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Patel P, Dillon M, Niedzwiecki D, Crowell KA, Horwitz ME, Wang E, Kelsey CR. High risk of acute pulmonary toxicity with both myeloablative and non-myeloablative total body irradiation-based conditioning for allogeneic stem cell transplantation. Bone Marrow Transplant 2024; 59:150-152. [PMID: 37923832 DOI: 10.1038/s41409-023-02140-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 10/13/2023] [Accepted: 10/18/2023] [Indexed: 11/06/2023]
Affiliation(s)
- Pranalee Patel
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, 27710, USA
| | - Mairead Dillon
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, 27710, USA
| | - Donna Niedzwiecki
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, 27710, USA
| | - Kerri-Anne Crowell
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, 27710, USA
| | - Mitchell E Horwitz
- Department of Medicine, Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, NC, 27710, USA
| | - Edina Wang
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, 27710, USA
| | - Chris R Kelsey
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, 27710, USA.
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Kelsey CR, Dillon M, Niedzwiecki D, Horwitz M, Patel P. Acute Pulmonary Toxicity after Allogeneic Stem Cell Transplantation Using Total Body Irradiation-Based Conditioning- Myeloablative vs. Non-Myeloablative Regimens. Int J Radiat Oncol Biol Phys 2023; 117:S161. [PMID: 37784405 DOI: 10.1016/j.ijrobp.2023.06.254] [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) Allogeneic hematopoietic stem cell transplantation (HSCT) is associated with a high risk of acute pulmonary toxicity, especially with total body irradiation-based (TBI) conditioning regimens. High-grade acute pulmonary toxicity occurs in ∼30% of patients when a myeloablative regimen is utilized (∼12-14 Gy). The risk of pulmonary toxicity with non-myeloablative regimens (∼2 Gy) is not well described. We evaluated the incidence and predictors of acute pulmonary toxicity after HSCT comparing myeloablative and non-myeloablative TBI-based conditioning regimens. MATERIALS/METHODS All adult (≥ 18 y/o) patients undergoing allogeneic HSCT with TBI (1995-2020) at our institution were evaluated. The dose to the lungs was attenuated to 7-10 Gy in all patients undergoing myeloablative TBI. Acute pulmonary toxicity, occurring within 6 months of HSCT, was scored using CTCAE v5.0. The incidence of acute pulmonary toxicity was calculated using the Kaplan-Meier method, and logistic regression was performed to assess for independent risk factors. RESULTS Five hundred fifty-two patients were included the analysis (myeloablative- 378; non-myeloablative- 174). Myeloablative TBI was most commonly 13.5 Gy/9Fx (335/378), while non-myeloablative TBI was delivered most often as 2 Gy/1Fx (165/174). Patients undergoing myeloablative TBI were younger than non-myeloablative patients (43 vs 58 years, p<0.001), but baseline pulmonary function parameters were similar. At 6 months after transplant, the cumulative incidences of any acute pulmonary toxicity for patients receiving myeloablative and non-myeloablative TBI were 39% and 33%, respectively (p = 0.11). The risk of low-grade (1-2) and high grade (3-5) pulmonary toxicity was 10% vs 12% (p = 0.59) and 28% vs 21% (p = 0.05), respectively, comparing myeloablative and non-myeloablative TBI. Proportions of high-grade toxicities among the myeloablative and non-myeloablative cohorts were as follows: infectious pneumonia (31% and 49%), bronchopulmonary hemorrhage (25% and 3%), respiratory failure NOS (17% and 10%), pleural effusion (5% and 1%), and pneumonitis (4% and 0%). Female sex (OR 1.52, p = 0.05) and refractory disease at the time of transplant (OR 2.25, p = 0.03) were associated with a higher risk of severe pulmonary toxicity on logistic regression. Younger age (OR 0.99, p = 0.35) and non-myeloablative TBI (OR 0.21, p = 0.60) were not significantly associated with a lower risk. CONCLUSION The risk of acute pulmonary toxicity was high with both myeloablative and non-myeloablative TBI-based regimens, though high-grade toxicity was modestly higher in the myeloablative cohort. A better understanding of pulmonary toxicity in the setting of non-myeloablative TBI (∼2 Gy) is needed.
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Affiliation(s)
- C R Kelsey
- Duke University Medical Center, Department of Radiation Oncology, Durham, NC
| | - M Dillon
- Duke University Medical Center, Department of Biostatistics and Bioinformatics, Durham, NC
| | - D Niedzwiecki
- Duke University Medical Center, Department of Biostatistics and Bioinformatics, Durham, NC
| | - M Horwitz
- Duke University Medical Center, Department of Medicine, Durham, NC
| | - P Patel
- Duke University Medical Center, Department of Radiation Oncology, Durham, NC
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Patel P, Dillon M, Niedzwiecki D, Kelsey CR. Long-Term Toxicity after Total Body Irradiation-Based Conditioning Regimens for Allogeneic Stem Cell Transplantation. Int J Radiat Oncol Biol Phys 2023; 117:S162. [PMID: 37784407 DOI: 10.1016/j.ijrobp.2023.06.257] [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) Total body irradiation (TBI) is an integral component of many conditioning regimens prior to allogeneic hematopoietic stem cell transplantation (HSCT). Few studies have investigated long-term sequelae. A large series of patients undergoing myeloablative and non-myeloablative regimens was studied. MATERIALS/METHODS Adult patients undergoing allogeneic HSCT utilizing TBI-based conditioning regimens from 1995-2020 at our institution were included. Baseline treatment-related factors and long-term toxicities (developing, or persisting beyond, 6 months after HSCT) were collected. The cumulative incidence of long-term toxicities and overall survival (OS) were calculated. Cox regression was used to assess for predictors of toxicity. RESULTS Five hundred fifty-two patients were analyzed: 378 myeloablative (typically 13.5 Gy/9fx) and 174 non-myeloablative (typically 2 Gy/1fx) TBI recipients. Median follow-up was 7.4 years for surviving patients. Cumulative incidences of long-term toxicities at 5 and 10 years are included in the Table. The most common toxicities were: pulmonary- infectious pneumonia and respiratory failure NOS; cardiac- heart failure and myocardial infarction; other endocrine- adrenal insufficiency and testosterone deficiency. The most common secondary malignancy was non-melanoma skin cancer. The proportion of all toxicities that were high-grade (3-5) for myeloablative and non-myeloablative regimens, respectively, were: pulmonary (65%, 52%), cardiac (66%, 39%), renal (23%, 27%), and other endocrine (3%, 18%). Increasing number of chemotherapy regimens (p = 0.05) and umbilical cord donor (p = 0.02) were associated with long-term pulmonary toxicity. Male sex (p = 0.03), increasing number of chemotherapy regimens (p<0.01), and elevated creatinine after transplant (p<0.01) were associated with long-term renal toxicity. Cataract development was associated with increasing age at transplant (p = 0.02). OS (5 years) was 40% (42% -myeloablative; 33%-non-myeloablative). CONCLUSION Allogeneic HSCT, often preceded by TBI-based conditioning regimens, has significant survivorship challenges. Recipients of non-myeloablative regimens are still at risk of significant long-term multisystem toxicity despite much lower doses of TBI and chemotherapy. Pre-transplant factors such as cumulative chemotherapy exposure and age at transplant were associated with some toxicities.
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Affiliation(s)
- P Patel
- Duke University Medical Center, Department of Radiation Oncology, Durham, NC
| | - M Dillon
- Duke University Medical Center, Department of Biostatistics and Bioinformatics, Durham, NC
| | - D Niedzwiecki
- Duke University Medical Center, Department of Biostatistics and Bioinformatics, Durham, NC
| | - C R Kelsey
- Duke University Medical Center, Department of Radiation Oncology, Durham, NC
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Ackerson BG, Sperduto W, D'Anna R, Niedzwiecki D, Christensen J, Patel P, Mullikin TC, Kelsey CR. Divergent Interpretations of Imaging After Stereotactic Body Radiation Therapy for Lung Cancer. Pract Radiat Oncol 2023; 13:e126-e133. [PMID: 36375770 DOI: 10.1016/j.prro.2022.09.006] [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: 05/31/2022] [Revised: 09/19/2022] [Accepted: 09/24/2022] [Indexed: 11/13/2022]
Abstract
PURPOSE Conflicting information from health care providers contributes to anxiety among cancer patients. The purpose of this study was to investigate discordant interpretations of follow-up imaging studies after lung stereotactic body radiation therapy (SBRT) between radiologists and radiation oncologists. METHODS AND MATERIALS Patients treated with SBRT for stage I non-small cell lung cancer from 2007 to 2018 at Duke University Medical Center were included. Radiology interpretations of follow-up computed tomography (CT) chest or positron emission tomography (PET)/CT scans and the corresponding radiation oncology interpretations in follow-up notes from the medical record were assessed. Based on language used, interpretations were scored as concerning for progression (Progression), neutral differential listed (Neutral Differential), or favor stability/postradiation changes (Stable). Neutral Differential required that malignancy was specifically listed as a possibility in the differential. Encounters were categorized as discordant when either radiology or radiation oncology interpreted the surveillance imaging as Progression when the other interpreted the imaging study as Stable or Neutral Differential. The incidence of discordant interpretations was the primary endpoint of the study. RESULTS From 2007 to 2018, 139 patients were treated with SBRT and had available follow-up CT or PET-CT imaging for the analysis. Median follow-up was 61 months and the median number of follow-up encounters per patient was 3. Of 534 encounters evaluated, 25 (4.7%) had overtly discordant interpretations of imaging studies. This most commonly arose when radiology felt the imaging study showed Progression but radiation oncology favored Stable or Neutral Differential (24/25, 96%). No patient or treatment variables were found to be significantly associated with discordant interpretations on univariate analysis including type of scan (CT 22/489, 4.5%; PET-CT 3/45, 7%; P = .46). CONCLUSIONS Surveillance imaging after lung SBRT is often interpreted differently by radiologists and radiation oncologists, but overt discordance was relatively low at our institution. Providers should be aware of differences in interpretation patterns that may contribute to increased patient distress.
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Affiliation(s)
- Bradley G Ackerson
- Departments of Radiation Oncology, Duke University Medical Center, Durham, North Carolina.
| | - William Sperduto
- Departments of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Rachel D'Anna
- Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Donna Niedzwiecki
- Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Jared Christensen
- Division of Cardiothoracic Imaging, Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - Pranalee Patel
- Departments of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Trey C Mullikin
- Departments of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Chris R Kelsey
- Departments of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
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Foreman BE, Mullikin TC, Floyd SR, Kelsey CR, Patel MP, Peters KB, Kirkpatrick JP, Reitman ZJ, Vaios EJ. Long-term outcomes with reduced-dose whole-brain radiotherapy and a stereotactic radiosurgery boost for primary central nervous system lymphoma. Neurooncol Adv 2023; 5:vdad097. [PMID: 37706200 PMCID: PMC10496939 DOI: 10.1093/noajnl/vdad097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023] Open
Abstract
Background Primary central nervous system lymphoma (PCNSL) is an aggressive diffuse large B-cell lymphoma. Treatment approaches are historically associated with neurotoxicity, particularly with high-dose whole-brain radiotherapy (WBRT). We hypothesized that reduced dose-WBRT (rd-WBRT) followed by a stereotactic radiosurgery (SRS) boost could provide durable disease control without significant adverse effects. Methods We retrospectively reviewed PCNSL patients treated with rd-WBRT plus an SRS boost at Duke University between 2008 and 2021. Progression-free survival and overall survival (OS) were estimated using competing risk and Kaplan-Meier methods. Results We identified 23 patients with pathologically confirmed PCNSL. Median age at diagnosis was 69 years (Q1Q3: 52-74) and median Karnofsky Performance Scale (KPS) was 80 (Q1Q3: 70-80). Median follow-up was 21 months. Median doses for rd-WBRT and SRS were 23.4 Gy (Q1Q3: 23.4-23.4) and 12 Gy (Q1Q3: 12-12.5), respectively. The cumulative incidence of intracranial progression at 2 years was 23% (95% CI: 8-42). Six patients (26%) developed distant radiographic progression while 2 patients (9%) developed both distant and local progression. Ten patients (44%) were alive without progression at last follow-up. By Kaplan-Meier estimate, the 2-year OS was 69% (95% CI: 46-84). There were no reported grade 3 + radiation-induced toxicities. Conclusions The combination of rd-WBRT with an SRS boost appears well-tolerated with durable intracranial control. This approach may represent a treatment option for select patients, such as those with progressive or refractory disease. Further prospective studies are needed to validate these findings and determine whether this approach could be incorporated into consolidation strategies.
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Affiliation(s)
| | - Trey C Mullikin
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Scott R Floyd
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Chris R Kelsey
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
| | - Mallika P Patel
- Department of Pharmacy, Duke University Medical Center, Durham, NC, USA
- The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA
| | - Katherine B Peters
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - John P Kirkpatrick
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
- The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA
| | - Zachary J Reitman
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
- Department of Pathology, Duke University Medical Center, Durham, NC, USA
- The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA
| | - Eugene J Vaios
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
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Jones G, Plastaras JP, Ng AK, Kelsey CR. The Evolving Role of Radiation Therapy in DLBCL: From Early-Stage to Refractory Disease. Oncology (Williston Park) 2022; 36:718-727. [PMID: 36548096 DOI: 10.46883/2022.25920980] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma. Historically, radiation therapy (RT) served as the primary treatment modality for patients with localized disease. While still an option for select patients who are not candidates for systemic therapy, RT is currently used most frequently as a consolidation treatment after chemoimmunotherapy. Consolidation RT is most commonly recommended after an abbreviated course of systemic therapy in patients who have bulky disease or multiple risk factors, or in the setting of a partial response. Consolidation RT is also appropriate in some patients with advanced DLBCL, including those presenting with bulky disease (≥7.5 cm). While many patients achieve sustained remissions after first-line therapy, up to 50% of patients with DLBCL will eventually relapse. The most common salvage options include second-line chemotherapy followed by high-dose chemotherapy and autologous stem cell transplantation (ASCT) and chimeric antigen receptor (CAR) T-cell therapy. RT can be used in both settings to optimize clinical outcomes. This includes consolidation RT in patients with localized presentations or bulky disease in the setting of ASCT and bridging RT in select patients undergoing CAR T-cell therapy. RT is also a valuable modality in any patient with symptomatic disease requiring palliation.
