affiliation(s)
- David P. Bray
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Bryan E. Buster
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Joseph W. Quillin
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, United States
| | | | - Bree R. Eaton
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Jeffrey J. Olson
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, United States
| |
Collapse
|
21
|
Avutu V, Weiss AR, Reed DR, Ahmed SK, Allen-Rhoades WA, Chen YLE, Davis LE, Eaton BR, Hawkins DS, Indelicato DJ, Patel SR, Randall RL, Reinke DK, Riedel RF, Scharschmidt TJ, Thornton KA, Wang D, Janeway KA, Kopp LM. Identified Enrollment Challenges of Adolescent and Young Adult Patients on the Nonchemotherapy Arm of Children's Oncology Group Study ARST1321. J Adolesc Young Adult Oncol 2021; 11:328-332. [PMID: 34515544 DOI: 10.1089/jayao.2021.0103] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
ARST1321, a trial of patients with advanced soft tissue sarcoma, was the first National Clinical Trials Network study codeveloped by pediatric and adult consortia with two treatment cohorts. We report on the findings of a survey to identify barriers to enrolling adolescent and young adult patients (15-39 years) onto the nonchemotherapy arm. The survey response rate was 31% with a 70% completion rate. Common identified reasons for low accrual in order of decreasing frequency included insufficient funding, lack of study awareness or interest, competing trials, toxicity concerns, philosophical differences in the therapy backbone, and regulatory and infrastructure barriers. Clinical Trials.gov ID: NCT02180867.
Collapse
Affiliation(s)
- Viswatej Avutu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Aaron R Weiss
- Department of Pediatrics, Maine Medical Center, Portland, Maine, USA
| | - Damon R Reed
- Department of Individualized Cancer Management, Moffitt Cancer Center, Tampa, Florida, USA
| | - Safia K Ahmed
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Wendy A Allen-Rhoades
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Yen-Lin E Chen
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lara E Davis
- Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Bree R Eaton
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Douglas S Hawkins
- Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington, USA
| | - Danny J Indelicato
- Department of Radiation Oncology, University of Florida, Jacksonville, Florida, USA
| | - Shreyaskumar R Patel
- Department of Medicine, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - R Lor Randall
- Department of Orthopaedic Surgery, UC Davis Health, Sacramento, California, USA
| | - Denise K Reinke
- Sarcoma Alliance for Research through Collaboration, Ann Arbor, Michigan, USA
| | - Richard F Riedel
- Department of Medicine, Duke Cancer Institute, Durham, North Carolina, USA
| | - Thomas J Scharschmidt
- Department of Orthopaedic Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Katherine A Thornton
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Dian Wang
- Department of Radiation Oncology, Rush University Medical Center, Chicago, Illinois, USA
| | - Katherine A Janeway
- Department of Pediatrics, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Lisa M Kopp
- Department of Epidemiology and Biostatistics, University of Arizona, Tucson, Arizona, USA
| |
Collapse
|
22
|
Bray DP, Quillin JW, Press RH, Yang Y, Chen Z, Eaton BR, Olson JJ. In Reply: Adjuvant Radiotherapy Versus Watchful Waiting for World Health Organization Grade II Atypical Meningioma: A Single-Institution Experience. Neurosurgery 2021; 89:E279-E280. [PMID: 34382655 DOI: 10.1093/neuros/nyab290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 06/27/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- David P Bray
- Department of Neurosurgery Emory University School of Medicine Atlanta, Georgia, USA
| | - Joseph W Quillin
- Department of Neurosurgery Emory University School of Medicine Atlanta, Georgia, USA
| | - Robert H Press
- Department of Radiation Oncology Emory University School of Medicine Atlanta, Georgia, USA
| | - Yilin Yang
- Winship Cancer Institute Department of Bioinformatics and Biostatistics Emory University School of Medicine Atlanta, Georgia, USA
| | - Zhengjia Chen
- Winship Cancer Institute Department of Bioinformatics and Biostatistics Emory University School of Medicine Atlanta, Georgia, USA
| | - Bree R Eaton
- Department of Radiation Oncology Emory University School of Medicine Atlanta, Georgia, USA
| | - Jeffrey J Olson
- Department of Neurosurgery Emory University School of Medicine Atlanta, Georgia, USA
| |
Collapse
|
23
|
Eaton BR, Fong GW, Ingerski LM, Pulsifer MB, Goyal S, Zhang C, Weyman EA, Esiashvili N, Klosky JL, MacDonald TJ, Ebb DH, MacDonald SM, Tarbell NJ, Yock TI. Intellectual functioning among case-matched cohorts of children treated with proton or photon radiation for standard-risk medulloblastoma. Cancer 2021; 127:3840-3846. [PMID: 34255345 DOI: 10.1002/cncr.33774] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 05/20/2021] [Accepted: 05/24/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Proton therapy may reduce cognitive deficits after radiotherapy among brain tumor survivors, although current data are limited to retrospective comparisons between historical cohorts. The authors compared intelligence quotient scores within a case-matched cohort of children with medulloblastoma treated with proton radiation (PRT) or photon radiation (XRT) over the same time period. METHODS Among 88 consecutive patients with standard-risk medulloblastoma treated with PRT or XRT at 2 institutions from 2000 to 2009, 50 were matched 1:1 (25 with PRT and 25 with XRT) according to age, gender, date of diagnosis, histology, radiation boost, and craniospinal irradiation dose. One-way analyses of variance were performed to compare the Full-Scale Intelligence Quotient (FSIQ) and associated index scores between the 2 cohorts. RESULTS Neurocognitive data were available for 37 survivors (17 with PRT and 20 with XRT) from the matched cohort. The mean age was 8.5 years (SD, 4.14 years). The median follow-up was 5.3 years (range, 1.0-11.4 years) and 4.6 years (range, 1.1-11.2 years) for the PRT and XRT cohorts, respectively (P = .193). Patients treated with PRT had significantly higher mean FSIQ (99.6 vs 86.2; P = .021), verbal (105.2 vs 88.6; P = .010), and nonverbal scores (103.1 vs 88.9; P = .011) than the XRT-treated cohort. Differences in processing speed (82.9 vs 77.2; P = .331) and working memory (97.0 vs 92.7; P = .388) were not statistically significant. CONCLUSIONS Radiotherapy-associated cognitive effects appear to be more attenuated after proton therapy. Comprehensive prospective studies are needed to appropriately evaluate the neurocognitive advantages of proton therapy.
Collapse
Affiliation(s)
- Bree R Eaton
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Grace W Fong
- Department of Psychology, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Lisa M Ingerski
- Department of Pediatrics, Emory University, Atlanta, Georgia.,Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Margaret B Pulsifer
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Subir Goyal
- Department of Biostatistics and Bioinformatics, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Chao Zhang
- Department of Biostatistics and Bioinformatics, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Elizabeth A Weyman
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Natia Esiashvili
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - James L Klosky
- Department of Pediatrics, Emory University, Atlanta, Georgia.,Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Tobey J MacDonald
- Department of Pediatrics, Emory University, Atlanta, Georgia.,Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - David H Ebb
- Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts
| | - Shannon M MacDonald
- Department of Biostatistics and Bioinformatics, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Nancy J Tarbell
- Department of Biostatistics and Bioinformatics, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Torunn I Yock
- Department of Biostatistics and Bioinformatics, Winship Cancer Institute, Emory University, Atlanta, Georgia
| |
Collapse
|
24
|
Bray DP, Quillin JW, Press RH, Yang Y, Chen Z, Eaton BR, Olson JJ. Adjuvant Radiotherapy Versus Watchful Waiting for World Health Organization Grade II Atypical Meningioma: A Single-Institution Experience. Neurosurgery 2021; 88:E435-E442. [PMID: 33582821 DOI: 10.1093/neuros/nyaa580] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [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: 01/28/2020] [Accepted: 11/04/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Atypical meningiomas (AMs) are meningiomas that have a higher rate of recurrence than grade I meningioma. Due to the higher risk of recurrence, adjuvant radiotherapy (RT) after resection of AM has been employed. At our institution, some neurosurgeons employ adjuvant RT on all primarily resected AMs, while others employ watchful waiting with serial imaging. OBJECTIVE To study the effect of adjuvant RT on newly resected AMs. METHODS A retrospective review of all AMs primarily resected at our institution from 1996 to 2018 was completed. Data on patient demographics, radiographic findings, use of adjuvant RT, time of follow-up, and recurrences were collected. Adjuvant RT was defined as RT that occurred within 6 mo of initial resection. RESULTS A total of 162 patients met the inclusion criteria. Gross total resection was achieved in 73% of cases. Average time until recurrence in the cohort was 37 mo. A total of 108 patients had adjuvant RT, while 54 patients did not. On multivariate survival analysis, sex, Simpson grade resection, and use of adjuvant RT were independent predictors of recurrence. Mean time to recurrence in patients who received adjuvant RT was 43.7 mo versus 34.7 mo for those who did not receive adjuvant RT. CONCLUSION This study includes the largest retrospective cohort of patients who have received adjuvant RT after primary resection of AM. Our results suggest that the use of adjuvant RT is independently associated with a lower chance of recurrence. These data suggest that practitioners can consider the use of adjuvant RT for newly resected AMs, regardless of Simpson grade resection.
Collapse
Affiliation(s)
- David P Bray
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Joseph W Quillin
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Robert H Press
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Yilin Yang
- Winship Cancer Institute, Department of Bioinformatics and Biostatistics, Emory University Medical Center, Atlanta, Georgia
| | - Zhengjia Chen
- Winship Cancer Institute, Department of Bioinformatics and Biostatistics, Emory University Medical Center, Atlanta, Georgia
| | - Bree R Eaton
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Jeffrey J Olson
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| |
Collapse
|
25
|
Bray DP, Quillin JW, Press RH, Yang Y, Chen Z, Eaton BR, Olson JJ. Letter: Commentary: Adjuvant Radiotherapy Versus Watchful Waiting for World Health Organization Grade II Atypical Meningioma: A Single-Institution Experience. Neurosurgery 2021; 89:E174-E175. [PMID: 34089326 DOI: 10.1093/neuros/nyab204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 04/24/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- David P Bray
- Department of Neurosurgery Emory University School of Medicine Atlanta, Georgia, USA
| | - Joseph W Quillin
- Department of Neurosurgery Emory University School of Medicine Atlanta, Georgia, USA
| | - Robert H Press
- Department of Radiation Oncology Emory University School of Medicine Atlanta, Georgia, USA
| | - Yilin Yang
- Winship Cancer Institute Department of Bioinformatics and Biostatistics Emory University School of Medicine Atlanta, Georgia, USA
| | - Zhengjia Chen
- Winship Cancer Institute Department of Bioinformatics and Biostatistics Emory University School of Medicine Atlanta, Georgia, USA
| | - Bree R Eaton
- Department of Radiation Oncology Emory University School of Medicine Atlanta, Georgia, USA
| | - Jeffrey J Olson
- Department of Neurosurgery Emory University School of Medicine Atlanta, Georgia, USA
| |
Collapse
|
26
|
S. Johnson T, Pacholczyk R, Aguilera D, Al-Basheer A, Bajaj M, Berrong Z, Castellino RC, Eaton BR, Esiashvili N, Foreman N, Heger IM, Kennedy EP, Martin W, Ring E, Sadek RF, Smith A, Smith C, Vaizer R, MacDonald TJ, Munn DH. IMMU-04. FIRST-IN-CHILDREN PHASE 1B STUDY USING THE IDO PATHWAY INHIBITOR INDOXIMOD IN COMBINATION WITH RADIATION AND CHEMOTHERAPY FOR CHILDREN WITH NEWLY DIAGNOSED DIPG (NCT02502708, NLG2105). Neuro Oncol 2021. [DOI: 10.1093/neuonc/noab090.112] [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: 11/13/2022] Open
Abstract
Abstract
Background
Diffuse intrinsic pontine glioma (DIPG) is a uniformly fatal brain tumor with no available cure. Indoximod blocks the IDO (indoleamine 2,3-dioxygenase) pathway, thereby reversing IDO-mediated immune suppression in the tumor microenvironment.
Methods
Patients aged 3 to 21 years with treatment-naive DIPG were eligible for this phase 1b dose-confirmation study of indoximod. The treatment regimen comprised continuous oral indoximod (38.4 mg/kg/day divided twice daily) with conformal photon radiation (54 Gy in 30 fractions), followed by cycles of indoximod with temozolomide (200 mg/m2/day, days 1–5 in 28-day cycles).
Results
Thirteen patients (median age 9 years, range 5 to 20 years) with DIPG were treated. Median OS was 14.5 months (follow-up ranged 4.8 to 29.3 months), 12-month OS was 61.5% (8/13), and 18-month OS was 30.8% (4/13), with 1 patient remaining in follow-up at the data cutoff. This compared favorably to expected median OS of approximately 10.8 months, 12-month OS of 45.3%, and 18-month OS of 16.2% taken from published historical data from the Pediatric Brain Tumor Consortium. Two patients showed near-complete responses lasting until relapsing after 7.6 months and 13.3 months of study therapy, respectively. Many patients had increased circulating non-classical monocytes (nc-Monos, CD16+, CD14neg, CD33+, HLA-DR+) within the first 3 treatment cycles, and elevation of this early pharmacodynamic marker was predictive of subsequent OS. Patients with nc-Monos >10% (n=7) had median OS of 19 months, whereas patients with nc-Monos below 10% (n=5) had median OS of 7 months (p=0.0047). No patients stopped therapy for toxicity. The most common indoximod-attributed adverse events were thrombocytopenia, neutropenia, nausea, vomiting, dizziness, and fatigue.
Conclusions
Adding indoximod immunotherapy to conventional radiation and chemotherapy for front-line treatment of pediatric patients with DIPG was well-tolerated. Improved outcomes were observed in patients having evidence of pharmacodynamic response. A follow-on phase 2 study is in progress (NCT04049669).
Collapse
Affiliation(s)
- Theodore S. Johnson
- Georgia Cancer Center, Augusta University, Augusta, GA, USA
- Department of Pediatrics, Augusta University, Augusta, GA, USA
| | | | - Dolly Aguilera
- Aflac Cancer & Blood Disorders Center at Children’s Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, GA, USA
| | - Ahmad Al-Basheer
- Georgia Cancer Center, Augusta University, Augusta, GA, USA
- Department of Radiation Oncology, Augusta University, Augusta, GA, USA
| | - Manish Bajaj
- Georgia Cancer Center, Augusta University, Augusta, GA, USA
- Department of Radiology, Augusta University, Augusta, GA, USA
| | - Zuzana Berrong
- Georgia Cancer Center, Augusta University, Augusta, GA, USA
| | - Robert C Castellino
- Aflac Cancer & Blood Disorders Center at Children’s Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, GA, USA
| | - Bree R Eaton
- Department of Radiation Oncology and Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Natia Esiashvili
- Department of Radiation Oncology and Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Nicholas Foreman
- Department of Pediatrics, Children’s Hospital Colorado, Aurora, CO, USA
| | - Ian M Heger
- Pediatric Neurosurgery Program, Medical City Children’s Hospital, Dallas, TX, USA
| | - Eugene P Kennedy
- Lumos Pharma (formerly NewLink Genetics Corporation), Ames, IA, USA
| | - William Martin
- Department of Radiation Oncology, Augusta University, Augusta, GA, USA
| | - Eric Ring
- Georgia Cancer Center, Augusta University, Augusta, GA, USA
- Department of Pediatrics, Augusta University, Augusta, GA, USA
| | - Ramses F Sadek
- Georgia Cancer Center, Augusta University, Augusta, GA, USA
- Department of Population Health Sciences, Augusta University, Augusta, GA, USA
| | - Amy Smith
- Department of Pediatrics, Arnold Palmer Hospital for Children, Orlando, FL, USA
| | - Chris Smith
- Lumos Pharma (formerly NewLink Genetics Corporation), Ames, IA, USA
| | - Rachel Vaizer
- Georgia Cancer Center, Augusta University, Augusta, GA, USA
- Department of Pediatrics, Augusta University, Augusta, GA, USA
| | - Tobey J MacDonald
- Aflac Cancer & Blood Disorders Center at Children’s Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, GA, USA
| | - David H Munn
- Georgia Cancer Center, Augusta University, Augusta, GA, USA
- Department of Pediatrics, Augusta University, Augusta, GA, USA
| |
Collapse
|
27
|
Qian DC, Marascio JA, Neill SG, Hoang KB, Olson JJ, Eaton BR, Shu HKG, Zhong J. Gene expression signature to predict radiation response in lower-grade gliomas. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.2019] [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
2019 Background: Standard of care for lower-grade glioma (LGG) is maximal safe resection and risk-adaptive adjuvant therapy. While patients who benefit the most from adjuvant chemotherapy have been elucidated in prospective randomized studies, comparable insights for adjuvant radiotherapy (RT) are lacking. We sought to identify and validate patterns of gene expression that are associated with differential outcomes among LGG patients treated by RT from two large genomics databases. Methods: Patients from The Cancer Genome Atlas (TCGA) with LGG (WHO grade II–III gliomas) treated by surgery and adjuvant RT were randomized 1:1 to a training set or an internal validation set. Using patients in the training set, association between gene expression from resected tumor and progression-free survival (PFS) as well as overall survival (OS) was evaluated with adjustment for clinicopathologic covariates. A genomic risk score (GRS) was then constructed from the expression levels of top genes also screened for involvement in glioma carcinogenesis. The prognostic value of GRS was subsequently validated in the internal validation set of TCGA and a second distinct database, compiled by the Chinese Glioma Genome Association (CGGA). Results: From TCGA, 289 patients with LGG received adjuvant RT alone (38 grade II, 30 grade III) or chemoradiotherapy (CRT) (51 grade II, 170 grade III) between 2009 and 2015. From CGGA, 178 patients with LGG received adjuvant RT alone (40 grade II, 13 grade III) or CRT (41 grade II, 84 grade III) between 2004 and 2016. The genes comprising GRS are MAP3K15, MAPK10, CCL3, CCL4, and ADAMTS1, involved in MAP kinase activity, T cell chemotaxis, and cell cycle transition. High GRS, defined as having a GRS in the top third, was significantly associated with worse outcomes independent of age, sex, glioma histology, WHO grade, IDH mutation, 1p/19q co-deletion, and chemotherapy status in the training set (OS HR 2.74, P < 0.001; PFS HR 1.61, P = 0.014). These findings were further validated in the internal validation set (OS HR 1.84, P = 0.015; PFS HR 1.58, P = 0.027) and again in the CGGA external validation set (OS HR 1.72, P = 0.001). Association between GRS and outcomes was observed only among patients who received RT (RT alone or CRT), in both TCGA and CGGA. Conclusions: This study successfully identified an expression signature of five genes that stratified outcomes among LGG patients who received adjuvant RT, with two rounds of validation leveraging independent genomics databases. Expression levels of the highlighted genes were associated with survival only among patients whose treatments included RT, but not among those with omission of RT, suggesting that expression of these genes may be predictive of radiation treatment response. While additional prospective studies are warranted, interrogation of these genes to determine high/low GRS may be considered in the multidisciplinary management of LGGs.