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Patel P, Dillon M, Niedzwiecki D, Horwitz ME, Kelsey CR. Optimizing Management of the Central Nervous System in Patients with Acute Lymphoblastic Leukemia Undergoing Allogeneic Stem Cell Transplantation. Adv Radiat Oncol 2022; 8:101082. [PMID: 36845621 PMCID: PMC9943767 DOI: 10.1016/j.adro.2022.101082] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 09/15/2022] [Indexed: 12/14/2022] Open
Abstract
Purpose To evaluate clinical outcomes and patterns of failure, specifically in regards to the central nervous system (CNS), in patients with acute lymphoblastic leukemia (ALL) undergoing allogeneic hematopoietic stem cell transplantation (HSCT) using total body irradiation (TBI)-based conditioning regimens. Methods and Materials All adult patients (aged ≥18 years) with ALL undergoing allogeneic HSCT using TBI-based conditioning regimens treated from 1995 to 2020 at Duke University Medical Center were evaluated. Various patient, disease, and treatment-related factors were collected, including CNS prophylaxis and treatment interventions. Clinical outcomes, including freedom from CNS relapse, were calculated using the Kaplan-Meier method for patients with and without CNS disease at presentation. Results One hundred and fifteen patients with ALL were included the analysis (myeloablative, 110; nonmyeloablative, 5). Of the 110 patients undergoing a myeloablative regimen, most (n = 100) did not have CNS disease before transplant. For this subgroup, peritransplant intrathecal chemotherapy was administered in 76% (median of 4 cycles) and 10 received a radiation boost to the CNS (cranial irradiation, 5; craniospinal, 5). Only 4 failed in the CNS after transplant, none of whom received a CNS boost, with freedom from CNS relapse at 5 years of 95% (95% confidence interval (CI), 84-98%). Freedom from CNS relapse was not improved with a radiation therapy boost to the CNS (100% vs 94%, P = .59). Overall survival, leukemia-free survival, and nonrelapse mortality at 5 years were 50%, 42%, and 36%, respectively. Among the 10 patients with CNS disease before transplant, 10 of 10 received intrathecal chemotherapy and 7 received a radiation boost to the CNS (cranial irradiation, 1; craniospinal, 6) and none subsequently failed in the CNS. A nonmyeloablative HSCT was pursued for 5 patients because of advanced age or comorbidities. None of these patients had prior CNS disease or received a CNS or testicular boost, and none failed in the CNS after transplant. Conclusions A CNS boost may not be necessary in patients with high-risk ALL without CNS disease undergoing a myeloablative HSCT using a TBI-based regimen. Favorable outcomes were observed with a low-dose craniospinal boost in patients with CNS disease.
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Affiliation(s)
- Pranalee Patel
- Departments of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Mairead Dillon
- Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Donna Niedzwiecki
- Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Mitchell E. Horwitz
- Medicine, Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Chris R. Kelsey
- Departments of Radiation Oncology, Duke University Medical Center, Durham, North Carolina,Corresponding author: Chris R. Kelsey, MD
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Erickson BG, Ackerson BG, Kelsey CR, Yin FF, Adamson J, Cui Y. The effect of various dose normalization strategies when implementing linear Boltzmann transport equation dose calculation for lung SBRT planning. Pract Radiat Oncol 2022; 12:446-456. [DOI: 10.1016/j.prro.2022.02.005] [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] [Received: 10/21/2021] [Revised: 01/19/2022] [Accepted: 02/07/2022] [Indexed: 11/16/2022]
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Lafata KJ, Corradetti MN, Gao J, Jacobs CD, Weng J, Chang Y, Wang C, Hatch A, Xanthopoulos E, Jones G, Kelsey CR, Yin FF. Radiogenomic Analysis of Locally Advanced Lung Cancer Based on CT Imaging and Intratreatment Changes in Cell-Free DNA. Radiol Imaging Cancer 2021; 3:e200157. [PMID: 34114913 DOI: 10.1148/rycan.2021200157] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The radiologic appearance of locally advanced lung cancer may be linked to molecular changes of the disease during treatment, but characteristics of this phenomenon are poorly understood. Radiomics, liquid biopsy of cell-free DNA (cfDNA), and next-generation sequencing of circulating tumor DNA (ctDNA) encode tumor-specific radiogenomic expression patterns that can be probed to study this problem. Preliminary findings are reported from a radiogenomic analysis of CT imaging, cfDNA, and ctDNA in 24 patients (median age, 64 years; range, 49-74 years) with stage III lung cancer undergoing chemoradiation on a prospective pilot study (NCT00921739) between September 2009 and September 2014. Unsupervised clustering of radiomic signatures resulted in two clusters that were associated with ctDNA TP53 mutations (P = .03) and changes in cfDNA concentration after 2 weeks of chemoradiation (P = .02). The radiomic features dissimilarity (hazard ratio [HR] = 0.56; P = .05), joint entropy (HR = 0.56; P = .04), sum entropy (HR = 0.53; P = .02), and normalized inverse difference (HR = 1.77; P = .05) were associated with overall survival. These results suggest heterogeneous and low-attenuating disease without a detectable ctDNA TP53 mutation was associated with early surges of cfDNA concentration in response to therapy and a generally better prognosis. Keywords: CT-Quantitative, Radiation Therapy, Lung, Computer Applications-3D, Oncology, Tumor Response, Outcomes Analysis Clinical trial registration no. NCT00921739 Supplemental material is available for this article. © RSNA, 2021.
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Affiliation(s)
- Kyle J Lafata
- From the Departments of Radiation Oncology (K.J.L., M.N.C., C.D.J., J.W., Y.C., C.W., C.R.K., F.F.Y.), Radiology (K.J.L.), Biostatistics and Bioinformatics (J.G.), and Medicine (A.H.), Duke University School of Medicine, 2301 Erwin Rd, Durham, NC 27710; Department of Electrical and Computer Engineering, Duke University Pratt School of Engineering, Durham, NC (K.J.L.); Radiology Medical Group of Napa, Napa, Calif (M.N.C.); Department of Radiation Oncology, Columbia University School of Medicine, New York, NY (E.X.); and Inivata, Cambridge, England (G.J.)
| | - Michael N Corradetti
- From the Departments of Radiation Oncology (K.J.L., M.N.C., C.D.J., J.W., Y.C., C.W., C.R.K., F.F.Y.), Radiology (K.J.L.), Biostatistics and Bioinformatics (J.G.), and Medicine (A.H.), Duke University School of Medicine, 2301 Erwin Rd, Durham, NC 27710; Department of Electrical and Computer Engineering, Duke University Pratt School of Engineering, Durham, NC (K.J.L.); Radiology Medical Group of Napa, Napa, Calif (M.N.C.); Department of Radiation Oncology, Columbia University School of Medicine, New York, NY (E.X.); and Inivata, Cambridge, England (G.J.)
| | - Junheng Gao
- From the Departments of Radiation Oncology (K.J.L., M.N.C., C.D.J., J.W., Y.C., C.W., C.R.K., F.F.Y.), Radiology (K.J.L.), Biostatistics and Bioinformatics (J.G.), and Medicine (A.H.), Duke University School of Medicine, 2301 Erwin Rd, Durham, NC 27710; Department of Electrical and Computer Engineering, Duke University Pratt School of Engineering, Durham, NC (K.J.L.); Radiology Medical Group of Napa, Napa, Calif (M.N.C.); Department of Radiation Oncology, Columbia University School of Medicine, New York, NY (E.X.); and Inivata, Cambridge, England (G.J.)
| | - Corbin D Jacobs
- From the Departments of Radiation Oncology (K.J.L., M.N.C., C.D.J., J.W., Y.C., C.W., C.R.K., F.F.Y.), Radiology (K.J.L.), Biostatistics and Bioinformatics (J.G.), and Medicine (A.H.), Duke University School of Medicine, 2301 Erwin Rd, Durham, NC 27710; Department of Electrical and Computer Engineering, Duke University Pratt School of Engineering, Durham, NC (K.J.L.); Radiology Medical Group of Napa, Napa, Calif (M.N.C.); Department of Radiation Oncology, Columbia University School of Medicine, New York, NY (E.X.); and Inivata, Cambridge, England (G.J.)
| | - Jingxi Weng
- From the Departments of Radiation Oncology (K.J.L., M.N.C., C.D.J., J.W., Y.C., C.W., C.R.K., F.F.Y.), Radiology (K.J.L.), Biostatistics and Bioinformatics (J.G.), and Medicine (A.H.), Duke University School of Medicine, 2301 Erwin Rd, Durham, NC 27710; Department of Electrical and Computer Engineering, Duke University Pratt School of Engineering, Durham, NC (K.J.L.); Radiology Medical Group of Napa, Napa, Calif (M.N.C.); Department of Radiation Oncology, Columbia University School of Medicine, New York, NY (E.X.); and Inivata, Cambridge, England (G.J.)
| | - Yushi Chang
- From the Departments of Radiation Oncology (K.J.L., M.N.C., C.D.J., J.W., Y.C., C.W., C.R.K., F.F.Y.), Radiology (K.J.L.), Biostatistics and Bioinformatics (J.G.), and Medicine (A.H.), Duke University School of Medicine, 2301 Erwin Rd, Durham, NC 27710; Department of Electrical and Computer Engineering, Duke University Pratt School of Engineering, Durham, NC (K.J.L.); Radiology Medical Group of Napa, Napa, Calif (M.N.C.); Department of Radiation Oncology, Columbia University School of Medicine, New York, NY (E.X.); and Inivata, Cambridge, England (G.J.)
| | - Chunhao Wang
- From the Departments of Radiation Oncology (K.J.L., M.N.C., C.D.J., J.W., Y.C., C.W., C.R.K., F.F.Y.), Radiology (K.J.L.), Biostatistics and Bioinformatics (J.G.), and Medicine (A.H.), Duke University School of Medicine, 2301 Erwin Rd, Durham, NC 27710; Department of Electrical and Computer Engineering, Duke University Pratt School of Engineering, Durham, NC (K.J.L.); Radiology Medical Group of Napa, Napa, Calif (M.N.C.); Department of Radiation Oncology, Columbia University School of Medicine, New York, NY (E.X.); and Inivata, Cambridge, England (G.J.)
| | - Ace Hatch
- From the Departments of Radiation Oncology (K.J.L., M.N.C., C.D.J., J.W., Y.C., C.W., C.R.K., F.F.Y.), Radiology (K.J.L.), Biostatistics and Bioinformatics (J.G.), and Medicine (A.H.), Duke University School of Medicine, 2301 Erwin Rd, Durham, NC 27710; Department of Electrical and Computer Engineering, Duke University Pratt School of Engineering, Durham, NC (K.J.L.); Radiology Medical Group of Napa, Napa, Calif (M.N.C.); Department of Radiation Oncology, Columbia University School of Medicine, New York, NY (E.X.); and Inivata, Cambridge, England (G.J.)
| | - Eric Xanthopoulos
- From the Departments of Radiation Oncology (K.J.L., M.N.C., C.D.J., J.W., Y.C., C.W., C.R.K., F.F.Y.), Radiology (K.J.L.), Biostatistics and Bioinformatics (J.G.), and Medicine (A.H.), Duke University School of Medicine, 2301 Erwin Rd, Durham, NC 27710; Department of Electrical and Computer Engineering, Duke University Pratt School of Engineering, Durham, NC (K.J.L.); Radiology Medical Group of Napa, Napa, Calif (M.N.C.); Department of Radiation Oncology, Columbia University School of Medicine, New York, NY (E.X.); and Inivata, Cambridge, England (G.J.)
| | - Greg Jones
- From the Departments of Radiation Oncology (K.J.L., M.N.C., C.D.J., J.W., Y.C., C.W., C.R.K., F.F.Y.), Radiology (K.J.L.), Biostatistics and Bioinformatics (J.G.), and Medicine (A.H.), Duke University School of Medicine, 2301 Erwin Rd, Durham, NC 27710; Department of Electrical and Computer Engineering, Duke University Pratt School of Engineering, Durham, NC (K.J.L.); Radiology Medical Group of Napa, Napa, Calif (M.N.C.); Department of Radiation Oncology, Columbia University School of Medicine, New York, NY (E.X.); and Inivata, Cambridge, England (G.J.)
| | - Chris R Kelsey
- From the Departments of Radiation Oncology (K.J.L., M.N.C., C.D.J., J.W., Y.C., C.W., C.R.K., F.F.Y.), Radiology (K.J.L.), Biostatistics and Bioinformatics (J.G.), and Medicine (A.H.), Duke University School of Medicine, 2301 Erwin Rd, Durham, NC 27710; Department of Electrical and Computer Engineering, Duke University Pratt School of Engineering, Durham, NC (K.J.L.); Radiology Medical Group of Napa, Napa, Calif (M.N.C.); Department of Radiation Oncology, Columbia University School of Medicine, New York, NY (E.X.); and Inivata, Cambridge, England (G.J.)
| | - Fang-Fang Yin
- From the Departments of Radiation Oncology (K.J.L., M.N.C., C.D.J., J.W., Y.C., C.W., C.R.K., F.F.Y.), Radiology (K.J.L.), Biostatistics and Bioinformatics (J.G.), and Medicine (A.H.), Duke University School of Medicine, 2301 Erwin Rd, Durham, NC 27710; Department of Electrical and Computer Engineering, Duke University Pratt School of Engineering, Durham, NC (K.J.L.); Radiology Medical Group of Napa, Napa, Calif (M.N.C.); Department of Radiation Oncology, Columbia University School of Medicine, New York, NY (E.X.); and Inivata, Cambridge, England (G.J.)