Collapse
Affiliation(s)
- David C Qian
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Joseph A. Marascio
- Section of Radiation Oncology, Veterans Affairs Medical Center, Atlanta, GA
| | - Stewart G. Neill
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | - Kimberly B. Hoang
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA
| | - Jeffrey J. Olson
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA
| | - Bree R. Eaton
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Hui-Kuo George Shu
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Jim Zhong
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| |
Collapse
|
28
|
Eaton BR, Schwarz R, Vatner R, Yeh B, Claude L, Indelicato DJ, Laack N. Osteosarcoma. Pediatr Blood Cancer 2021; 68 Suppl 2:e28352. [PMID: 32779875 DOI: 10.1002/pbc.28352] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 04/06/2020] [Accepted: 04/07/2020] [Indexed: 12/19/2022]
Abstract
Osteosarcoma is a rare tumor that requires complex multidisciplinary management. This paper reviews the general management and standard radiotherapy guidelines for osteosarcoma in both North America and Europe in a joined effort between the Children's Oncology Group and International Society of Pediatric Oncology. Standard treatment involves multiagent induction chemotherapy followed by surgical resection for local tumor control and consolidation local control to metastatic sites. Radiotherapy is reserved for cases with a marginal or incomplete resection or for definitive treatment in the case of unresectable disease. We present supporting data for the role of chemotherapy, surgery, and radiation therapy.
Collapse
Affiliation(s)
- Bree R Eaton
- Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Rudolf Schwarz
- Radiotherapy and Radiooncology, Outpatient Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ralph Vatner
- Radiation Oncology, University of Cincinnati, Cincinnati, Ohio
| | - Brian Yeh
- Radiation Oncology, Mount Sinai Hospital, New York, New York
| | - Line Claude
- Radiation Oncology, Centre Léon Bérard, Lyon, France
| | - Daniel J Indelicato
- Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Nadia Laack
- Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
29
|
Eaton BR, Claude L, Indelicato DJ, Vatner R, Yeh B, Schwarz R, Laack N. Ewing sarcoma. Pediatr Blood Cancer 2021; 68 Suppl 2:e28355. [PMID: 33818887 DOI: 10.1002/pbc.28355] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 04/06/2020] [Accepted: 04/07/2020] [Indexed: 12/27/2022]
Abstract
Ewing sarcoma is a rare tumor that requires complex multidisciplinary management. This report describes the general management and standard radiotherapy guidelines in both North America (Children's Oncology Group) and Europe (International Society of Pediatric Oncology). Standard treatment involves multiagent induction chemotherapy followed by local treatment with surgery, definitive radiation, or a combination of surgery and radiation followed by additional chemotherapy and consolidation local treatment to metastatic sites. The data supporting the role of chemotherapy, surgery, and radiation and specific radiation therapy guidelines are presented.
Collapse
Affiliation(s)
- Bree R Eaton
- Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Line Claude
- Radiation Oncology, Centre Léon Bérard, Lyon, France
| | - Daniel J Indelicato
- Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Ralph Vatner
- Radiation Oncology, University of Cincinnati, Cincinnati, Ohio
| | - Brian Yeh
- Radiation Oncology, Mount Sinai Hospital, New York, New York
| | - Rudolf Schwarz
- Radiotherapy and Radiooncology, Outpatient Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nadia Laack
- Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
30
|
Eaton BR, Goldberg S, Tarbell NJ, Lawell MP, Gallotto SL, Weyman EA, Kuhlthau KA, Ebb DH, MacDonald SM, Yock TI. Long-term health-related quality of life in pediatric brain tumor survivors receiving proton radiotherapy at <4 years of age. Neuro Oncol 2021; 22:1379-1387. [PMID: 32064512 DOI: 10.1093/neuonc/noaa042] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The purpose of this analysis is to report long-term health-related quality of life (HRQoL) among brain tumor survivors treated with proton therapy (PRT) at a very young age. METHODS Fifty-nine children <4 years old received PRT between 2000 and 2011. Forty families participated. HRQoL was assessed by child self-report (CSR; age ≥5) and parent proxy report (PPR; age 2+) using the PedsQL Core. RESULTS The median age was 2.5 years (range, 0.3-3.8) at PRT and 9.1 years (5.5-18) at last follow-up. The most common diagnoses were ependymoma (n = 22) and medulloblastoma (n = 7). Median follow-up is 6.7 years (3-15.4). Follow-up mean CSR and PPR scores were: total core (78.4 and 72.9), physical (82.9 and 75.2), psychosocial (76.0 and 71.6), emotional (74.4 and 70.7), social (81.2 and 75.1), and school (72.4 and 69.9). Parent-reported HRQoL fell within a previously defined range for healthy children in 37.5% of patients, and for children with severe health conditions in 45% of patients. PPR HRQoL was stable from baseline to last follow-up among all domains except for social functioning. History of gastrostomy tube was significantly associated with poorer CSR and PPR HRQoL on multivariable analysis. Ninety percent of children functioned in a regular classroom, 14 (36%) used a classroom aid, 9 (23%) used an outside tutor, and 18 (46%) had an individualized education plan. CONCLUSION Long-term HRQoL among brain tumor survivors treated with PRT at a very young age is variable, with over a third achieving HRQoL levels commensurate with healthy children. KEY POINTS 1. One third of survivors reported long-term HRQoL scores comparable to those of healthy children.2. Treatment for hydrocephalus or a feeding tube was associated with significantly lower HRQoL.3. Total core HRQoL scores remained stable from baseline to last follow-up.
Collapse
Affiliation(s)
- Bree R Eaton
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Saveli Goldberg
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Nancy J Tarbell
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Miranda P Lawell
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Sara L Gallotto
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Elizabeth A Weyman
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Karen A Kuhlthau
- Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts
| | - David H Ebb
- Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Torunn I Yock
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
31
|
Affiliation(s)
- Bree R Eaton
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Torunn I Yock
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
32
|
Press RH, Shafer SL, Jiang R, Buchwald ZS, Abugideiri M, Tian S, Morgan TM, Behera M, Sengupta S, Voloschin AD, Olson JJ, Hasan S, Blumenthal DT, Curran WJ, Eaton BR, Shu HKG, Zhong J. Optimal timing of chemoradiotherapy after surgical resection of glioblastoma: Stratification by validated prognostic classification. Cancer 2020; 126:3255-3264. [PMID: 32342992 DOI: 10.1002/cncr.32797] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 01/10/2020] [Accepted: 01/21/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Previous studies examining the time to initiate chemoradiation (CRT) after surgical resection of glioblastoma have been conflicting. To better define the effect that the timing of adjuvant treatment may have on outcomes, the authors examined patients within the National Cancer Database (NCDB) stratified by a validated prognostic classification system. METHODS Patients with glioblastoma in the NCDB who underwent surgery and CRT from 2004 through 2013 were analyzed. Radiation Therapy Oncology Group recursive partitioning analysis (RPA) class (III, IV, V) was extrapolated for the cohort. Time intervals were grouped weekly, with weeks 4 to 5 serving as the reference category for analyses. Kaplan-Meier analysis, log-rank testing, and multivariate (MVA) Cox proportional hazards regression were performed. RESULTS In total, 30,414 patients were included. RPA classes III, IV, and V contained 5250, 20,855, and 4309 patients, respectively. On MVA, no time point after week 5 was associated with a change in overall survival for the entire cohort or for any RPA class subgroup. The periods of weeks 0 to 1 (hazard ratio [HR], 1.18; 95% CI, 1.02-1.36), >1 to 2 (HR, 1.23; 95% CI, 1.16-1.31), and >2 to 3 (HR, 1.11; 95% CI, 1.07-1.15) demonstrated slightly worse overall survival (all P < .03). The detriment to early initiation was consistent across each RPA class subgroup. CONCLUSIONS The current data provide insight into the optimal timing of CRT in patients with glioblastoma and describe RPA class-specific outcomes. In general, short delays beyond 5 weeks did not negatively affect outcomes, whereas early initiation before 3 weeks may be detrimental.
Collapse
Affiliation(s)
- Robert H Press
- Department of Radiation Oncology, New York Proton Center, New York, New York
| | - Sarah L Shafer
- Winship Research Informatics, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Renjian Jiang
- Winship Research Informatics, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Zachary S Buchwald
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Mustafa Abugideiri
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Sibo Tian
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Tiffany M Morgan
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Madhusmita Behera
- Winship Research Informatics, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Soma Sengupta
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Alfredo D Voloschin
- Department of Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Jeffrey J Olson
- Department of Neurosurgery, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Shaakir Hasan
- Department of Radiation Oncology, New York Proton Center, New York, New York
| | - Deborah T Blumenthal
- Department of Neuro-Oncology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Walter J Curran
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Bree R Eaton
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Hui-Kuo G Shu
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Jim Zhong
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| |
Collapse
|
33
|
Press RH, Zhang C, Chowdhary M, Prabhu RS, Ferris MJ, Xu KM, Olson JJ, Eaton BR, Shu HKG, Curran WJ, Crocker IR, Patel KR. Hemorrhagic and Cystic Brain Metastases Are Associated With an Increased Risk of Leptomeningeal Dissemination After Surgical Resection and Adjuvant Stereotactic Radiosurgery. Neurosurgery 2020; 85:632-641. [PMID: 30335175 DOI: 10.1093/neuros/nyy436] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [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: 04/24/2018] [Accepted: 08/19/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Brain metastases (BM) treated with surgical resection and focal postoperative radiotherapy have been associated with an increased risk of subsequent leptomeningeal dissemination (LMD). BMs with hemorrhagic and/or cystic features contain less solid components and may therefore be at higher risk for tumor spillage during resection. OBJECTIVE To investigate the association between hemorrhagic and cystic BMs treated with surgical resection and stereotactic radiosurgery and the risk of LMD. METHODS One hundred thirty-four consecutive patients with a single resected BM treated with adjuvant stereotactic radiosurgery from 2008 to 2016 were identified. Intracranial outcomes including LMD were calculated using the cumulative incidence model with death as a competing risk. Univariable analysis and multivariable analysis were assessed using the Fine & Gray model. Overall survival was analyzed using the Kaplan-Meier method. RESULTS Median imaging follow-up was 14.2 mo (range 2.5-132 mo). Hemorrhagic and cystic features were present in 46 (34%) and 32 (24%) patients, respectively. The overall 12- and 24-mo cumulative incidence of LMD with death as a competing risk was 11.0 and 22.4%, respectively. On multivariable analysis, hemorrhagic features (hazard ratio [HR] 2.34, P = .015), cystic features (HR 2.34, P = .013), breast histology (HR 3.23, P = .016), and number of brain metastases >1 (HR 2.09, P = .032) were independently associated with increased risk of LMD. CONCLUSION Hemorrhagic and cystic features were independently associated with increased risk for postoperative LMD. Patients with BMs containing these intralesion features may benefit from alternative treatment strategies to mitigate this risk.
Collapse
Affiliation(s)
- Robert H Press
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Chao Zhang
- Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Mudit Chowdhary
- Department of Radiation Oncology, Rush University, Chicago, Illinois
| | - Roshan S Prabhu
- Southeast Radiation Oncology Group, Levine Cancer Institute, Charlotte, North Carolina
| | - Matthew J Ferris
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Karen M Xu
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Jeffrey J Olson
- Department of Neurological Surgery, Emory University, Atlanta, Georgia
| | - Bree R Eaton
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Hui-Kuo G Shu
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Walter J Curran
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Ian R Crocker
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Kirtesh R Patel
- Department of Therapeutic Radiology, Smilow Cancer Center, Yale University, New Haven, Connecticut
| |
Collapse
|
34
|
Tian S, Sudmeier LJ, Zhang C, Madden NA, Buchwald ZS, Shu HKG, Curran WJ, Eaton BR, Esiashvili N. Reduced-volume tumor-bed boost is not associated with inferior local control and survival outcomes in high-risk medulloblastoma. Pediatr Blood Cancer 2020; 67:e28027. [PMID: 31571408 DOI: 10.1002/pbc.28027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 08/05/2019] [Accepted: 09/13/2019] [Indexed: 11/11/2022]
Abstract
BACKGROUND Radiotherapy boost to the entire posterior fossa (PF) is standard of care for high-risk (H-R) medulloblastoma patients; the utility of tumor bed (TB)-only boost is unclear. The purpose of this study was to examine the impact of PF versus TB boost volume on tumor control and survival in the H-R medulloblastoma population. METHODS Single-institution records for patients with H-R medulloblastoma were reviewed. The median craniospinal irradiation dose was 36 Gy (range, 23.4-45 Gy), and boost doses to either PF or TB were 54 to 55.8 Gy. PF (local) failures were scored as in-field, marginal (between 80% and 95% isodose lines), or distant. Kaplan-Meier methods and Cox proportional hazards were used to assess the impact of radiation boost technique on local control (LC) and survival endpoints. RESULTS Thirty-two patients with H-R medulloblastoma were treated between 1990 and 2015, with a median follow-up length of 5.12 years. Twenty-two patients received PF boost, and 10 received TB boost. Patient and disease characteristic were comparable between groups. A total of 11 PF failures occurred, including 3 isolated LFs (2 in the PF and 1 in the TB group). Most PF failures were in-field: three of four in the TB group and six of seven in the PF group; the remainder were marginal failures. TB boost was not associated with inferior LC (hazard ratio [HR] 0.86, log-rank P = 0.81) or overall survival (HR 1.40, P = 0.56) compared with PF boost. CONCLUSION Reduced-volume radiotherapy boost to the TB does not appear to compromise LC or survival in patients with H-R medulloblastoma; it may reduce the risk of ototoxicity.
Collapse
Affiliation(s)
- Sibo Tian
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Lisa J Sudmeier
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Chao Zhang
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia
| | - Nicholas A Madden
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Zachary S Buchwald
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Hui-Kuo G Shu
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Walter J Curran
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Bree R Eaton
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Natia Esiashvili
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| |
Collapse
|
35
|
Lawell MP, Indelicato DJ, Paulino AC, Hartsell W, Laack NN, Ermoian RP, Perentesis JP, Vatner R, Perkins S, Mangona VS, Hill-Kayser CE, Wolden SL, Kwok Y, Chang JHC, Wilkinson JB, MacEwan I, Chang AL, Eaton BR, Ladra MM, Gallotto SL, Weyman EA, Bajaj BVM, Baliga S, Yeap BY, Berrington de Gonzalez A, Yock TI. An open invitation to join the Pediatric Proton/Photon Consortium Registry to standardize data collection in pediatric radiation oncology. Br J Radiol 2019; 93:20190673. [PMID: 31600082 DOI: 10.1259/bjr.20190673] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE The Pediatric Proton/Photon Consortium Registry (PPCR) is a comprehensive data registry composed of pediatric patients treated with radiation. It was established to expedite outcomes-based research. The attributes which allow the PPCR to be a successful collaboration are reviewed. METHODS AND MATERIALS Current eligibility criteria are radiotherapy patients < 22 years treated at one of the 15 US participating institutions. Detailed health and treatment data are collected about the disease presentation and treatment exposures, and annually thereafter, in REDCap (Research Electronic Data Capture). DICOM (Digital Imaging and Communications in Medicine) imaging and radiation plans are collected through MIM/MIMcloud. An optional patient-reported quality-of-life (PedsQL) study is administered at 10 sites. RESULTS Accrual started October 2012 with 2,775 participants enrolled as of 25 July 2019. Most patients, 62.0%, were treated for central nervous system (CNS) tumors, the most common of which are medulloblastoma (n = 349), ependymoma (n = 309), and glial/astrocytoma tumors (n = 279). The most common non-CNS diagnoses are rhabdomyosarcoma (n = 284), Ewing's sarcoma (n = 153), and neuroblastoma (n = 130). While the majority of participants are US residents, 18.7% come from 36 other countries. Over 685 patients participate in the PedsQL study. CONCLUSIONS The PPCR is a valuable research platform capable of answering countless research questions that will ultimately improve patient care. Centers outside of the USA are invited to participate directly or may engage with the PPCR to align data collection strategies to facilitate large-scale international research. ADVANCES IN KNOWLEDGE For investigators looking to carry out research in a large pediatric oncology cohort or interested in registry work, this paper provides an updated overview of the PPCR.
Collapse
Affiliation(s)
- Miranda P Lawell
- Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, United States
| | - Daniel J Indelicato
- Department of Radiation Oncology, University of Florida, Gainesville, United States
| | - Arnold C Paulino
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, United States
| | - William Hartsell
- Department of Radiation Oncology, Northwestern Medicine Chicago Proton Center, Warrenville, United States
| | - Nadia N Laack
- Department of Radiation Oncology, Mayo Clinic, Rochester, United States
| | - Ralph P Ermoian
- Department of Radiation Oncology, University of Washington, Seattle, United States
| | - John P Perentesis
- Division of Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, United States
| | - Ralph Vatner
- Department of Radiation Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, United States
| | - Stephanie Perkins
- Department of Radiation Oncology, Washington University, St. Louis, United States
| | - Victor S Mangona
- Department of Radiation Oncology, Texas Center for Proton Therapy, Irving, United States
| | | | - Suzanne L Wolden
- Department of Radiation Oncology, ProCure Proton Therapy Center, New Jersey, United States
| | - Young Kwok
- Department of Radiation Oncology, University of Maryland, College park, United States
| | - John Han-Chih Chang
- Department of Radiation Oncology, Oklahoma Proton Therapy Center, Oklahoma, United States
| | - J Ben Wilkinson
- Department of Radiation Oncology, Provision Healthcare, Knoxville, United States
| | - Iain MacEwan
- Department of Radiation Oncology, California Protons Cancer Therapy Center, San Diego, United States
| | - Andrew L Chang
- Department of Radiation Oncology, California Protons Cancer Therapy Center, San Diego, United States
| | - Bree R Eaton
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, United States
| | - Matthew M Ladra
- Department of Pediatric Radiation Oncology, John Hopkins Kimmel Cancer Center at Sibley Memorial Hospital, Washington, United States
| | - Sara L Gallotto
- Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, United States
| | - Elizabeth A Weyman
- Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, United States
| | - Benjamin V M Bajaj
- Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, United States
| | - Sujith Baliga
- Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, United States
| | - Beow Y Yeap
- Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, United States
| | - Amy Berrington de Gonzalez
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer InstituteNational Institutes of Health, Bethesda, United States
| | - Torunn I Yock
- Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, United States
| |
Collapse
|
36
|
Jhaveri J, Chowdhary M, Zhang X, Press RH, Switchenko JM, Ferris MJ, Morgan TM, Roper J, Dhabaan A, Elder E, Eaton BR, Olson JJ, Curran WJ, Shu HKG, Crocker IR, Patel KR. Does size matter? Investigating the optimal planning target volume margin for postoperative stereotactic radiosurgery to resected brain metastases. J Neurosurg 2019; 130:797-803. [PMID: 29676690 DOI: 10.3171/2017.9.jns171735] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 09/08/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The optimal margin size in postoperative stereotactic radiosurgery (SRS) for brain metastases is unknown. Herein, the authors investigated the effect of SRS planning target volume (PTV) margin on local recurrence and symptomatic radiation necrosis postoperatively. METHODS Records of patients who received postoperative LINAC-based SRS for brain metastases between 2006 and 2016 were reviewed and stratified based on PTV margin size (1.0 or > 1.0 mm). Patients were treated using frameless and framed SRS techniques, and both single-fraction and hypofractionated dosing were used based on lesion size. Kaplan-Meier and cumulative incidence models were used to estimate survival and intracranial outcomes, respectively. Multivariate analyses were also performed. RESULTS A total of 133 patients with 139 cavities were identified; 36 patients (27.1%) and 35 lesions (25.2%) were in the 1.0-mm group, and 97 patients (72.9%) and 104 lesions (74.8%) were in the > 1.0-mm group. Patient characteristics were balanced, except the 1.0-mm cohort had a better Eastern Cooperative Group Performance Status (grade 0: 36.1% vs 19.6%), higher mean number of brain metastases (1.75 vs 1.31), lower prescription isodose line (80% vs 95%), and lower median single fraction-equivalent dose (15.0 vs 17.5 Gy) (all p < 0.05). The median survival and follow-up for all patients were 15.6 months and 17.7 months, respectively. No significant difference in local recurrence was noted between the cohorts. An increased 1-year rate of symptomatic radionecrosis was seen in the larger margin group (20.9% vs 6.0%, p = 0.028). On multivariate analyses, margin size > 1.0 mm was associated with an increased risk for symptomatic radionecrosis (HR 3.07, 95% CI 1.13-8.34; p = 0.028), while multifraction SRS emerged as a protective factor for symptomatic radionecrosis (HR 0.13, 95% CI 0.02-0.76; p = 0.023). CONCLUSIONS Expanding the PTV margin beyond 1.0 mm is not associated with improved local recurrence but appears to increase the risk of symptomatic radionecrosis after postoperative SRS.