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Jacobs CD, Mehta K, Gao J, Wang X, Salama JK, Kelsey CR, Torok JA. Nomogram Predicting Overall Survival Benefit of Stereotactic Ablative Radiotherapy for Early-Stage Non-Small Cell Lung Cancer. Clin Lung Cancer 2021; 23:177-184. [PMID: 34301453 DOI: 10.1016/j.cllc.2021.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 05/27/2021] [Accepted: 06/15/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To develop and validate a nomogram that predicts overall survival (OS) for patients with early-stage non-small cell lung cancer (NSCLC) treated with stereotactic ablative radiotherapy (SABR) vs. observation. MATERIALS AND METHODS Adults with biopsy-proven T1-T2N0 NCSLC treated with SABR (30-70 Gy in 1-10 fractions with biologically effective dose ≥100 Gy10) or observation between 2004 and 2015 in the National Cancer Database (NCDB) were identified. Propensity score was used to match SABR and observation cohorts on prognostic demographic and clinicopathologic factors identified by logistic regression. Using backward selection, a multivariable Cox proportional hazard was identified predicting 2- and 5-year OS via a nomogram. Model prediction accuracy was assessed by time-dependent receiver operating characteristic (ROC) curves and integrated area under the ROC curve (AUC) analysis. RESULTS A total of 22,073 adults met inclusion criteria and 4418 matched pairs (total n = 8836) were identified for nomogram development. The factors most strongly associated with improved OS on multivariable analysis included younger age (HR 0.82 by decade, P < .001), female sex (HR 0.81, P < .001), lower comorbidity index (HR 0.65 for 0 vs. ≥3, P < .001), smaller tumor size (HR 0.60 for ≤3 cm vs. 5.1-7 cm, P < .001), adenocarcinoma histology (P < .001), and receipt of SABR (P < .001). Interaction between SABR and histology was significantly associated with OS (P = .017). Relative to adenocarcinoma, patients with squamous cell carcinoma who were observed (HR 1.44, 95% CI 1.33-1.56) or treated with SABR (HR 1.24, 95% CI 1.14-1.35) had significantly worse OS. The nomogram demonstrated fair accuracy for predicting OS, with an integrated time-dependent AUC of 0.694 over the entire follow-up period. CONCLUSION This nomogram estimates OS at 2 and 5 years based on whether medically inoperable early-stage NSCLC patients receive SABR or elect for observation. Incorporation of other variables not captured within the NCDB may improve the model accuracy.
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Affiliation(s)
- Corbin D Jacobs
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC
| | - Kurren Mehta
- Department of Internal Medicine, Duke University Hospital, Durham, NC
| | - Junheng Gao
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC
| | - Xiaofei Wang
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC
| | - Joseph K Salama
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC
| | - Chris R Kelsey
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC
| | - Jordan A Torok
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC.
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11
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Mistro M, Sheng Y, Ge Y, Kelsey CR, Palta JR, Cai J, Wu Q, Yin FF, Wu QJ. Knowledge Models as Teaching Aid for Training Intensity Modulated Radiation Therapy Planning: A Lung Cancer Case Study. Front Artif Intell 2021; 3:66. [PMID: 33733183 PMCID: PMC7861316 DOI: 10.3389/frai.2020.00066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 07/21/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose: Artificial intelligence (AI) employs knowledge models that often behave as a black-box to the majority of users and are not designed to improve the skill level of users. In this study, we aim to demonstrate the feasibility that AI can serve as an effective teaching aid to train individuals to develop optimal intensity modulated radiation therapy (IMRT) plans. Methods and Materials: The training program is composed of a host of training cases and a tutoring system that consists of a front-end visualization module powered by knowledge models and a scoring system. The current tutoring system includes a beam angle prediction model and a dose-volume histogram (DVH) prediction model. The scoring system consists of physician chosen criteria for clinical plan evaluation as well as specially designed criteria for learning guidance. The training program includes six lung/mediastinum IMRT patients: one benchmark case and five training cases. A plan for the benchmark case is completed by each trainee entirely independently pre- and post-training. Five training cases cover a wide spectrum of complexity from easy (2), intermediate (1) to hard (2). Five trainees completed the training program with the help of one trainer. Plans designed by the trainees were evaluated by both the scoring system and a radiation oncologist to quantify planning quality. Results: For the benchmark case, trainees scored an average of 21.6% of the total max points pre-training and improved to an average of 51.8% post-training. In comparison, the benchmark case's clinical plans score an average of 54.1% of the total max points. Two of the five trainees' post-training plans on the benchmark case were rated as comparable to the clinically delivered plans by the physician and all five were noticeably improved by the physician's standards. The total training time for each trainee ranged between 9 and 12 h. Conclusion: This first attempt at a knowledge model based training program brought unexperienced planners to a level close to experienced planners in fewer than 2 days. The proposed tutoring system can serve as an important component in an AI ecosystem that will enable clinical practitioners to effectively and confidently use KBP.
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Affiliation(s)
- Matt Mistro
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States.,Medical Physics Graduate Program, Duke University, Durham, NC, United States
| | - Yang Sheng
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States
| | - Yaorong Ge
- Department of Software and Information Systems, University of North Carolina at Charlotte, Charlotte, NC, United States
| | - Chris R Kelsey
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States
| | - Jatinder R Palta
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, United States
| | - Jing Cai
- Department of Health Technology and Informatics, Hong Kong Polytechnic University, Hong Kong, China
| | - Qiuwen Wu
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States
| | - Fang-Fang Yin
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States
| | - Q Jackie Wu
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States
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12
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Chodavadia PA, Jacobs CD, Wang F, Salama JK, Kelsey CR, Clarke JM, Ready NE, Torok JA. Synergy between early-incorporation immunotherapy and extracranial radiotherapy in metastatic non-small cell lung cancer. Transl Lung Cancer Res 2021; 10:261-273. [PMID: 33569310 PMCID: PMC7867754 DOI: 10.21037/tlcr-20-537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Combining radiotherapy (RT) and immunotherapy (IT) may enhance outcomes for metastatic non-small cell lung cancer (mNSCLC). However, data on the immunomodulatory effects of extracranial RT remains limited. This retrospective database analysis examined real-world practice patterns, predictors of survival, and comparative effectiveness of extracranial radioimmunotherapy (RT + IT) versus early-incorporation immunotherapy (eIT) in patients with mNSCLC. Methods Patients diagnosed with mNSCLC between 2004-2016 treated with eIT or RT + IT were identified in the National Cancer Database. Practice patterns were assessed using Cochrane-Armitrage trend test. Cox proportional hazards and Kaplan-Meier method were used to analyze overall survival (OS). Propensity score matching was performed to account for baseline imbalances. Biologically effective doses (BED) were stratified based on the median (39 Gy10). Stereotactic body radiotherapy (SBRT) was defined as above median BED in ≤5 fractions. Results eIT utilization increased from 0.3% in 2010 to 13.2% in 2016 (P<0.0001). Rates of RT + eIT increased from 38.8% in 2010 to 49.1% in 2016 among those who received eIT (P<0.0001). Compared to eIT alone, RT + eIT demonstrated worse median OS (11.2 vs. 13.2 months) while SBRT + eIT demonstrated improved median OS (25 vs. 13.2 months) (P<0.0001). There were no significant differences in OS based on sequencing of eIT relative to RT (log-rank P=0.4415) or irradiated site (log-rank P=0.1606). On multivariate analysis, factors associated with improved OS included chemotherapy (HR 0.86, P=0.0058), treatment at academic facilities (HR 0.83, P<0.0001), and SBRT (HR 0.60, P=0.0009); after propensity-score multivariate analysis, SBRT alone showed improved OS (HR 0.28, P<0.0001). Conclusions Utilization of RT + eIT in mNSCLC is increasing. SBRT + eIT was associated with improved OS on propensity-score matched analysis. There were no significant differences in OS based on RT + eIT sequencing or site irradiated. Whether these observations reflect patient selection or possible immunomodulatory benefits of RT is unclear and warrants further study.
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Affiliation(s)
| | - Corbin D Jacobs
- Department of Radiation Oncology, Duke University, Durham, NC 27710, USA
| | - Frances Wang
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC 27710, USA
| | - Joseph K Salama
- Department of Radiation Oncology, Duke University, Durham, NC 27710, USA
| | - Chris R Kelsey
- Department of Radiation Oncology, Duke University, Durham, NC 27710, USA
| | - Jeffrey M Clarke
- Duke Cancer Institute, Duke University Medical Center, Durham, NC 27710, USA
| | - Neal E Ready
- Duke Cancer Institute, Duke University Medical Center, Durham, NC 27710, USA
| | - Jordan A Torok
- Department of Radiation Oncology, Duke University, Durham, NC 27710, USA
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Fairchild A, McCall CM, Oyekunle T, Niedzwiecki D, Champ C, McKinney M, Kelsey CR. Primary Mediastinal (Thymic) Large B-Cell Lymphoma: Fidelity of Diagnosis Using WHO Criteria. Clin Lymphoma Myeloma Leuk 2020; 21:e464-e469. [PMID: 33487576 DOI: 10.1016/j.clml.2020.12.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 12/11/2020] [Accepted: 12/19/2020] [Indexed: 11/18/2022]
Abstract
PURPOSE Diagnosing primary mediastinal (thymic) large B-cell lymphoma (PMBCL) is challenging because it is a clinicopathologic entity that shares characteristics with other lymphomas and lacks pathognomonic features. We sought to investigate the fidelity between a working diagnosis of PMBCL at our institution and the clinicopathologic criteria established within the 2017 World Health Organization (WHO) classification. PATIENTS AND METHODS Medical records and archived tissue of patients treated for stage I-II PMBCL from 1998 to 2018 were retrospectively reviewed for clinical and pathologic conformity with current WHO criteria. Disease was characterized as definitely PMBCL if all of the following were present: anterior mediastinal mass with or without lymph node involvement, no extranodal disease, B-cell antigen expression, Epstein-Barr virus negativity, and at least one supportive feature: female gender under age 40, bulky primary tumor, CD30 weakly positive, compartmentalizing alveolar fibrosis, lack of surface immunoglobulin expression, and MUM1 or CD23 positivity. Disease without supportive features or other pathologic findings more suggestive of other entities was characterized as equivocal for PMBCL. Lack of an anterior mediastinal mass, presence of distant lymph node involvement or extranodal disease, lack of B-cell antigen expression, or Epstein-Barr virus positivity were characterized as definitely not PMBCL. Clinical management and outcomes were also assessed. RESULTS Of 63 patients treated for presumed stage I-II PMBCL, 58 (92%) met the criteria for PMBCL. The most common reason for a discordant diagnosis was lack of an anterior mediastinal mass (n = 3). Two additional patients were characterized as having disease equivocal for PMBCL. In retrospect, one patient most likely had a mediastinal gray zone lymphoma due to CD15 positivity and another diffuse large B cell, not otherwise specified, at pathologic review. Five-year progression-free and overall survival were 67% (95% confidence interval, 54-77) and 81% (95% confidence interval, 68-89), respectively, for all patients. CONCLUSION Despite the complexity of the clinicopathologic criteria of PMBCL, most patients (92%) who were treated for stage I-II PMBCL at our institution appear to have been accurately diagnosed.
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Affiliation(s)
- Andrew Fairchild
- Department of Radiation Oncology Duke University Medical Center, Durham, NC.
| | - Chad M McCall
- Department of Pathology, Duke University Medical Center, Durham, NC
| | - Taofik Oyekunle
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC
| | - Donna Niedzwiecki
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC
| | - Colin Champ
- Department of Radiation Oncology Duke University Medical Center, Durham, NC
| | - Matthew McKinney
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, NC
| | - Chris R Kelsey
- Department of Radiation Oncology Duke University Medical Center, Durham, NC
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14
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Kelsey CR. Excessive Exposure. Int J Radiat Oncol Biol Phys 2020; 106:462. [DOI: 10.1016/j.ijrobp.2019.02.023] [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] [Received: 12/18/2018] [Revised: 12/18/2018] [Accepted: 02/06/2019] [Indexed: 10/25/2022]
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15
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Gao H, Kelsey CR, Boyle J, Xie T, Catalano S, Wang X, Yin FF. Impact of Esophageal Motion on Dosimetry and Toxicity With Thoracic Radiation Therapy. Technol Cancer Res Treat 2019; 18:1533033819849073. [PMID: 31130076 PMCID: PMC6537299 DOI: 10.1177/1533033819849073] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Purpose: To investigate the impact of intra- and inter-fractional esophageal motion on dosimetry
and observed toxicity in a phase I dose escalation study of accelerated radiotherapy
with concurrent chemotherapy for locally advanced lung cancer. Methods and Materials: Patients underwent computed tomography imaging for radiotherapy treatment planning (CT1
and 4DCT1) and at 2 weeks (CT2 and 4DCT2) and 5 weeks (CT3 and 4DCT3) after initiating
treatment. Each computed tomography scan consisted of 10-phase 4DCTs in addition to a
static free-breathing or breath-hold computed tomography. The esophagus was
independently contoured on all computed tomographies and 4DCTs. Both CT2 and CT3 were
rigidly registered with CT1 and doses were recalculated using the original
intensity-modulated radiation therapy plan based on CT1 to assess the impact of
interfractional motion on esophageal dosimetry. Similarly, 4DCT1 data sets were rigidly
registered with CT1 to assess the impact of intrafractional motion. The motion was
characterized based on the statistical analysis of slice-by-slice center shifts (after
registration) for the upper, middle, and lower esophageal regions, respectively. For the
dosimetric analysis, the following quantities were calculated and assessed for
correlation with toxicity grade: the percent volumes of esophagus that received at least
20 Gy (V20) and 60 Gy (V60), maximum esophageal dose, equivalent uniform dose, and
normal tissue complication probability. Results: The interfractional center shifts were 4.4 ± 1.7 mm, 5.5 ± 2.0 mm and 4.9 ± 2.1 mm for
the upper, middle, and lower esophageal regions, respectively, while the intrafractional
center shifts were 0.6 ± 0.4 mm, 0.7 ± 0.7 mm, and 0.9 ± 0.7 mm, respectively. The mean
V60 (and corresponding normal tissue complication probability) values estimated from the
interfractional motion analysis were 7.8% (10%), 4.6% (7.5%), 7.5% (8.6%), and 31% (26%)
for grade 0, grade 1, grade 2, and grade 3 toxicities, respectively. Conclusions: Interfractional esophageal motion is significantly larger than intrafractional motion.