Collapse
Affiliation(s)
- Jaymin Jhaveri
- Departments of1Radiation Oncology and.,2Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Mudit Chowdhary
- Departments of1Radiation Oncology and.,3Department of Radiation Oncology, Rush University Medical Center, Chicago, Illinois; and
| | - Xinyan Zhang
- 4Biostatistics and Bioinformatics Shared Resource
| | - Robert H Press
- Departments of1Radiation Oncology and.,2Winship Cancer Institute, Emory University, Atlanta, Georgia
| | | | - Matthew J Ferris
- Departments of1Radiation Oncology and.,2Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Tiffany M Morgan
- Departments of1Radiation Oncology and.,2Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Justin Roper
- Departments of1Radiation Oncology and.,2Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Anees Dhabaan
- Departments of1Radiation Oncology and.,2Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Eric Elder
- Departments of1Radiation Oncology and.,2Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Bree R Eaton
- Departments of1Radiation Oncology and.,2Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Jeffrey J Olson
- 2Winship Cancer Institute, Emory University, Atlanta, Georgia.,5Neurosurgery, and
| | - Walter J Curran
- Departments of1Radiation Oncology and.,2Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Hui-Kuo G Shu
- Departments of1Radiation Oncology and.,2Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Ian R Crocker
- Departments of1Radiation Oncology and.,2Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Kirtesh R Patel
- Departments of1Radiation Oncology and.,2Winship Cancer Institute, Emory University, Atlanta, Georgia.,6Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| |
Collapse
|
37
|
Zhong J, Press RH, Olson JJ, Oyesiku NM, Shu HKG, Eaton BR. The use of Hypofractionated Radiosurgery for the Treatment of Intracranial Lesions Unsuitable for Single-Fraction Radiosurgery. Neurosurgery 2019; 83:850-857. [PMID: 29718388 DOI: 10.1093/neuros/nyy145] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 09/07/2017] [Accepted: 03/22/2018] [Indexed: 11/15/2022] Open
Abstract
Stereotactic radiosurgery (SRS) is commonly used in the treatment of brain metastases, benign tumors, and arteriovenous malformations (AVM). Single-fraction radiosurgery, though ubiquitous, is limited by lesion size and location. In these cases, hypofractionated radiosurgery (hfSRS) offers comparable efficacy and toxicity. We review the recent literature concerning hfSRS in the treatment of brain metastases, benign tumors, and AVMs that are poorly suited for single-fraction SRS. Published retrospective analyses suggest that local control rates for brain metastases and benign tumors, as well as the rates of AVM obliteration, following hfSRS treatment are comparable to those reported for single-fraction SRS. Additionally, the toxicities from hypofractionated treatment appear comparable to those seen with single-fractioned SRS to small lesions.
Collapse
Affiliation(s)
- Jim Zhong
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Robert H Press
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Jeffrey J Olson
- Department of Neurosurgery, Emory University, Atlanta, Georgia
| | | | - Hui-Kuo G Shu
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Bree R Eaton
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| |
Collapse
|
38
|
Eaton BR. Book Review: Pediatric Radiation Oncology. Neurosurgery 2019. [DOI: 10.1093/neuros/nyy584] [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: 11/15/2022] Open
|
39
|
Press RH, Zhong J, Gurbani SS, Weinberg BD, Eaton BR, Shim H, Shu HKG. The Role of Standard and Advanced Imaging for the Management of Brain Malignancies From a Radiation Oncology Standpoint. Neurosurgery 2018; 85:165-179. [DOI: 10.1093/neuros/nyy461] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 08/30/2018] [Indexed: 01/20/2023] Open
Abstract
Abstract
Radiation therapy (RT) plays a critical role in the overall management of many central nervous system (CNS) tumors. Advances in RT treatment planning, with techniques such as intensity modulated radiation therapy, volumetric modulated arc therapy, and stereotactic radiosurgery, now allow the delivery of highly conformal dose with great precision. These techniques rely on high-resolution 3-dimensional anatomical imaging modalities such as computed tomography or magnetic resonance imaging (MRI) scans to accurately and reliably define CNS targets and normal tissue avoidance structures. The integration of cross-sectional imaging into radiation oncology has directly translated into improvements in the therapeutic window of RT, and the union between radiation oncology and imaging is only expected to grow stronger. In addition, advanced imaging modalities including diffusion, perfusion, and spectroscopic MRIs as well as positron emission tomography (PET) scans with novel tracers are being utilized to provide additional insight into tumor biology and behavior beyond anatomy. Together, these standard and advanced imaging modalities hold significant potential to improve future RT delivery and response assessment. In this review, we will discuss the current utilization of standard/advanced imaging for CNS tumors from a radiation oncology perspective as well as the implications of novel MRI and PET modalities currently under investigation.
Collapse
Affiliation(s)
- Robert H Press
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Jim Zhong
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Saumya S Gurbani
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, Georgia
| | - Brent D Weinberg
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
| | - Bree R Eaton
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Hyunsuk Shim
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, Georgia
| | - Hui-Kuo G Shu
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| |
Collapse
|
40
|
Jhaveri J, Cheng E, Tian S, Buchwald Z, Chowdhary M, Liu Y, Gillespie TW, Olson JJ, Diaz AZ, Voloschin A, Eaton BR, Crocker IR, McDonald MW, Curran WJ, Patel KR. Proton vs. Photon Radiation Therapy for Primary Gliomas: An Analysis of the National Cancer Data Base. Front Oncol 2018; 8:440. [PMID: 30547008 PMCID: PMC6279888 DOI: 10.3389/fonc.2018.00440] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 09/20/2018] [Indexed: 11/13/2022] Open
Abstract
Background: To investigate the impact of proton radiotherapy (PBT) on overall survival (OS) and evaluate PBT usage trends for patients with gliomas in the National Cancer Data Base (NCDB). Methods: Patients with a diagnosis of World Health Organization (WHO) Grade I-IV glioma treated with definitive radiation therapy (RT) between the years of 2004–13 were identified. Patients were stratified based on WHO Grade and photon radiotherapy (XRT) vs. PBT. Univariate (UVA) and multivariable analysis (MVA) with OS were performed by Cox proportional hazards model and log-rank tests. Propensity score (PS) weighting was utilized to account for differences in patient characteristics and to minimize selection bias. Results: There were a total of 49,405 patients treated with XRT and 170 patients treated with PBT. Median follow-up time was 62.1 months. On MVA, the following factors were associated with receipt of PBT (all p < 0.05): WHO Grade I-II gliomas, treatment at an academic/research program, west geographic facility location, and surgical resection. After PS weighting, all patients treated with PBT were found to have superior median and 5 year survival than patients treated with XRT: 45.9 vs. 29.7 months (p = 0.009) and 46.1 vs. 35.5% (p = 0.0160), respectively. Conclusions: PBT is associated with improved OS compared to XRT for patients with gliomas. This finding warrants verification in the randomized trial setting in order to account for potential patient imbalances not adequately captured by the NCDB, such as tumor molecular characteristics and patient performance status. Importance of the Study: This is the first study that compares the outcomes of patients treated with photon based radiotherapy vs. proton based radiotherapy for patients with gliomas. In this retrospective analysis, the results demonstrate that proton therapy is associated with improved outcomes which support ongoing prospective, randomized clinical trials comparing the two modalities in patients with gliomas.
Collapse
Affiliation(s)
- Jaymin Jhaveri
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - En Cheng
- Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Sibo Tian
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Zachary Buchwald
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Mudit Chowdhary
- Department of Radiation Oncology, Rush University, Chicago, IL, United States
| | - Yuan Liu
- Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | | | - Jeffrey J Olson
- Department of Neurosurgery and Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Aidnag Z Diaz
- Department of Radiation Oncology, Rush University, Chicago, IL, United States
| | - Alfredo Voloschin
- Department of Hematology and Medical Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Bree R Eaton
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Ian R Crocker
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Mark W McDonald
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Walter J Curran
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Kirtesh R Patel
- Department of Therapeutic Radiology, Yale University, New Haven, CT, United States
| |
Collapse
|
41
|
Morgan TM, Zaenger D, Switchenko JM, Eaton BR, Crocker IR, Ali AN, Shu HKG. Fractionated Radiotherapy Is Associated with Lower Rates of Treatment-Related Edema than Stereotactic Radiosurgery in Magnetic Resonance Imaging-Defined Meningiomas. World Neurosurg 2018; 121:e640-e646. [PMID: 30292026 DOI: 10.1016/j.wneu.2018.09.179] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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: 06/19/2018] [Revised: 09/22/2018] [Accepted: 09/24/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Both stereotactic radiosurgery (SRS) and fractionated radiation therapy (FRT) techniques are used for treatment of intracranial meningiomas with excellent local control (LC) rates. Although SRS techniques are convenient, toxicity including treatment-related edema can significantly impact patient quality of life. The long-term clinical outcomes of patients with magnetic resonance imaging (MRI)-defined meningiomas treated with radiation therapy (RT) alone are reported. METHODS The charts of 211 patients with meningiomas diagnosed by contrast-enhanced MRI treated with either SRS or FRT between 1991 and 2012 at a single institution were reviewed. Actuarial rates for LC and development of treatment-related radiographic edema (TRE) were determined by the Kaplan-Meier method. RESULTS There were 211 patients who received radiation therapy for 223 lesions. Median follow-up was 5.7 years. Eleven patients experienced a local failure; of these, 2 were ultimately found to have pathologically proven metastatic carcinoma. Two- and 5-year LC was 97.8% and 94.6%, respectively, with no significant difference based on modality of therapy. Actuarial rate for development of TRE at 1 and 2 years was 30.1% and 34.6% for the SRS group and 1.6% and 2.5% for the FRT group, respectively (P < 0.001). CONCLUSIONS RT alone using a limited margin is an effective treatment option for MRI-defined meningiomas and should be considered even without biopsy if surgery will present significant morbidity. Although LC with SRS versus FRT was comparable, FRT was associated with a significantly decreased risk of TRE.
Collapse
Affiliation(s)
- Tiffany M Morgan
- Department of Radiation Oncology, Emory University, Atlanta, Georgia, USA; Department of Winship Cancer Institute, Emory University, Atlanta, Georgia, USA.
| | - David Zaenger
- Department of Radiation Oncology, Emory University, Atlanta, Georgia, USA; Department of Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Jeffrey M Switchenko
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia, USA; Department of Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Bree R Eaton
- Department of Radiation Oncology, Emory University, Atlanta, Georgia, USA; Department of Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Ian R Crocker
- Department of Radiation Oncology, Emory University, Atlanta, Georgia, USA; Department of Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Arif N Ali
- Department of Radiation Oncology, Emory University, Atlanta, Georgia, USA; Department of Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Hui-Kuo G Shu
- Department of Radiation Oncology, Emory University, Atlanta, Georgia, USA; Department of Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| |
Collapse
|
42
|
Johnson TS, Aguilera D, Al-Basheer A, Castellino C, Eaton BR, Esiashvili N, Foreman N, Heger IM, Kennedy EP, Link CJ, Martin W, Ring E, Sadek RF, Smith A, Vahanian NN, MacDonald TJ, Munn DH. IMMU-25. RADIO-IMMUNOTHERAPY USING THE IDO PATHWAY INHIBITOR INDOXIMOD FOR CHILDREN WITH NEWLY-DIAGNOSED DIPG. Neuro Oncol 2018. [DOI: 10.1093/neuonc/noy059.341] [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: 11/14/2022] Open
Affiliation(s)
| | - Dolly Aguilera
- Aflac Cancer & Blood Disorders Center, Children’s Healthcare of Atlanta, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Craig Castellino
- Aflac Cancer & Blood Disorders Center, Children’s Healthcare of Atlanta, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Bree R Eaton
- Department of Radiation Oncology and Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Natia Esiashvili
- Department of Radiation Oncology and Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Nicholas Foreman
- Department of Pediatrics, Children’s Hospital Colorado, Aurora, CO, USA
| | - Ian M Heger
- Georgia Cancer Center, Augusta University, Augusta, GA, USA
| | | | | | - William Martin
- Department of Radiation Oncology, Augusta University, Augusta, GA, USA
| | - Eric Ring
- Georgia Cancer Center, Augusta University, Augusta, GA, USA
| | - Ramses F Sadek
- Georgia Cancer Center, Augusta University, Augusta, GA, USA
| | - Amy Smith
- Department of Pediatrics, Arnold Palmer Hospital for Children, Orlando, FL, USA
| | | | - Tobey J MacDonald
- Aflac Cancer & Blood Disorders Center, Children’s Healthcare of Atlanta, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - David H Munn
- Georgia Cancer Center, Augusta University, Augusta, GA, USA
| |
Collapse
|
43
|
Ferris MJ, Tian S, Switchenko JM, Madden NA, Eaton BR, Esiashvili N. Musculoskeletal outcomes and the effect of radiation to the vertebral bodies on growth trajectories for long-term survivors of high-risk neuroblastoma. J Radiat Oncol 2018; 7:187-193. [PMID: 34178250 PMCID: PMC8225230 DOI: 10.1007/s13566-018-0349-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 03/19/2018] [Indexed: 06/02/2023]
Abstract
OBJECTIVE Here, we report musculoskeletal outcomes and the impact of radiotherapy dose on vertebral body growth for an institutional series of long-term survivors of high-risk neuroblastoma. METHODS We conducted a retrospective study of 23 patients who were disease-free and at least 36 months from the end of treatment. The patients were initially treated from July 2003 to May 2012. Patient records were reviewed for growth percentiles (obtained at approximately 6-month intervals from onset of treatment to the last follow-up) and musculoskeletal comorbidities. RT plans and most recent surveillance CT scans were reviewed for locations of in-field vertebral bodies and corresponding vertebral growth patterns. RESULTS The median follow-up was 7.93 years. The median prescribed radiation dose was 21.6 Gy. Musculoskeletal abnormalities included scoliosis (5 patients), muscular hypoplasia (3), and hypodontia (1). The median growth percentile at treatment onset was 35.5 (range, 4.7-100) versus 10 (0-94.1) at the last follow-up. The median numbers of vertebral bodies encompassed (by at least half of their volume) by the 5-, 10-, 15-, and 20-Gy isodose lines were 7 (mean, 6.78), 7 (6.56), 6 (6.17), and 6 (5.52), respectively. Sixteen patients (70.0%) had in-field abnormalities in vertebral body growth, manifesting as stretches of successive vertebral bodies at the same height, while normally there is a gradual vertebral body height increase progressing caudally down the spinal column. CONCLUSIONS Musculoskeletal abnormalities, below average height, and stunted in-field vertebral body growth are routine in long-term survivors of high-risk neuroblastoma. Sparing vertebral bodies when feasible may lead to improvement in patient growth trajectories.
Collapse
Affiliation(s)
- Matthew J. Ferris
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
- The Emory Clinic, 1365 Clifton Road NE, Atlanta, GA 30322, USA
| | - Sibo Tian
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Jeffrey M. Switchenko
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
- Department of Biostatistics & Bioinformatics, Emory University, Atlanta, GA, USA
| | - Nicholas A. Madden
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Bree R. Eaton
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Natia Esiashvili
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
| |
Collapse
|
44
|
Ferris MJ, Zhong J, Switchenko JM, Higgins KA, Cassidy RJ, McDonald MW, Eaton BR, Patel KR, Steuer CE, Baddour HM, Miller AH, Bruner DW, Xiao C, Beitler JJ. Brainstem dose is associated with patient-reported acute fatigue in head and neck cancer radiation therapy. Radiother Oncol 2018; 126:100-106. [PMID: 28826628 PMCID: PMC5841457 DOI: 10.1016/j.radonc.2017.08.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 07/17/2017] [Accepted: 08/05/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE Radiation (RT) dose to the central nervous system (CNS) has been implicated as a contributor to treatment-related fatigue in head and neck cancer (HNC) patients undergoing radiation therapy (RT). This study evaluates the association of RT dose to CNS structures with patient-reported (PRO) fatigue scores in a population of HNC patients. MATERIALS AND METHODS At pre-RT (baseline), 6th week of RT, and 1-month post-RT time points, Multidimensional Fatigue Inventory (MFI-20) scores were prospectively obtained from 124 patients undergoing definitive treatment for HNC. Medulla, pons, midbrain, total brainstem, cerebellum, posterior fossa, and pituitary dosimetry were evaluated using summary statistics and dose-volume histograms, and associations with MFI-20 scores were analyzed. RESULTS Maximum dose (Dmax) to the brainstem and medulla was significantly associated with MFI-20 scores at 6th week of RT and 1-month post-RT time points, after controlling for baseline scores (p<0.05). Each 1Gy increase in medulla Dmax resulted in an increase in total MFI-20 score over baseline of 0.30 (p=0.026), and 0.25 (p=0.037), at the 6th week of RT and 1-month post-RT, respectively. Each 1Gy increase in brainstem Dmax resulted in an increase in total MFI-20 score over baseline of 0.30 (p=0.027), and 0.25 (p=0.037) at the 6th week of RT, 1-month post-RT, respectively. Statistically significant associations were not found between dosimetry for the other CNS structures and MFI-20 scores. CONCLUSIONS In this analysis of PRO fatigue scores from a population of patients undergoing definitive RT for HNC, maximum dose to the brainstem and medulla was associated with a significantly increased risk of acute patient fatigue.