The mean values of V60 and corresponding normal tissue complication probability,
incorporating interfractional esophageal motion, correlated positively with esophageal
toxicity grade.
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Affiliation(s)
- Hao Gao
- 1 Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Chris R Kelsey
- 1 Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - John Boyle
- 2 Essentia Health Radiation Oncology, Northwest Wisconsin Cancer Center, Ashland, WI, USA
| | - Tianyi Xie
- 1 Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Suzanne Catalano
- 1 Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Xiaofei Wang
- 3 Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA
| | - Fang-Fang Yin
- 1 Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA.,4 Medical Physics Graduate Program, Duke Kunshan University, Kunshan, Jiangsu, China
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16
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Jacobs CD, Gao J, Wang X, Clarke JM, Tong B, Ready NE, Suneja G, Kelsey CR, Torok JA. Definitive Radiotherapy for Inoperable Stage IIB Non-small-cell Lung Cancer: Patterns of Care and Comparative Effectiveness. Clin Lung Cancer 2019; 21:238-246. [PMID: 31757764 DOI: 10.1016/j.cllc.2019.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 07/01/2019] [Accepted: 10/01/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND The purpose of this study was to analyze practice patterns and perform comparative effectiveness of definitive radiotherapy techniques for inoperable stage IIB (American Joint Committee on Cancer eighth edition) non-small-cell lung cancer (NSCLC). MATERIALS AND METHODS Adults in the National Cancer Database diagnosed with T3N0M0 or T1-2N1M0 NCSLC between 2004 and 2015 who received definitive radiotherapy were identified. Cases were divided as stereotactic body radiotherapy (SBRT), hypofractionated radiotherapy (HFRT), or conventionally fractionated radiotherapy (CFRT) and stratified by systemic therapy (ST). Cox proportional hazards models evaluated the effect of covariates on overall survival (OS). Subgroup analysis by tumor size, chest wall invasion, multifocality, and ST use was performed with Kaplan-Meier estimates of OS. RESULTS A total of 10,081 subjects met inclusion criteria: 4401 T3N0M0 (66.5% CFRT, 11.0% HFRT, and 22.5% SBRT) and 5680 T1-2N1M0 (92.5% CFRT and 7.5% HFRT). For T3N0M0 NSCLC, SBRT utilization increased from 3.7% in 2006% to 35.4% in 2015. Subjects treated with SBRT were more likely to have smaller tumors, multifocal tumors, or adenocarcinoma histology. SBRT resulted in similar or superior OS compared with CFRT for tumors > 5 cm, tumors invading the chest wall, or multifocal tumors. SBRT was significantly associated with improved OS on multivariate analysis (hazard ratio, 0.715; P < .001). For T1-2N1M0 NSCLC, patients treated with HFRT were significantly older and less likely to receive ST; nevertheless, there was no difference in OS between HFRT and CFRT on multivariate analysis. CONCLUSION CFRT + ST is utilized most frequently to treat stage IIB NSCLC in the United States when surgery is not performed, though it is decreasing. SBRT utilization for T3N0M0 NSCLC is increasing and was associated with improved OS.
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Affiliation(s)
- Corbin D Jacobs
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC
| | - Junheng Gao
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC
| | - Xiaofei Wang
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC
| | - Jeffrey M Clarke
- Department of Medical Oncology, Duke University Medical Center, Durham, NC
| | - Betty Tong
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC
| | - Neal E Ready
- Department of Medical Oncology, Duke University Medical Center, Durham, NC
| | - Gita Suneja
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC
| | - Chris R Kelsey
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC
| | - Jordan A Torok
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC.
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Kelsey CR, Broadwater G, James O, Chino J, Diehl L, Beaven AW, Chang C, Koontz BF, Prosnitz LR. Phase 2 Study of Dose-Reduced Consolidation Radiation Therapy in Diffuse Large B-Cell Lymphoma. Int J Radiat Oncol Biol Phys 2019; 105:96-101. [PMID: 30858144 PMCID: PMC10171462 DOI: 10.1016/j.ijrobp.2019.02.055] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 02/04/2019] [Accepted: 02/26/2019] [Indexed: 01/19/2023]
Abstract
PURPOSE To evaluate the feasibility of reducing the dose of consolidation radiation therapy (RT) in diffuse large B-cell lymphoma. METHODS AND MATERIALS This phase 2 study enrolled patients with diffuse large B-cell lymphoma, not otherwise specified and primary mediastinal (thymic) large B-cell lymphoma in complete response on positron emission tomography-computed tomography imaging after ≥4 cycles of a rituximab/anthracycline-containing combination chemotherapy regimen. Consolidation RT used a dose of 19.5 to 20 Gy. The primary endpoint was 5-year freedom from local recurrence. RESULTS Sixty-two patients were enrolled between 2010 and 2016. Stage distribution was as follows: I to II (n = 49, 79%) and III to IV (n = 13, 21%). Bulky disease (defined as ≥7.5 cm or ≥10 cm) was present in 23 (40%) and 16 (28%) patients, respectively. Chemotherapy was R-CHOP (then list the drugs) in 58 (94%) and R-EPOCH (then list the drugs) in 4 (6%) with a median of 6 cycles. With a median follow-up of 51 months, 7 patients developed disease progression (6 outside the RT field, 1 within the RT field). Freedom from local recurrence at 5 years was 98% (90% lower confidence bound, 88%). Progression-free and overall survival at 5 years were 83% and 90%, respectively. CONCLUSIONS With more effective systemic therapy (e.g., addition of rituximab) and more refined chemotherapy response assessment (e.g., positron emission tomography-computed tomography), the dose of RT in combined modality treatment programs may potentially be reduced to 20 Gy. This achieves excellent local control with the potential to decrease acute and long-term side effects.
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Affiliation(s)
- Chris R Kelsey
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina.
| | - Gloria Broadwater
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Olga James
- Department of Radiology, Division of Nuclear Medicine, Duke University Medical Center, Durham, North Carolina
| | - Junzo Chino
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Louis Diehl
- Department of Medicine, Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Anne W Beaven
- Department of Medicine, Division of Medical Oncology, University of North Carolina Medical Center, Chapel Hill, North Carolina
| | - Catherine Chang
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Bridget F Koontz
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Leonard R Prosnitz
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
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18
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Lee JW, Prosnitz LR, Stefanovic A, Kelsey CR. Are Higher Doses of Consolidation Radiation Therapy Necessary in Diffuse Large B-cell Lymphoma Involving Osseous Sites? Adv Radiat Oncol 2019; 4:507-512. [PMID: 31360807 PMCID: PMC6639737 DOI: 10.1016/j.adro.2019.03.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 02/22/2019] [Accepted: 03/20/2019] [Indexed: 11/18/2022] Open
Abstract
Purpose This study aimed to evaluate whether higher doses of consolidation radiation therapy (RT), which have been traditionally recommended for osseous sites in diffuse large B-cell lymphoma (DLBCL), are still necessary. Methods and materials Patients with DLBCL with osseous involvement treated with first-line chemotherapy followed by consolidation RT between 1995 and 2016 were reviewed. The primary endpoint was 5-year freedom from local recurrence, estimated using the Kaplan-Meier method. Outcomes based on the RT dose received were also assessed. Results A total of 51 patients were identified. The most common chemotherapy regimens were rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (80%) and cyclophosphamide, doxorubicin, vincristine, and prednisone (12%) with a median of 6 cycles (range, 3-8 cycles). After chemotherapy, 82% of patients achieved a complete response (CR), and 18% achieved a partial response (PR). All patients in PR were deemed appropriate for consolidation RT. The median dose was 29 Gy (24 Gy for CR; 36 Gy for PR). After a median follow-up of 86 months, 8 patients relapsed, with 2 relapses in the RT field after consolidation RT of 30 and 39.6 Gy, respectively. Overall, the 5-year freedom from local recurrence was 96% (95% confidence interval [CI], 91%-100%), disease-free survival was 76% (95% CI, 65%-89%), and overall survival was 86% (95% CI, 76%-96%). No dose-response relationship was observed. Conclusions In patients with DLBCL with osseous involvement who achieved a CR after first-line chemotherapy, 20 to 30 Gy of consolidation RT led to high rates of local control. Higher doses should be reserved for patients in PR.
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Affiliation(s)
- Jessica W. Lee
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
- Corresponding author. Department of Radiation Oncology, DUMC 3085, Durham, NC 27710.
| | - Leonard R. Prosnitz
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Alexandra Stefanovic
- Department of Medicine, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina
| | - Chris R. Kelsey
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
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Corradetti MN, Torok JA, Hatch AJ, Xanthopoulos EP, Lafata K, Jacobs C, Rushing C, Calaway J, Jones G, Kelsey CR, Nixon AB. Dynamic Changes in Circulating Tumor DNA During Chemoradiation for Locally Advanced Lung Cancer. Adv Radiat Oncol 2019; 4:748-752. [PMID: 31673668 PMCID: PMC6817521 DOI: 10.1016/j.adro.2019.05.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 04/30/2019] [Accepted: 05/02/2019] [Indexed: 12/25/2022] Open
Abstract
Purpose Concurrent chemoradiation therapy (CRT) is the principal treatment modality for locally advanced lung cancer. Cell death due to CRT leads to the release of cell-free DNA (cfDNA) and circulating tumor DNA (ctDNA) into the bloodstream, but the kinetics and characteristics of this process are poorly understood. We hypothesized that there could be clinically meaningful changes in cfDNA and ctDNA during a course of CRT for lung cancer. Methods and materials Multiple samples of plasma were obtained from 24 patients treated with CRT for locally advanced lung cancer to a mean dose of 66 Gy (range, 58-74 Gy) at the following intervals: before CRT, at weeks 2 and 5 during CRT, and 6 weeks after treatment. cfDNA was quantified, and a novel next generation sequencing (NGS) technique using enhanced tagged/targeted-amplicon sequencing was performed to analyze ctDNA. Results Patients for whom specific mutations in ctDNA were undetectable at the baseline time point had improved survival, and potentially etiologic driver mutations could be tracked throughout the course of CRT via NGS in multiple patients. We quantified the levels of cfDNA from patients before CRT, at week 2, week 5, and at 6 weeks after treatment. No differences were observed at weeks 2 and 5 of therapy, but we noted a significant increase in cfDNA in the posttreatment follow-up samples compared with samples collected before CRT (P = .05). Conclusions Dynamic changes in both cfDNA and ctDNA were observed throughout the course of CRT in patients with locally advanced lung cancer. Specific mutations with therapeutic implications can be identified and tracked using NGS methodologies. Further work is required to characterize the changes in cfDNA and ctDNA over time in patients treated with CRT and to assess the predictive and prognostic potential of this powerful technology.
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Affiliation(s)
- Michael N Corradetti
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina
| | - Jordan A Torok
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina
| | - Ace J Hatch
- Department of Medicine, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina
| | - Eric P Xanthopoulos
- Department of Radiation Oncology, Columbia University School of Medicine, New York, New York
| | - Kyle Lafata
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina
| | - Corbin Jacobs
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina
| | - Christel Rushing
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina
| | - John Calaway
- Inivata, Inc, Research Triangle Park, North Carolina
| | - Greg Jones
- Inivata, Inc, Research Triangle Park, North Carolina
| | - Chris R Kelsey
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina
| | - Andrew B Nixon
- Department of Medicine, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina
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Ng AK, Yahalom J, Goda JS, Constine LS, Pinnix CC, Kelsey CR, Hoppe B, Oguchi M, Suh CO, Wirth A, Qi S, Davies A, Moskowitz CH, Laskar S, Li Y, Mauch PM, Specht L, Illidge T. Role of Radiation Therapy in Patients With Relapsed/Refractory Diffuse Large B-Cell Lymphoma: Guidelines from the International Lymphoma Radiation Oncology Group. Int J Radiat Oncol Biol Phys 2019; 100:652-669. [PMID: 29413279 DOI: 10.1016/j.ijrobp.2017.12.005] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 11/16/2017] [Accepted: 12/03/2017] [Indexed: 01/15/2023]
Abstract
Approximately 30% to 40% of patients with diffuse large B-cell lymphoma (DLBCL) will have either primary refractory disease or relapse after chemotherapy. In transplant-eligible patients, those with disease sensitive to salvage chemotherapy will significantly benefit from high-dose therapy with autologous stem cell transplantation. The rationale for considering radiation therapy (RT) for selected patients with relapsed/refractory DLBCL as a part of the salvage program is based on data regarding the patterns of relapse and retrospective series showing improved local control and clinical outcomes for patients who received peritransplant RT. In transplant-ineligible patients, RT can provide effective palliation and, in selected cases, be administered with curative intent if the relapsed/refractory disease is localized. We have reviewed the indications for RT in the setting of relapsed/refractory DLBCL and provided recommendations regarding the optimal timing of RT, dose fractionation scheme, and treatment volume in the context of specific case scenarios.
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Affiliation(s)
- Andrea K Ng
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts.
| | - Joachim Yahalom
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jayant S Goda
- Department of Radiation Oncology, Tata Memorial Center, Navi, Mumbai, India
| | - Louis S Constine
- Departments of Radiation Oncology and Pediatrics, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - Chelsea C Pinnix
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Chris R Kelsey
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Bradford Hoppe
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - Masahiko Oguchi
- Department of Radiation Oncology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Chang-Ok Suh
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Andrew Wirth
- Division of Radiation Oncology, Peter MacCallum Cancer Institute, Melbourne, Victoria, Australia
| | - Shunan Qi
- Department of Radiation Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Andrew Davies
- Cancer Research UK Centre, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Craig H Moskowitz
- Lymphoma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Siddhartha Laskar
- Department of Radiation Oncology, Tata Memorial Center, Navi, Mumbai, India
| | - Yexiong Li
- Department of Radiation Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Peter M Mauch
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts
| | - Lena Specht
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Timothy Illidge
- Institute of Cancer Sciences, University of Manchester, Manchester Academic Health Sciences Centre, The Christie National Health Service Foundation Trust, Manchester, United Kingdom
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Lafata KJ, Hong JC, Geng R, Ackerson BG, Liu JG, Zhou Z, Torok J, Kelsey CR, Yin FF. Association of pre-treatment radiomic features with lung cancer recurrence following stereotactic body radiation therapy. Phys Med Biol 2019; 64:025007. [PMID: 30524018 DOI: 10.1088/1361-6560/aaf5a5] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The purpose of this work was to investigate the potential relationship between radiomic features extracted from pre-treatment x-ray CT images and clinical outcomes following stereotactic body radiation therapy (SBRT) for non-small-cell lung cancer (NSCLC). Seventy patients who received SBRT for stage-1 NSCLC were retrospectively identified. The tumor was contoured on pre-treatment free-breathing CT images, from which 43 quantitative radiomic features were extracted to collectively capture tumor morphology, intensity, fine-texture, and coarse-texture. Treatment failure was defined based on cancer recurrence, local cancer recurrence, and non-local cancer recurrence following SBRT. The univariate association between each radiomic feature and each clinical endpoint was analyzed using Welch's t-test, and p-values were corrected for multiple hypothesis testing. Multivariate associations were based on regularized logistic regression with a singular value decomposition to reduce the dimensionality of the radiomics data. Two features demonstrated a statistically significant association with local failure: Homogeneity2 (p = 0.022) and Long-Run-High-Gray-Level-Emphasis (p = 0.048). These results indicate that relatively dense tumors with a homogenous coarse texture might be linked to higher rates of local recurrence. Multivariable logistic regression models produced maximum [Formula: see text] values of [Formula: see text], and [Formula: see text], for the recurrence, local recurrence, and non-local recurrence endpoints, respectively. The CT-based radiomic features used in this study may be more associated with local failure than non-local failure following SBRT for stage I NSCLC. This finding is supported by both univariate and multivariate analyses.
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Affiliation(s)
- Kyle J Lafata
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, United States of America. Medical Physics Graduate Program, Duke University, Durham, NC 27710, United States of America. Department of Physics, Duke University, Durham, NC 27710, United States of America. Authors to whom any correspondence should be addressed
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22
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Lafata K, Cai J, Wang C, Hong J, Kelsey CR, Yin FF. Spatial-temporal variability of radiomic features and its effect on the classification of lung cancer histology. Phys Med Biol 2018; 63:225003. [PMID: 30272571 DOI: 10.1088/1361-6560/aae56a] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The purpose of this research was to study the sensitivity of Computed Tomography (CT) radiomic features to motion blurring and signal-to-noise ratios (SNR), and investigate its downstream effect regarding the classification of non-small cell lung cancer (NSCLC) histology. Forty-three radiomic features were considered and classified into one of four categories: Morphological, Intensity, Fine Texture, and Coarse Texture. First, a series of simulations were used to study feature-sensitivity to changes in spatial-temporal resolution. A dynamic digital phantom was used to generate images with different breathing amplitudes and SNR, from which features were extracted and characterized relative to initial simulation conditions. Stage I NSCLC patients were then retrospectively identified, from which three different acquisition-specific feature-spaces were generated based on free-breathing (FB), average-intensity-projection (AIP), and end-of-exhalation (EOE) CT images. These feature-spaces were derived to cover a wide range of spatial-temporal tradeoff. Normalized percent differences and concordance correlation coefficients (CCC) were used to assess the variability between the 3D and 4D acquisition techniques. Subsequently, three corresponding acquisition-specific logistic regression models were developed to classify lung tumor histology. Classification performance was compared between the different data-dependent models. Simulation results demonstrated strong linear dependences (p > 0.95) between respiratory motion and morphological features, as well as between SNR and texture features. The feature Short Run Emphasis was found to be particularly stable to both motion blurring and changes in SNR. When comparing FB-to-EOE, 37% of features demonstrated high CCC agreement (CCC > 0.8), compared to only 30% for FB-to-AIP. In classifying tumor histology, EoE images achieved an average AUC, Accuracy, Sensitivity, and Specificity of [Formula: see text], respectively. FB images achieved respective values of [Formula: see text], and AIP images achieved respective values of [Formula: see text]. Several radiomic features have been identified as being relatively robust to spatial-temporal variations based on both simulation data and patient data. In general, features that were sensitive to motion blurring were not necessarily the same features that were sensitive to changes in SNR. Our modeling results suggest that the EoE phase of a 4DCT acquisition may provide useful radiomic information, particularly for features that are highly sensitive to respiratory motion.
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Affiliation(s)
- Kyle Lafata
- Department of Radiation Oncology, Duke University Medical Center, DUMC Box 3295, Durham, NC 27710, United States of America. Medical Physics Graduate Program, Duke University, 2424 Erwin Road Suite 101, Durham, NC 27705, United States of America
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23
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Ackerson BG, Tong BC, Hong JC, Gu L, Chino J, Trotter JW, D’Amico TA, Torok JA, Lafata K, Chang C, Kelsey CR. Stereotactic body radiation therapy versus sublobar resection for stage I NSCLC. Lung Cancer 2018; 125:185-191. [DOI: 10.1016/j.lungcan.2018.09.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 09/19/2018] [Accepted: 09/23/2018] [Indexed: 12/17/2022]
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Rankine LJ, Wang Z, Driehuys B, Marks LB, Kelsey CR, Das SK. Correlation of Regional Lung Ventilation and Gas Transfer to Red Blood Cells: Implications for Functional-Avoidance Radiation Therapy Planning. Int J Radiat Oncol Biol Phys 2018; 101:1113-1122. [PMID: 29907488 PMCID: PMC6689416 DOI: 10.1016/j.ijrobp.2018.04.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [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: 11/13/2017] [Revised: 03/02/2018] [Accepted: 04/05/2018] [Indexed: 02/08/2023]
Abstract
PURPOSE To investigate the degree to which lung ventilation and gas exchange are regionally correlated, using the emerging technology of hyperpolarized (HP)-129Xe magnetic resonance imaging (MRI). METHODS AND MATERIALS Hyperpolarized-129Xe MRI studies were performed on 17 institutional review board-approved human subjects, including 13 healthy volunteers, 1 emphysema patient, and 3 non-small cell lung cancer patients imaged before and approximately 11 weeks after radiation therapy (RT). Subjects inhaled 1 L of HP-129Xe mixture, followed by the acquisition of interleaved ventilation and gas exchange images, from which maps were obtained of the relative HP-129Xe distribution in three states: (1) gaseous, in lung airspaces; (2) dissolved interstitially, in alveolar barrier tissue; and (3) transferred to red blood cells (RBCs), in the capillary vasculature. The relative spatial distributions of HP-129Xe in airspaces (regional ventilation) and RBCs (regional gas transfer) were compared. Further, we investigated the degree to which ventilation and RBC transfer images identified similar functional regions of interest (ROIs) suitable for functionally guided RT. For the RT patients, both ventilation and RBC functional images were used to calculate differences in the lung dose-function histogram and functional effective uniform dose. RESULTS The correlation of ventilation and RBC transfer was ρ = 0.39 ± 0.15 in healthy volunteers. For the RT patients, this correlation was ρ = 0.53 ± 0.02 before treatment and ρ = 0.39 ± 0.07 after treatment; for the emphysema patient it was ρ = 0.24. Comparing functional ROIs, ventilation and RBC transfer demonstrated poor spatial agreement: Dice similarity coefficient = 0.50 ± 0.07 and 0.26 ± 0.12 for the highest-33%- and highest-10%-function ROIs in healthy volunteers, and in RT patients (before treatment) these were 0.58 ± 0.04 and 0.40 ± 0.04. The average magnitude of the differences between RBC- and ventilation-derived functional effective uniform dose, fV20Gy, fV10Gy, and fV5Gy were 1.5 ± 1.4 Gy, 4.1% ± 3.8%, 5.0% ± 3.8%, and 5.3% ± 3.9%, respectively. CONCLUSION Ventilation may not be an effective surrogate for true regional lung function for all patients.
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Affiliation(s)
- Leith J Rankine
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, North Carolina; Medical Physics Graduate Program, Duke University, Durham, North Carolina.
| | - Ziyi Wang
- Department of Biomedical Engineering, Duke University, Durham, North Carolina
| | - Bastiaan Driehuys
- Medical Physics Graduate Program, Duke University, Durham, North Carolina; Department of Biomedical Engineering, Duke University, Durham, North Carolina; Radiology, Duke University, Durham, North Carolina
| | - Lawrence B Marks
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Chris R Kelsey
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Shiva K Das
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Tsang RW, Campbell BA, Goda JS, Kelsey CR, Kirova YM, Parikh RR, Ng AK, Ricardi U, Suh CO, Mauch PM, Specht L, Yahalom J. Radiation Therapy for Solitary Plasmacytoma and Multiple Myeloma: Guidelines From the International Lymphoma Radiation Oncology Group. Int J Radiat Oncol Biol Phys 2018; 101:794-808. [PMID: 29976492 DOI: 10.1016/j.ijrobp.2018.05.009] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 04/16/2018] [Accepted: 05/02/2018] [Indexed: 12/15/2022]
Abstract
PURPOSE To develop guidelines for the work-up and radiation therapy (RT) management of patients with plasma cell neoplasms. METHODS AND MATERIALS A literature review was conducted covering staging, work-up, and RT management of plasma cell neoplasms. Guidelines were developed through consensus by an international panel of radiation oncologists with expertise in these diseases, from the International Lymphoma Radiation Oncology Group. RT volume definitions are based on the International Commission on Radiation Units and Measurements. RESULTS Plasma cell neoplasms account for approximately one-fifth of mature B-cell neoplasms in the United States. The majority (∼95%) are diagnosed as multiple myeloma, in which there has been tremendous progress in systemic therapy approaches with novel drugs over the last 2 decades, resulting in improvements in disease control and survival. In contrast, a small proportion of patients with plasma cell neoplasms present with a localized plasmacytoma in the bone, or in extramedullary (extraosseous) soft tissues, and definitive RT is the standard treatment. RT provides long-term local control in the solitary bone plasmacytomas and is potentially curative in the extramedullary cases. This guideline reviews the diagnostic work-up, principles, and indications for RT, target volume definition, treatment planning, and follow-up procedures for solitary plasmacytoma. Specifically, detailed recommendations for RT volumes and dose/fractionation are provided, illustrated with specific case scenarios. The role of palliative RT in multiple myeloma is also discussed. CONCLUSIONS The International Lymphoma Radiation Oncology Group presents a standardized approach to the use and implementation of definitive RT in solitary plasmacytomas. The modern principles outlining the supportive role of palliative RT in multiple myeloma in an era of novel systemic therapies are also discussed.
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Affiliation(s)
- Richard W Tsang
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada.
| | - Belinda A Campbell
- Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Jayant S Goda
- Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India
| | - Chris R Kelsey
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Youlia M Kirova
- Department of Radiation Therapy, Institut Curie, Paris, France
| | - Rahul R Parikh
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Andrea K Ng
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, Massachusetts
| | - Umberto Ricardi
- Radiation Oncology Unit, Department of Oncology, University of Torino, Torino, Italy
| | - Chang-Ok Suh
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, South Korea
| | - Peter M Mauch
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, Massachusetts
| | - Lena Specht
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Joachim Yahalom
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
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26
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Torok JA, Wu Y, Chino J, Prosnitz LR, Beaven AW, Kim GJ, Kelsey CR. Chemotherapy or Combined Modality Therapy for Early-stage Hodgkin Lymphoma. Anticancer Res 2018; 38:2875-2881. [PMID: 29715111 DOI: 10.21873/anticanres.12533] [Citation(s) in RCA: 3] [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] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 03/16/2018] [Accepted: 03/19/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM Optimizing treatment of early-stage Hodgkin lymphoma (HL) requires balancing cure with potential acute and late toxicities from treatment. We reviewed our institutional experience with chemotherapy alone (ChT) versus combined modality therapy (CMT). MATERIALS AND METHODS Patients with stage I-II classical HL in a complete response (CR) by functional imaging after chemotherapy were included. Progression-free survival (PFS) and overall survival (OS) were calculated and a multivariate analysis (MVA) was performed. RESULTS A total of 136 patients with a CR to chemotherapy were identified. Consolidation radiation therapy (RT) was administered to 117 while 19 received no further therapy. PFS (5 years) was 97% with CMT and 84% with chemotherapy alone (p=0.02). Long-term (10 year) survival was no different (96 vs. 94%, p=0.8). On MVA, CMT improved PFS. Secondary malignancies were rare and no cardiac events were observed. CONCLUSION Consolidation RT results in superior PFS in early-stage Hodgkin lymphoma with minimal added toxicity.