Collapse
Affiliation(s)
- Matthew J Ferris
- Department of Radiation Oncology, Emory University, Atlanta, USA; Winship Cancer Institute of Emory University, Atlanta, USA.
| | - Jim Zhong
- Department of Radiation Oncology, Emory University, Atlanta, USA; Winship Cancer Institute of Emory University, Atlanta, USA
| | - Jeffrey M Switchenko
- Winship Cancer Institute of Emory University, Atlanta, USA; Department of Biostatistics & Bioinformatics, Emory University, Atlanta, USA
| | - Kristin A Higgins
- Department of Radiation Oncology, Emory University, Atlanta, USA; Winship Cancer Institute of Emory University, Atlanta, USA
| | - Richard J Cassidy
- Department of Radiation Oncology, Emory University, Atlanta, USA; Winship Cancer Institute of Emory University, Atlanta, USA
| | - Mark W McDonald
- Department of Radiation Oncology, Emory University, Atlanta, USA; Winship Cancer Institute of Emory University, Atlanta, USA
| | - Bree R Eaton
- Department of Radiation Oncology, Emory University, Atlanta, USA; Winship Cancer Institute of Emory University, Atlanta, USA
| | - Kirtesh R Patel
- Department of Radiation Oncology, Emory University, Atlanta, USA; Winship Cancer Institute of Emory University, Atlanta, USA
| | - Conor E Steuer
- Winship Cancer Institute of Emory University, Atlanta, USA; Department of Hematology and Medical Oncology, Emory University, Atlanta, USA
| | - H Michael Baddour
- Winship Cancer Institute of Emory University, Atlanta, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, USA
| | - Andrew H Miller
- Winship Cancer Institute of Emory University, Atlanta, USA; Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, USA
| | - Deborah W Bruner
- Department of Radiation Oncology, Emory University, Atlanta, USA; Winship Cancer Institute of Emory University, Atlanta, USA; Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, USA
| | - Canhua Xiao
- Winship Cancer Institute of Emory University, Atlanta, USA; Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, USA
| | - Jonathan J Beitler
- Department of Radiation Oncology, Emory University, Atlanta, USA; Winship Cancer Institute of Emory University, Atlanta, USA
| |
Collapse
|
45
|
Jhaveri J, Liu Y, Chowdhary M, Buchwald ZS, Gillespie TW, Olson JJ, Voloschin AD, Eaton BR, Shu HKG, Crocker IR, Curran WJ, Patel KR. Is less more? Comparing chemotherapy alone with chemotherapy and radiation for high-risk grade 2 glioma: An analysis of the National Cancer Data Base. Cancer 2017; 124:1169-1178. [PMID: 29205287 DOI: 10.1002/cncr.31158] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Revised: 09/28/2017] [Accepted: 10/31/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND The addition of chemotherapy to adjuvant radiotherapy (chemotherapy and radiation therapy [CRT]) improves overall survival (OS) for patients with high-risk grade 2 gliomas; however, the impact of chemotherapy alone (CA) is unknown. This study compares the OS of patients with high-risk grade 2 gliomas treated with CA versus CRT. METHODS Patients with high-risk grade 2 gliomas (subtotal resection or age ≥ 40 years) with oligodendrogliomas, astrocytomas, or mixed tumors were identified with the National Cancer Data Base. Patients were grouped into CA and CRT cohorts. Univariate analyses and multivariate analyses (MVAs) were performed. Propensity score (PS) matching was also implemented. The Kaplan-Meier method was used to analyze OS. RESULTS A total of 1054 patients with high-risk grade 2 gliomas were identified: 496 (47.1%) received CA, and 558 (52.9%) received CRT. Patients treated with CA were more likely (all P values < .05) to have oligodendroglioma histology (65.5% vs 34.2%), exhibit a 1p/19q codeletion (22.8% vs 7.5%), be younger (median age, 47.0 vs 48.0 years), and receive treatment at an academic facility (65.2% vs 50.3%). The treatment type was not a significant predictor for OS (P = .125) according to the MVA; a tumor size > 6 cm, astrocytoma histology, and older age were predictors for worse OS (all P values < .05). After 1:1 PS matching (n = 331 for each cohort), no OS difference was seen (P = .696) between the CA and CRT cohorts at 5 (69.3% vs 67.4%) and 8 years (52.8% vs 56.7%). CONCLUSIONS No long-term OS difference was seen in patients with high-risk grade 2 gliomas treated with CA versus CRT. These findings are hypothesis-generating, and prospective clinical trials comparing these treatment paradigms are warranted. Cancer 2018;124:1169-78. © 2017 American Cancer Society.
Collapse
Affiliation(s)
- Jaymin Jhaveri
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Yuan Liu
- Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Mudit Chowdhary
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia.,Department of Radiation Oncology, Rush University Medical Center, Chicago, Illinois
| | - Zachary S Buchwald
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Theresa W Gillespie
- Department of Surgery and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Jeffrey J Olson
- Department of Neurosurgery and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Alfredo D Voloschin
- Department of Hematology and Medical Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Bree R Eaton
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Hui-Kuo G Shu
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Ian R Crocker
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Walter J Curran
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Kirtesh R Patel
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia.,Department of Therapeutic Radiology and Smilow Cancer Center, Yale School of Medicine, New Haven, Connecticut
| |
Collapse
|
46
|
Press R, Zhang C, Chowdhary M, Xu K, Prabhu R, Ferris M, Olson JJ, Eaton BR, Shu HK, Curran W, Crocker I, Patel K. CMET-38. HEMORRHAGIC BRAIN METASTASES UNDERGOING SURGICAL RESECTION ARE ASSOCIATED WITH INCREASED RISK OF LEPTOMENINGEAL DISSEMINATION. Neuro Oncol 2017. [DOI: 10.1093/neuonc/nox168.185] [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: 11/12/2022] Open
|
47
|
Johnson TS, Aguilera D, Al-Basheer A, Cooksey RM, Eaton BR, Esiashvili N, Firat S, Fiveash JB, Foreman N, Fridlyand D, Friedman GK, Giller CA, Grosshans DR, Heger IM, Kelly M, Kennedy EP, Knipstein J, Kolhe RB, Liu AK, Martin W, Mourad WF, Pacholczyk R, Parker R, Rojiani AM, Sadek RF, Thornton A, Vahanian NN, MacDonald T, Munn D. PDCT-06. RADIO-IMMUNOTHERAPY USING THE IDO-INHIBITOR INDOXIMOD IN COMBINATION WITH RE-IRRADIATION FOR CHILDREN WITH PROGRESSIVE BRAIN TUMORS IN THE PHASE 1 SETTING: AN UPDATED REPORT OF SAFETY AND TOLERABILITY (NCT02502708). Neuro Oncol 2017. [DOI: 10.1093/neuonc/nox168.750] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
48
|
Zhong J, Ferris MJ, Switchenko J, Press RH, Buchwald Z, Olson JJ, Eaton BR, Curran WJ, Shu HKG, Crocker IR, Patel KR. Postoperative stereotactic radiosurgery for resected brain metastases: A comparison of outcomes for large resection cavities. Pract Radiat Oncol 2017; 7:e419-e425. [PMID: 28668668 DOI: 10.1016/j.prro.2017.04.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 02/23/2017] [Accepted: 04/21/2017] [Indexed: 02/01/2023]
Abstract
PURPOSE Although historical trials have established the role of surgical resection followed by whole brain irradiation (WBRT) for brain metastases, WBRT has recently been shown to cause significant neurocognitive decline. Many practitioners have employed postoperative stereotactic radiosurgery (SRS) to tumor resection cavities to increase local control without causing significant neurocognitive sequelae. However, studies analyzing outcomes of large brain metastases treated with resection and postoperative SRS are lacking. Here we compare outcomes in patients with large brain metastases >4 cm to those with smaller metastases ≤4 cm treated with surgical resection followed by SRS to the resection cavity. METHODS AND MATERIALS Consecutive patients with brain metastases treated at our institution with surgical resection and postoperative SRS were retrospectively reviewed. Patients were stratified into ≤4 cm and >4 cm cohorts based on preoperative maximal tumor dimension. Cumulative incidence of local failure, radiation necrosis, and death were analyzed for the 2 cohorts using a competing-risk model, defined as the time from SRS treatment date to the measured event, death, or last follow-up. RESULTS A total of 117 consecutive cases were identified. Of these patients, 90 (77%) had preoperative tumors ≤4 cm, and 27 (23%) >4 cm in greatest dimension. The only significant baseline difference between the 2 groups was a higher proportion of patients who underwent gross total resection in the ≤4 cm compared with the >4 cm cohort, 76% versus 48%, respectively (P <.01). The 1-year rates of local failure, radiation necrosis, and overall survival for the ≤4 cm and >4 cm cohorts were 12.3% and 16.0%, 26.9% and 28.4%, and 80.6% and 67.6%, respectively (all P >.05). The rates of local failure and radiation necrosis were not statistically different on multivariable analysis based on tumor size. CONCLUSIONS Brain metastases >4 cm in largest dimension managed by resection and radiosurgery to the tumor cavity have promising local control rates without a significant increase in radiation necrosis on our retrospective review.