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Affiliation(s)
- Jordan A Torok
- Department of Radiation Oncology, Duke University, Durham, NC, U.S.A
| | - Yuan Wu
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, U.S.A
| | - Junzo Chino
- Department of Radiation Oncology, Duke University, Durham, NC, U.S.A
| | | | - Anne W Beaven
- Department of Medicine, Division of Medical Oncology, University of North Carolina, Chapel Hill, NC, U.S.A
| | - Grace J Kim
- Department of Radiation Oncology, Duke University, Durham, NC, U.S.A
| | - Chris R Kelsey
- Department of Radiation Oncology, Duke University, Durham, NC, U.S.A.
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Song EJ, Torok J, Wu Y, Chino J, Prosnitz LR, Beaven AW, Kelsey CR. Consolidation Radiation Therapy for Patients With Advanced Hodgkin Lymphoma in Complete Metabolic Response According to PET-CT or Gallium Imaging. Clin Lymphoma Myeloma Leuk 2017; 18:145-151. [PMID: 29358045 DOI: 10.1016/j.clml.2017.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 12/26/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The purpose of this study was to evaluate the role of consolidation radiation therapy (RT) in advanced Hodgkin lymphoma (HL) in the setting of a complete metabolic response (CR) to chemotherapy (ChT). PATIENTS AND METHODS Patients with stage III/IV HL treated with ChT alone or combined modality therapy (CMT) between 1992 and 2012 were reviewed. Only patients in a CR according to positron emission tomography-computed tomography (PET-CT) or gallium imaging were included. Clinical end points were estimated using the Kaplan-Meier method and a multivariate analysis using the Cox proportional hazards model was performed. RESULTS Ninety patients were identified (46 CMT; 44 ChT alone). Median follow-up was 50 months. ChT (median 6 cycles) consisted primarily of ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine; 74%) or an ABVD hybrid (10%). Post-ChT imaging consisted of PET-CT (71%) or gallium (29%). RT plans primarily included all initially involved sites of disease with a median dose of 21 Gy (range, 13-31 Gy). CMT was associated with improved 5-year progression-free survival (PFS; 88% vs. 65%, respectively; P < .001) and overall survival (97% vs. 78%, respectively; P = .002) compared with ChT alone. In multivariate analysis, age younger than 45 years (hazard ratio [HR], 0.23; 95% confidence interval [CI], 0.07-0.74; P = .013) and CMT (HR, 0.32; 95% CI, 0.11-0.96; P = .04) were independently associated with improved PFS. Secondary malignancies were comparable in both cohorts (5 with CMT, 4 with ChT), whereas cardiac events were slightly more frequent with CMT (5 vs. 2). CONCLUSION Low-dose RT, administered to all sites of original involvement, was associated with improved PFS, even in the setting of a metabolic CR after ABVD.
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Affiliation(s)
- Erin J Song
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC
| | - Jordan Torok
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC
| | - Yuan Wu
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC
| | - Junzo Chino
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC
| | - Leonard R Prosnitz
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC
| | - Anne W Beaven
- Department of Medicine, Division of Medical Oncology, University of North Carolina, Chapel Hill, NC
| | - Chris R Kelsey
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC.
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Tandberg DJ, Tong BC, Ackerson BG, Kelsey CR. Surgery versus stereotactic body radiation therapy for stage I non-small cell lung cancer: A comprehensive review. Cancer 2017; 124:667-678. [PMID: 29266226 DOI: 10.1002/cncr.31196] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 11/10/2017] [Accepted: 11/18/2017] [Indexed: 12/14/2022]
Abstract
Non-small cell lung cancer (NSCLC) is the leading cause of cancer-related death in the United States. With the implementation of lung cancer screening, the number and proportion of patients diagnosed with early-stage disease are anticipated to increase. Surgery is currently the standard of care for patients with operable stage I NSCLC. However, promising outcomes with stereotactic body radiation therapy (SBRT) in patients with inoperable disease has led to interest in directly comparing SBRT and surgery in operable patients. Unfortunately, early randomized trials comparing surgery and SBRT closed early because of poor accrual. In this article, the nuances of surgery and SBRT for early-stage NSCLC are reviewed. Furthermore, retrospective and prospective analyses of SBRT in early-stage NSCLC are discussed, and active randomized trials comparing these 2 approaches are described. Cancer 2018;124:667-78. © 2017 American Cancer Society.
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Affiliation(s)
- Daniel J Tandberg
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina
| | - Betty C Tong
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Bradley G Ackerson
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina
| | - Chris R Kelsey
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina
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Song EJ, Kelsey CR, Driehuys B, Rankine L. Functional airway obstruction observed with hyperpolarized 129 Xenon-MRI. J Med Imaging Radiat Oncol 2017; 62:91-93. [PMID: 28940774 DOI: 10.1111/1754-9485.12660] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 08/20/2017] [Indexed: 11/27/2022]
Abstract
Hyperpolarized 129 Xenon-MRI (HP 129 Xe MRI) is an emerging imaging modality that allows assessment of both ventilation and gas transfer. Most research to date has focused on non-malignant pulmonary diseases. However, the capability of evaluating the two primary physiological processes of the lung (ventilation and gas transfer) makes HP 129 Xe MRI a promising imaging modality in the management of patients with lung cancer.
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Affiliation(s)
- Erin J Song
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina, USA
| | - Chris R Kelsey
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina, USA
| | - Bastiaan Driehuys
- Center for In Vivo Microscopy, Duke University, Durham, North Carolina, USA
| | - Leith Rankine
- Center for In Vivo Microscopy, Duke University, Durham, North Carolina, USA.,Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Videtic GMM, Donington J, Giuliani M, Heinzerling J, Karas TZ, Kelsey CR, Lally BE, Latzka K, Lo SS, Moghanaki D, Movsas B, Rimner A, Roach M, Rodrigues G, Shirvani SM, Simone CB, Timmerman R, Daly ME. Stereotactic body radiation therapy for early-stage non-small cell lung cancer: Executive Summary of an ASTRO Evidence-Based Guideline. Pract Radiat Oncol 2017; 7:295-301. [PMID: 28596092 DOI: 10.1016/j.prro.2017.04.014] [Citation(s) in RCA: 288] [Impact Index Per Article: 41.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 04/17/2017] [Indexed: 12/24/2022]
Abstract
PURPOSE This guideline presents evidence-based recommendations for stereotactic body radiation therapy (SBRT) in challenging clinical scenarios in early-stage non-small cell lung cancer (NSCLC). METHODS AND MATERIALS The American Society for Radiation Oncology convened a task force to perform a systematic literature review on 4 key questions addressing: (1) application of SBRT to operable patients; (2) appropriate use of SBRT in tumors that are centrally located, large, multifocal, or unbiopsied; (3) individual tailoring of SBRT in "high-risk" clinical scenarios; and (4) SBRT as salvage therapy after recurrence. Guideline recommendations were created using a predefined consensus-building methodology supported by American Society for Radiation Oncology-approved tools for grading evidence quality and recommendation strength. RESULTS Although few randomized trials have been completed for SBRT, strong consensus recommendations based on extensive, consistent publications were generated for several questions, including recommendations for fractionation for central tumors and surgery versus SBRT in standard-risk medically operable patients with early-stage NSCLC. Lower quality evidence led to conditional recommendations on use of SBRT for tumors >5 cm, patients with prior pneumonectomy, T3 tumors with chest wall invasion, synchronous multiple primary lung cancer, and as a salvage therapy after prior radiation therapy. These areas of moderate- and low-quality evidence highlight the importance of clinical trial enrollment as well as the role of prospective data registries. CONCLUSIONS SBRT has an important role to play in treating early-stage NSCLC, particularly for medically inoperable patients with limited other treatment options. Shared decision-making with patients should be performed in all cases to ensure the patient understands the risks related to SBRT, the side effects, and the alternative treatments available.
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Affiliation(s)
| | - Jessica Donington
- Department of Cardiothoracic Surgery, New York University, New York, New York
| | - Meredith Giuliani
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - John Heinzerling
- Department of Radiation Oncology, Southeast Radiation Oncology, Levine Cancer Institute, Charlotte, North Carolina
| | - Tomer Z Karas
- Department of Cardiothoracic Surgery, Miami VA Healthcare System, Miami, Florida
| | - Chris R Kelsey
- Department of Radiation Oncology, Duke University, Durham, North Carolina
| | - Brian E Lally
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington
| | - Drew Moghanaki
- Radiation Oncology Service, Hunter Holmes McGuire VA Medical Center and Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - Benjamin Movsas
- Department of Radiation Oncology, Henry Ford Hospital, Detroit, Michigan
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael Roach
- Department of Radiation Oncology, Washington University, St. Louis, Missouri
| | - George Rodrigues
- Department of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Shervin M Shirvani
- Department of Radiation Oncology, Banner MD Anderson Cancer Center, Phoenix, Arizona
| | - Charles B Simone
- Department of Radiation Oncology, University of Maryland, Baltimore, Maryland
| | - Robert Timmerman
- Department of Radiation Oncology, University of Texas Southwestern, Dallas, Texas
| | - Megan E Daly
- Department of Radiation Oncology, University of California, Davis, Sacramento, California
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Tandberg DJ, Holt T, Kelsey CR. Plasma Metabolites and Risk of Radiation-induced Esophagitis: A Secondary Analysis from a Prospective Study. Anticancer Res 2017; 37:719-725. [PMID: 28179322 DOI: 10.21873/anticanres.11369] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 12/14/2016] [Accepted: 12/16/2016] [Indexed: 11/10/2022]
Abstract
AIM Metabolic profiling was performed on plasma samples obtained prior to and during radiation therapy (RT) for locally advanced lung cancer to identify metabolites predictive of RT-induced esophagitis. PATIENTS AND METHODS Patients received cisplatin/etoposide with RT as part of a prospective dose-escalation study (n=24). Plasma samples were collected at baseline, weeks 2 and 5 during RT, and 6 weeks post-RT. Metabolites were measured by ultrahigh-performance liquid chromatography-tandem mass spectroscopy at each time-point. Metabolite concentrations were compared between patients developing grade 0-1 and those with grade 2 or more esophagitis. RESULTS At baseline, 23 metabolites differed significantly (p<0.05) between patients with grade 0-1 esophagitis and those with grade 2 or esophagitis. Sixty-seven metabolites were different at week 2. None reached statistical significance (q<0.05) after corrections for multiple comparisons. On random forest modeling, the predictive accuracy of the metabolite data was 33% at baseline and 50% at 2 weeks. CONCLUSION No individual metabolite or group of metabolites was predictive of acute RT-induced esophagitis.
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Affiliation(s)
- Daniel J Tandberg
- Department of Radiation Oncology, Duke University School of Medicine, Durham, NC, U.S.A.
| | | | - Chris R Kelsey
- Department of Radiation Oncology, Duke University School of Medicine, Durham, NC, U.S.A
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Boyle J, Ackerson B, Gu L, Kelsey CR. Dosimetric advantages of intensity modulated radiation therapy in locally advanced lung cancer. Adv Radiat Oncol 2017; 2:6-11. [PMID: 28740910 PMCID: PMC5514227 DOI: 10.1016/j.adro.2016.12.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 12/21/2016] [Accepted: 12/22/2016] [Indexed: 12/25/2022] Open
Abstract
Purpose Radiation therapy plays an essential role in the treatment of locally advanced lung cancer, but it inevitably leads to incidental and unnecessary dose to critical organs, including the lung, heart, and esophagus. Numerous radiation dose-volumetric parameters have been associated with increased risk of morbidity and mortality. The purpose of the present study is to quantify differences in normal tissue radiation exposure with intensity modulated radiation therapy (IMRT) compared with 3-dimensional conformal radiation therapy (3D-CRT). Methods and materials Twenty-four consecutive patients with locally advanced lung cancer undergoing definitive IMRT were enrolled on a phase 1 protocol. For each patient, an optimized 3D-CRT plan was also designed. Plans were normalized in terms of planning target coverage with a standard dose of 60 Gy in 2-Gy fractions with a subset of patients also receiving elective nodal irradiation to a dose of 44 Gy in 2-Gy fractions. Normal tissue dosimetric comparisons were made for the lung, heart, and esophagus. Results IMRT decreased incidental dose to the lungs, heart, and esophagus. For lung, both V20 Gy (21.5% vs 26.5%, P < .01) and mean lung dose (11.9 Gy vs 14.9 Gy, P < .01) were improved with IMRT without a corresponding increase in V5 Gy (P = .76). For heart, there was improvement in V5 (28.9% vs 33.7%, P < .01) but no difference in V30 Gy (9.8% vs 15.9%. P = .10). For esophagus, all dosimetric endpoints were improved (V20 Gy, V45 Gy, V60 Gy, mean dose). For example, V60 was 6.5% with IMRT compared with 21% with 3D-CRT (P < .01). Conclusions IMRT significantly decreased unnecessary dose to critical organs with equivalent coverage of planning target volumes. IMRT may therefore improve the tolerability of therapy.
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Affiliation(s)
- John Boyle
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Brad Ackerson
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Lin Gu
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Chris R Kelsey
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
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Stephens SJ, Thomas S, Rizzieri DA, Horwitz ME, Chao NJ, Engemann AM, Lassiter M, Kelsey CR. Myeloablative conditioning with total body irradiation for AML: Balancing survival and pulmonary toxicity. Adv Radiat Oncol 2016; 1:272-280. [PMID: 28740897 PMCID: PMC5514157 DOI: 10.1016/j.adro.2016.07.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 07/06/2016] [Indexed: 11/18/2022] Open
Abstract
Purpose The purpose of this study was to compare leukemia-free survival (LFS) and other clinical outcomes in patients with acute myelogenous leukemia who underwent a myeloablative allogeneic stem cell transplant with and without total body irradiation (TBI). Methods and materials Adult patients with acute myelogenous leukemia undergoing myeloablative allogeneic stem cell transplant at Duke University Medical Center between 1995 and 2012 were included. The primary endpoint was LFS. Secondary outcomes included overall survival (OS), nonrelapse mortality, and the risk of pulmonary toxicity. Kaplan-Meier survival estimates and Cox proportional hazards multivariate analyses were performed. Results A total of 206 patients were evaluated: 90 received TBI-based conditioning regimens and 116 received chemotherapy alone. Median follow-up was 36 months. For all patients, 2-year LFS and OS were 36% (95% confidence interval [CI], 29-43) and 39% (95% CI, 32-46), respectively. After adjusting for known prognostic factors using a multivariate analysis, TBI was associated with improved LFS (hazard ratio: 0.63; 95% CI: 0.44-0.91) and OS (hazard ratio: 0.63; 95% CI, 0.43-0.91). There was no difference in nonrelapse mortality between cohorts, but pulmonary toxicity was significantly more common with TBI (2-year incidence 42% vs 12%, P < .001). High-grade pulmonary toxicity predominated with both conditioning strategies (70% and 93% of cases were grade 3-5 with TBI and chemotherapy alone, respectively). Conclusions TBI-based regimens were associated with superior LFS and OS but at the cost of increased pulmonary toxicity.
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Affiliation(s)
- Sarah J. Stephens
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Samantha Thomas
- Department of Biostatistics and Bioinformatics, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - David A. Rizzieri
- Division of Hematological Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Mitchell E. Horwitz
- Division of Hematological Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Nelson J. Chao
- Division of Hematological Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Ashley M. Engemann
- Division of Hematological Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Martha Lassiter
- Division of Hematological Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Chris R. Kelsey
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
- Corresponding author: Duke University Medical Center, DUMC Box 3085, Durham, NC 27710Duke University Medical CenterDUMC Box 3085DurhamNC27710
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Boyer MJ, Gu L, Wang X, Kelsey CR, Yoo DS, Onaitis MW, Dunphy FR, Crawford J, Ready NE, Salama JK. Toxicity of definitive and post-operative radiation following ipilimumab in non-small cell lung cancer. Lung Cancer 2016; 98:76-78. [PMID: 27393510 DOI: 10.1016/j.lungcan.2016.05.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 04/27/2016] [Accepted: 05/24/2016] [Indexed: 10/21/2022]
Abstract
To determine the feasibility and toxicity of radiation therapy, delivered either as definitive treatment or following surgery, following neo-adjuvant immune checkpoint inhibition for locally advanced NSCLC sixteen patients who received neo-adjuvant chemotherapy including ipilimumab as part of a phase II study were identified. Patients were analyzed by intent of radiation and toxicity graded based on CTCAE 4.0. There were seven patients identified who received definitive radiation and nine who received post-operative radiation. There was no grade 3 or greater toxicity in the definitive treatment group although one patient stopped treatment early due to back pain secondary to progression outside of the treatment field. In the post-operative treatment group, one patient required a one week break due to grade 2 odynophagia and no grade 3 or greater toxicity was observed. In this study of radiation as definitive or post-operative treatment following neo-adjuvant chemotherapy including ipilimumab for locally advanced NSCLC was feasible and well tolerated with limited toxicity.
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Affiliation(s)
- Matthew J Boyer
- Department of Radiation Oncology, Duke University, Durham, NC 27710, USA.
| | - Lin Gu
- Duke Cancer Institute, Department of Biostatistics, Duke University, Durham, NC 27710, USA
| | - Xiaofei Wang
- Duke Cancer Institute, Department of Biostatistics, Duke University, Durham, NC 27710, USA
| | - Chris R Kelsey
- Department of Radiation Oncology, Duke University, Durham, NC 27710, USA
| | - David S Yoo
- Department of Radiation Oncology, Duke University, Durham, NC 27710, USA
| | - Mark W Onaitis
- Department of Surgery, Division of Cardiothoracic Surgery, Duke University, Durham, NC 27710, USA
| | - Frank R Dunphy
- Department of Medicine, Division of Medical Oncology, Duke University, Durham, NC 27710, USA
| | - Jeffrey Crawford
- Department of Medicine, Division of Medical Oncology, Duke University, Durham, NC 27710, USA
| | - Neal E Ready
- Department of Medicine, Division of Medical Oncology, Duke University, Durham, NC 27710, USA
| | - Joseph K Salama
- Department of Radiation Oncology, Duke University, Durham, NC 27710, USA
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Kelsey CR, Christensen JD, Chino JP, Adamson J, Ready NE, Perez BA. Adaptive planning using positron emission tomography for locally advanced lung cancer: A feasibility study. Pract Radiat Oncol 2016; 6:96-104. [DOI: 10.1016/j.prro.2015.10.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 10/16/2015] [Accepted: 10/17/2015] [Indexed: 12/25/2022]
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Kelsey CR, Das S, Gu L, Dunphy FR, Ready NE, Marks LB. Phase 1 Dose Escalation Study of Accelerated Radiation Therapy With Concurrent Chemotherapy for Locally Advanced Lung Cancer. Int J Radiat Oncol Biol Phys 2015; 93:997-1004. [PMID: 26581138 DOI: 10.1016/j.ijrobp.2015.09.007] [Citation(s) in RCA: 9] [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: 04/29/2015] [Revised: 07/30/2015] [Accepted: 09/08/2015] [Indexed: 12/25/2022]
Abstract
PURPOSE To determine the maximum tolerated dose of radiation therapy (RT) given in an accelerated fashion with concurrent chemotherapy using intensity modulated RT. METHODS AND MATERIALS Patients with locally advanced lung cancer (non-small cell and small cell) with good performance status and minimal weight loss received concurrent cisplatin and etoposide with RT. Intensity modulated RT with daily image guidance was used to facilitate esophageal avoidance and delivered using 6 fractions per week (twice daily on Fridays with a 6-hour interval). The dose was escalated from 58 Gy to a planned maximum dose of 74 Gy in 4 Gy increments in a standard 3 + 3 trial design. Dose-limiting toxicity (DLT) was defined as acute grade 3-5 nonhematologic toxicity attributed to RT. RESULTS A total of 24 patients were enrolled, filling all dose cohorts, all completing RT and chemotherapy as prescribed. Dose-limiting toxicity occurred in 1 patient at 58 Gy (grade 3 esophagitis) and 1 patient at 70 Gy (grade 3 esophageal fistula). Both patients with DLTs had large tumors (12 cm and 10 cm, respectively) adjacent to the esophagus. Three additional patients were enrolled at both dose cohorts without further DLT. In the final 74-Gy cohort, no DLTs were observed (0 of 6). CONCLUSIONS Dose escalation and acceleration to 74 Gy with intensity modulated RT and concurrent chemotherapy was tolerable, with a low rate of grade ≥3 acute esophageal reactions.
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Affiliation(s)
- Chris R Kelsey
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina.
| | - Shiva Das
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Lin Gu
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Frank R Dunphy
- Division of Medical Oncology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Neal E Ready
- Division of Medical Oncology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Lawrence B Marks
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Pepek JM, Christensen JD, Kelsey CR. In Reply to Giron et al. Pract Radiat Oncol 2015; 5:e551. [PMID: 26362709 DOI: 10.1016/j.prro.2014.12.010] [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: 12/18/2014] [Accepted: 12/21/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Joseph M Pepek
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC
| | - Jared D Christensen
- Department of Radiology, Division of Cardiothoracic Imaging, Duke University Medical Center, Durham, NC
| | - Chris R Kelsey
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC
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Abstract
Radiation therapy is an extraordinarily effective skin-directed therapy for cutaneous T-cell lymphomas. Lymphocytes are extremely sensitive to radiation and a complete response is generally achieved even with low doses. Radiation therapy has several important roles in the management of mycosis fungoides. For the rare patient with unilesional disease, radiation therapy alone is potentially curative. For patients with more advanced cutaneous disease, radiation therapy to local lesions or to the entire skin can effectively palliate symptomatic disease and provide local disease control. Compared with other skin-directed therapies, radiation therapy is particularly advantageous because it can effectively penetrate and treat thicker plaques and tumors.
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Affiliation(s)
- Daniel J Tandberg
- Department of Radiation Oncology, Duke University Medical Center, DUMC BOX 3085, Durham, NC 27710, USA
| | - Oana Craciunescu
- Department of Radiation Oncology, Duke University Medical Center, DUMC BOX 3085, Durham, NC 27710, USA
| | - Chris R Kelsey
- Department of Radiation Oncology, Duke University Medical Center, DUMC BOX 3085, Durham, NC 27710, USA.
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Torok JA, Wu Y, Prosnitz LR, Kim GJ, Beaven AW, Diehl LF, Kelsey CR. Low-dose consolidation radiation therapy for early stage unfavorable Hodgkin lymphoma. Int J Radiat Oncol Biol Phys 2015; 92:54-9. [PMID: 25863754 DOI: 10.1016/j.ijrobp.2015.02.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 01/14/2015] [Accepted: 02/02/2015] [Indexed: 11/25/2022]
Abstract
PURPOSE The German Hodgkin Study Group (GHSG) trial HD11 established 4 cycles of doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) and 30 Gy of radiation therapy (RT) as a standard for early stage (I, II), unfavorable Hodgkin lymphoma (HL). Additional cycles of ABVD may allow for a reduction in RT dose and improved toxicity profile. METHODS AND MATERIALS Patients treated with combined modality therapy at the Duke Cancer Institute for early stage, unfavorable HL by GHSG criteria from 1994 to 2012 were included. Patients who did not undergo post-chemotherapy functional imaging (positron emission tomography or gallium imaging) or who failed to achieve a complete response were excluded. Clinical outcomes were estimated using the Kaplan-Meier method. Late effects were also evaluated. RESULTS A total of 90 patients met inclusion criteria for analysis. Median follow-up was 5 years. Chemotherapy consisted primarily of ABVD (88%) with a median number of 6 cycles. The median dose of consolidation RT was 23.4 Gy. Four patients had relapses, 2 of which were in-field. Ten-year progression-free survival (PFS) and overall survival (OS) were 93% (95% confidence interval [CI]: 0.82-0.97) and 98% (95% CI: 0.92-0.99), respectively. For the subset of patients (n=46) who received 5 to 6 cycles of chemotherapy and ≤ 24 Gy, the 10-year PFS and OS values were 88% (95% CI: 70%-96%) and 98% (95% CI: 85% - 99%), respectively. The most common late effect was hypothyroidism (20%) with no cardiac complications. Seven secondary malignancies were diagnosed, with only 1 arising within the RT field. CONCLUSIONS Lower doses of RT may be sufficient when combined with more than 4 cycles of ABVD for early stage, unfavorable HL and may result in a more favorable toxicity profile than 4 cycles of ABVD and 30 Gy of RT.
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Affiliation(s)
- Jordan A Torok
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina.
| | - Yuan Wu
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Leonard R Prosnitz
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Grace J Kim
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Anne W Beaven
- Division of Hematologic Malignancy and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Louis F Diehl
- Division of Hematologic Malignancy and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Chris R Kelsey
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
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Boyle J, Beaven AW, Diehl LF, Prosnitz LR, Kelsey CR. Improving outcomes in advanced DLBCL: systemic approaches and radiotherapy. Oncology (Williston Park) 2014; 28:1074-1084. [PMID: 25510806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma. Approximately half of patients will present with advanced (stage III/IV) disease. The cornerstone of treatment is a combination of chemotherapy and immunotherapy, most commonly R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone). Efforts to improve upon R-CHOP-including more chemotherapy cycles, dose-dense chemotherapy, alternative drug combinations, high-dose chemotherapy with autologous stem cell transplant, and maintenance rituximab-have generally proved unsuccessful. There is a growing body of retrospective and prospective data, however, suggesting a benefit for consolidation radiation therapy (RT) in select patients with advanced DLBCL. Consolidation RT has been shown to improve outcomes for patients with advanced DLBCL generally, and in specific instances including initially bulky disease, bone involvement, or in the setting of a partial response to systemic therapy. In these settings consolidation RT is highly efficacious at achieving local disease control and improving overall outcomes.