Collapse
Affiliation(s)
- Jim Zhong
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia.
| | - Matthew J Ferris
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Jeffrey Switchenko
- Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Robert H Press
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Zachary Buchwald
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Jeffrey J Olson
- Department of Neurosurgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Bree R Eaton
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Walter J Curran
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Hui-Kuo G Shu
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Ian R Crocker
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Kirtesh R Patel
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia; Department of Radiation Oncology, Veterans Affairs Hospital, Decatur, Georgia
| |
Collapse
|
49
|
Cassidy RJ, Switchenko JM, Jegadeesh N, Sayan M, Ferris MJ, Eaton BR, Higgins KA, Wadsworth JT, Magliocca KR, Saba NF, Beitler JJ. Association of Lymphovascular Space Invasion With Locoregional Failure and Survival in Patients With Node-Negative Oral Tongue Cancers. JAMA Otolaryngol Head Neck Surg 2017; 143:382-388. [PMID: 28097311 PMCID: PMC5398912 DOI: 10.1001/jamaoto.2016.3795] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance The indications for adjuvant therapy in resected oral tongue cancers are based on both clinical and pathological factors, with clear evidence for adjuvant radiation in patients with pathologically positive neck lymph nodes, positive margins, and extracapsular extension, but the data for patients with no nodal disease are sparse. Objective To investigate determinants of failure and survival in patients with node-negative oral tongue cancer. Design, Setting, and Participants Medical records for patients with oral tongue cancer treated with definitive surgery from 2003 to 2013 were reviewed. All patients were cN0 negative and classified as pathologically node-negative (pN0) if a neck dissection was performed. Patients received adjuvant radiotherapy (RT) or chemoradiotherapy (CRT) based on standard clinical and pathological determinants. Main Outcomes and Measures Kaplan-Meier and multivariable (MVA) logistic regression and Cox proportional hazard regression analyses were performed to identify patient, tumor, and treatment characteristics predictive of locoregional control (LRC) and overall survival (OS). Results A total of 180 patients met entry criteria, with a median follow-up time of 4.9 years (range, 0.9-12.5 years); 102 patients (56.7%) were female and 42 patients (23.3%) were younger than 45 years at diagnosis. One hundred fifty-three patients (85%) had T1/T2 tumors, and 112 patients (62%) had elective neck dissections with confirmed pN0. Lymphovascular space invasion (LVSI) was present in 36 patients (20%). On MVA, LVSI (OR, 0.06; 95% CI, 0.02-0.19; P < .01) was associated with worse LRC. Elective neck dissection (odds ratio [OR], 2.99; 95% CI, 1.16-7.73; P = .02) and receipt of RT (OR, 7.74; 95% CI, 2.27-26.42; P < .01) were associated with improved LRC. Three-year LRC rates were significantly lower for patients with LVSI (38.8%; 95% CI, 22.8%, 54.6%) than those without LVSI (81.9%; 95% CI, 74.4%, 87.4%). On MVA, only LVSI (hazard ratio, 2.20; 95% CI, 1.19-4.06; P = .01) and age greater than 44 years (hazard ratio, 4.38; 95% CI, 1.34-14.27; P = .01) were associated with worse OS. Three-year OS rates were significantly lower in patients with LVSI (71.3%; 95% CI, 53.2%-83.4%) than those without LVSI (90.3%; 95% CI, 83.8%-94.3%). Conclusions and Relevance Lymphovascular space invasion in patients with node-negative oral tongue cancer treated with upfront definitive surgery is associated with worse LRC and OS. Node-negative oral cavity cancers with LVSI warrant consideration of further adjuvant therapy, which should be further evaluated in a prospective setting.
Collapse
Affiliation(s)
- Richard J Cassidy
- Department of Radiation Oncology, Emory University, Atlanta, Georgia2Winship Cancer Institute at Emory University, Atlanta, Georgia
| | - Jeffrey M Switchenko
- Winship Cancer Institute at Emory University, Atlanta, Georgia3Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia
| | - Naresh Jegadeesh
- Department of Radiation Oncology, Emory University, Atlanta, Georgia2Winship Cancer Institute at Emory University, Atlanta, Georgia
| | - Mutlay Sayan
- University of Vermont, College of Medicine, Burlington5Department of Otolaryngology, Emory University, Atlanta, Georgia
| | - Matthew J Ferris
- Department of Radiation Oncology, Emory University, Atlanta, Georgia2Winship Cancer Institute at Emory University, Atlanta, Georgia
| | - Bree R Eaton
- Department of Radiation Oncology, Emory University, Atlanta, Georgia2Winship Cancer Institute at Emory University, Atlanta, Georgia
| | - Kristin A Higgins
- Department of Radiation Oncology, Emory University, Atlanta, Georgia2Winship Cancer Institute at Emory University, Atlanta, Georgia
| | - Jeffrey T Wadsworth
- Winship Cancer Institute at Emory University, Atlanta, Georgia5Department of Otolaryngology, Emory University, Atlanta, Georgia
| | - Kelly R Magliocca
- Winship Cancer Institute at Emory University, Atlanta, Georgia6Department of Pathology, Atlanta, Emory University, Georgia
| | - Nabil F Saba
- Winship Cancer Institute at Emory University, Atlanta, Georgia7Department of Medical Oncology, Emory University, Atlanta, Georgia
| | - Jonathan J Beitler
- Department of Radiation Oncology, Emory University, Atlanta, Georgia2Winship Cancer Institute at Emory University, Atlanta, Georgia5Department of Otolaryngology, Emory University, Atlanta, Georgia7Department of Medical Oncology, Emory University, Atlanta, Georgia
| |
Collapse
|
50
|
Nanda RH, Ganju RG, Schreibmann E, Chen Z, Zhang C, Jegadeesh N, Cassidy R, Deng C, Eaton BR, Esiashvili N. Correlation of Acute and Late Brainstem Toxicities With Dose-Volume Data for Pediatric Patients With Posterior Fossa Malignancies. Int J Radiat Oncol Biol Phys 2017; 98:360-366. [PMID: 28463155 DOI: 10.1016/j.ijrobp.2017.02.092] [Citation(s) in RCA: 14] [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: 09/09/2016] [Revised: 02/14/2017] [Accepted: 02/21/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE Radiation-induced brainstem toxicity after treatment of pediatric posterior fossa malignancies is incompletely understood, especially in the era of intensity modulated radiation therapy (IMRT). The rates of, and predictive factors for, brainstem toxicity after photon RT for posterior fossa tumors were examined. METHODS AND MATERIALS After institutional review board approval, 60 pediatric patients treated at our institution for nonmetastatic infratentorial ependymoma and medulloblastoma with IMRT were included in the present analysis. Dosimetric variables, including the mean and maximum dose to the brainstem, the dose to 10% to 90% of the brainstem (in 10% increments), and the volume of the brainstem receiving 40, 45, 50, and 55 Gy were recorded for each patient. Acute (onset within 3 months) and late (>3 months of RT completion) RT-induced brainstem toxicities with clinical and radiographic correlates were scored using Common Terminology Criteria for Adverse Events, version 4.0. RESULTS Patients aged 1.4 to 21.8 years underwent IMRT or volumetric arc therapy postoperatively to the posterior fossa or tumor bed. At a median clinical follow-up period of 2.8 years, 14 patients had developed symptomatic brainstem toxicity (crude incidence 23.3%). No correlation was found between the dosimetric variables examined and brainstem toxicity. Vascular injury or ischemia showed a strong trend toward predicting brainstem toxicity (P=.054). Patients with grade 3 to 5 brainstem toxicity had undergone treatment to significant volumes of the posterior fossa. CONCLUSION The results of the present series demonstrate a low, but not negligible, risk of brainstem radiation necrosis for pediatric patients with posterior fossa malignancies treated with IMRT. No specific dose-volume correlations were identified; however, modern treatment volumes might help limit the incidence of severe toxicity. Additional work investigating inherent biologic sensitivity might also provide further insight into this clinical problem.
Collapse
Affiliation(s)
- Ronica H Nanda
- Department of Radiation Oncology, Winship Cancer Institute, Emory University College of Medicine, Atlanta, Georgia.
| | - Rohit G Ganju
- Department of Radiation Oncology, Winship Cancer Institute, Emory University College of Medicine, Atlanta, Georgia
| | - Edward Schreibmann
- Department of Radiation Oncology, Winship Cancer Institute, Emory University College of Medicine, Atlanta, Georgia
| | - Zhengjia Chen
- Department of Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Chao Zhang
- Department of Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Naresh Jegadeesh
- Department of Radiation Oncology, Winship Cancer Institute, Emory University College of Medicine, Atlanta, Georgia
| | - Richard Cassidy
- Department of Radiation Oncology, Winship Cancer Institute, Emory University College of Medicine, Atlanta, Georgia
| | - Claudia Deng
- Department of Radiation Oncology, Winship Cancer Institute, Emory University College of Medicine, Atlanta, Georgia
| | - Bree R Eaton
- Department of Radiation Oncology, Winship Cancer Institute, Emory University College of Medicine, Atlanta, Georgia
| | - Natia Esiashvili
- Department of Radiation Oncology, Winship Cancer Institute, Emory University College of Medicine, Atlanta, Georgia
| |
Collapse
|