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Kirkpatrick JP, Wang Z, Sampson JH, McSherry F, Herndon JE, Allen KJ, Duffy E, Hoang JK, Chang Z, Yoo DS, Kelsey CR, Yin FF. Defining the optimal planning target volume in image-guided stereotactic radiosurgery of brain metastases: results of a randomized trial. Int J Radiat Oncol Biol Phys 2014; 91:100-8. [PMID: 25442342 DOI: 10.1016/j.ijrobp.2014.09.004] [Citation(s) in RCA: 114] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 08/27/2014] [Accepted: 09/02/2014] [Indexed: 11/15/2022]
Abstract
PURPOSE To identify an optimal margin about the gross target volume (GTV) for stereotactic radiosurgery (SRS) of brain metastases, minimizing toxicity and local recurrence. METHODS AND MATERIALS Adult patients with 1 to 3 brain metastases less than 4 cm in greatest dimension, no previous brain radiation therapy, and Karnofsky performance status (KPS) above 70 were eligible for this institutional review board-approved trial. Individual lesions were randomized to 1- or 3- mm uniform expansion of the GTV defined on contrast-enhanced magnetic resonance imaging (MRI). The resulting planning target volume (PTV) was treated to 24, 18, or 15 Gy marginal dose for maximum PTV diameters less than 2, 2 to 2.9, and 3 to 3.9 cm, respectively, using a linear accelerator-based image-guided system. The primary endpoint was local recurrence (LR). Secondary endpoints included neurocognition Mini-Mental State Examination, Trail Making Test Parts A and B, quality of life (Functional Assessment of Cancer Therapy-Brain), radionecrosis (RN), need for salvage radiation therapy, distant failure (DF) in the brain, and overall survival (OS). RESULTS Between February 2010 and November 2012, 49 patients with 80 brain metastases were treated. The median age was 61 years, the median KPS was 90, and the predominant histologies were non-small cell lung cancer (25 patients) and melanoma (8). Fifty-five, 19, and 6 lesions were treated to 24, 18, and 15 Gy, respectively. The PTV/GTV ratio, volume receiving 12 Gy or more, and minimum dose to PTV were significantly higher in the 3-mm group (all P<.01), and GTV was similar (P=.76). At a median follow-up time of 32.2 months, 11 patients were alive, with median OS 10.6 months. LR was observed in only 3 lesions (2 in the 1 mm group, P=.51), with 6.7% LR 12 months after SRS. Biopsy-proven RN alone was observed in 6 lesions (5 in the 3-mm group, P=.10). The 12-month DF rate was 45.7%. Three months after SRS, no significant change in neurocognition or quality of life was observed. CONCLUSIONS SRS was well tolerated, with low rates of LR and RN in both cohorts. However, given the higher potential risk of RN with a 3-mm margin, a 1-mm GTV expansion is more appropriate.
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Affiliation(s)
- John P Kirkpatrick
- Department of Radiation Oncology, Duke University, Durham, North Carolina; Department of Surgery, Duke University, Durham, North Carolina.
| | - Zhiheng Wang
- Department of Radiation Oncology, Duke University, Durham, North Carolina
| | - John H Sampson
- Department of Radiation Oncology, Duke University, Durham, North Carolina; Department of Surgery, Duke University, Durham, North Carolina
| | - Frances McSherry
- Department of Biostatistics & Bioinformatics, Duke University, Durham, North Carolina
| | - James E Herndon
- Department of Biostatistics & Bioinformatics, Duke University, Durham, North Carolina
| | - Karen J Allen
- Department of Radiation Oncology, Duke University, Durham, North Carolina
| | - Eileen Duffy
- Department of Radiation Oncology, Duke University, Durham, North Carolina
| | - Jenny K Hoang
- Department of Radiology, Duke University, Durham, North Carolina
| | - Zheng Chang
- Department of Radiation Oncology, Duke University, Durham, North Carolina
| | - David S Yoo
- Department of Radiation Oncology, Duke University, Durham, North Carolina
| | - Chris R Kelsey
- Department of Radiation Oncology, Duke University, Durham, North Carolina
| | - Fang-Fang Yin
- Department of Radiation Oncology, Duke University, Durham, North Carolina
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Boyle JM, Tandberg DJ, Chino JP, D'Amico TA, Ready NE, Kelsey CR. Smoking history predicts for increased risk of second primary lung cancer: A comprehensive analysis. Cancer 2014; 121:598-604. [DOI: 10.1002/cncr.29095] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Revised: 09/10/2014] [Accepted: 09/12/2014] [Indexed: 01/22/2023]
Affiliation(s)
- John M. Boyle
- Department of Radiation Oncology; Duke University Medical Center; Durham North Carolina
| | - Daniel J. Tandberg
- Department of Radiation Oncology; Duke University Medical Center; Durham North Carolina
| | - Junzo P. Chino
- Department of Radiation Oncology; Duke University Medical Center; Durham North Carolina
| | - Thomas A. D'Amico
- Division of Cardiothoracic Surgery, Department of Surgery; Duke University Medical Center; Durham North Carolina
| | - Neal E. Ready
- Division of Medical Oncology, Department of Medicine; Duke University Medical Center; Durham North Carolina
| | - Chris R. Kelsey
- Department of Radiation Oncology; Duke University Medical Center; Durham North Carolina
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Zhang F, Kelsey CR, Yoo D, Yin FF, Cai J. Uncertainties of 4-dimensional computed tomography-based tumor motion measurement for lung stereotactic body radiation therapy. Pract Radiat Oncol 2014; 4:e59-65. [DOI: 10.1016/j.prro.2013.02.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Revised: 02/18/2013] [Accepted: 02/19/2013] [Indexed: 12/25/2022]
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Yang Y, Catalano S, Kelsey CR, Yoo DS, Yin FF, Cai J. Dosimetric effects of rotational offsets in stereotactic body radiation therapy (SBRT) for lung cancer. Med Dosim 2014; 39:117-21. [DOI: 10.1016/j.meddos.2013.11.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Revised: 10/28/2013] [Accepted: 11/11/2013] [Indexed: 10/25/2022]
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Tandberg DJ, Gee NG, Chino JP, D'Amico TA, Ready NE, Coleman RE, Kelsey CR. Are discordant positron emission tomography and pathological assessments of the mediastinum in non-small cell lung cancer significant? J Thorac Cardiovasc Surg 2013; 146:796-801. [PMID: 23870158 DOI: 10.1016/j.jtcvs.2013.05.027] [Citation(s) in RCA: 3] [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: 01/28/2013] [Revised: 05/09/2013] [Accepted: 05/23/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Many patients with non-small cell lung cancer have positive mediastinal lymph nodes on preoperative positron emission tomography (PET) but do not have mediastinal involvement after surgery. The prognostic significance of this discordance was assessed. METHODS This Institutional Review Board-approved study evaluated patients treated with upfront surgery at Duke Cancer Institute (Durham, NC) for non-small cell lung cancer from 1995 to 2008. Those staged with PET with pN0-1 disease after negative invasive mediastinal assessment were included. Mediastinal lymph nodes were scored as positive or negative based on visual analysis of the preoperative PET. Clinical outcomes of the PET-positive and PET-negative cohorts were estimated using the Kaplan-Meier method and compared using a log-rank test. Prognostic factors were assessed using a multivariate analysis. RESULTS A total of 547 patients were assessed, of whom 105 (19%) were PET positive in the mediastinum. The median number of mediastinal lymph node stations sampled was 4 (range, 1-9). The 5-year risk of local recurrence was 26% in PET-positive versus 21% in PET-negative patients (P = .50). Patterns of local failure were similar between the 2 groups. Distant recurrence (35% vs 29%; P = .63) and overall survival (44% vs 54%; P = .52) were comparable for PET-positive and PET-negative patients. On multivariate analysis, a positive PET was not significant for local recurrence (hazard ratio [HR], 1; P = 1), distant recurrence (HR, 0.82; P = .42), or overall survival (HR, 1.08; P = .62). CONCLUSIONS Patients with positive mediastinal lymph nodes on preoperative PET, but negative on histologic analysis, are not at increased risk of disease recurrence. Pathologic staging remains the standard.
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Affiliation(s)
- Daniel J Tandberg
- Department of Radiation Oncology, Duke University School of Medicine, Durham, NC.
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Kelsey CR, Salama JK. Stereotactic Body Radiation Therapy for Treatment of Primary and Metastatic Pulmonary Malignancies. Surg Oncol Clin N Am 2013; 22:463-81. [DOI: 10.1016/j.soc.2013.02.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Washington I, Chino JP, Marks LB, D'Amico TA, Berry MF, Ready NE, Higgins KA, Yoo DS, Kelsey CR. Diabetes mellitus: A significant co-morbidity in the setting of lung cancer? Thorac Cancer 2013; 4:123-130. [DOI: 10.1111/j.1759-7714.2012.00162.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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Kelsey CR, Fornili M, Ambrogi F, Higgins K, Boyd JA, Biganzoli E, Demicheli R. Metastasis dynamics for non-small-cell lung cancer: effect of patient and tumor-related factors. Clin Lung Cancer 2013; 14:425-32. [PMID: 23499299 DOI: 10.1016/j.cllc.2013.01.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Revised: 12/21/2012] [Accepted: 01/08/2013] [Indexed: 01/05/2023]
Abstract
BACKGROUND We studied event dynamics (probability of an event occurring over a specific time interval) in patients undergoing surgery for early-stage non-small-cell lung cancer (NSCLC) according to patient and tumor characteristics. METHODS By using a database of 1506 patients who underwent initial surgery for NSCLC, event dynamics, based on a time-specific hazard rate, were evaluated. The event of interest was the development of distant metastases, with or without a local recurrence. The effect of sex, tumor size, nodal involvement, histology, lymphovascular space invasion, pleural invasion, age, and race were studied. RESULTS The hazard rate for developing distant metastases was not constant over time but was characterized by specific peaks, the first being approximately 9 months after surgery and the second at 18 to 20 months for men and 24 to 26 months for women. For women, the hazard rate peaked considerably in the first year. For men, the hazard rate peaks were smaller but lasted for a longer duration. Pathologic factors associated with a higher risk of recurrence (eg, size, lymph node involvement, pleural invasion) all increased the sex-specific hazard rates. CONCLUSIONS The probability of developing distant metastases after surgery for NSCLC peaks at specific and consistent time intervals after surgery, with specific differences between men and women. A factor-specific modulation of peak heights that ranged from no impact (eg, race) to relevant effects for primary tumor size, nodal involvement, and pleural invasion, possibly related to sex, was also observed. The bimodal distant metastases dynamics may be an intrinsic feature of metastatic progression in NSCLC.
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Affiliation(s)
- Chris R Kelsey
- Department of Radiation Oncology, Duke Cancer Institute, Durham, NC, USA
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Kelsey CR, Jackson IL, Langdon S, Owzar K, Hubbs J, Vujaskovic Z, Das S, Marks LB. Analysis of single nucleotide polymorphisms and radiation sensitivity of the lung assessed with an objective radiologic endpoin. Clin Lung Cancer 2013; 14:267-74. [PMID: 23313170 DOI: 10.1016/j.cllc.2012.10.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Revised: 09/25/2012] [Accepted: 10/16/2012] [Indexed: 12/30/2022]
Abstract
BACKGROUND The primary objective of this study was to evaluate the association between radiation sensitivity of the lungs and candidate single nucleotide polymorphisms (SNP) in genes implicated in radiation-induced toxicity. METHODS Patients with lung cancer who received radiation therapy (RT) had pre-RT and serial post-RT single photon emission computed tomography (SPECT) lung perfusion scans. RT-induced changes in regional perfusion were related to regional dose, which generated patient-specific dose-response curves (DRC). The slope of the DRC is independent of total dose and the irradiated volume, and is taken as a reflection of the patient's inherent sensitivity to RT. DNA was extracted from blood samples obtained at baseline. SNPs were determined by using a combination of high-resolution melting, TaqMan assays, and direct sequencing. Genotypes from 33 SNPs in 22 genes were compared against the slope of the DRC by using the Kruskal-Wallis test for ordered alternatives. RESULTS Thirty-nine self-reported Caucasian patients with pre-RT and ≥6 month post-RT SPECTs, and blood samples were identified. An association between genotype and increasing slope of the DRC was noted in G(1301) A in XRCC1 (rs25487) (P = .01) and G(3748) A in BRCA1 (rs16942) (P = .03). CONCLUSIONS By using an objective radiologic assessment, polymorphisms within genes involved in repair of DNA damage (XRCC1 and BRCA1) were associated with radiation sensitivity of the lungs.
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Affiliation(s)
- Chris R Kelsey
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA.
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Kelsey CR, Beaven AW, Diehl LF, Prosnitz LR. Combined-modality therapy for early-stage Hodgkin lymphoma: maintaining high cure rates while minimizing risks. Oncology (Williston Park) 2012; 26:1182-1193. [PMID: 23413599] [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] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Multiple randomized studies have demonstrated that chemotherapy, most commonly ABVD (doxorubicin [Adriamycin], bleomycin, vinblastine, dacarbazine), followed by consolidation radiation therapy is the most effective treatment program for early-stage Hodgkin lymphoma. With a combined-modality approach, the great majority of patients are cured of their disease. It is also apparent that both chemotherapy and radiation therapy can increase the risk of complications in the decades following treatment, with second cancers and cardiac disease being the most common. Most studies,evaluating such risks primarily include patients treated in decades past with what are now considered outdated approaches, including high-dose, wide-field radiation therapy. The treatment of Hodgkin lymphoma has evolved significantly, particularly in regard to radiation therapy. In combination with chemotherapy, much lower doses and smaller fields are employed, with success equivalent to that achieved using older methods. Many studies have shown a significant decline in both the rates of second cancers and the risk of cardiac disease with low-dose radiation confined to the original extent of disease. In favorable patients, as few as 2 cycles of ABVD have been shown to be effective. The current combined-modality approach seeks to maintain high cure rates but minimize risks by optimizing both chemotherapy and radiation therapy
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Affiliation(s)
- Chris R Kelsey
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina, USA.
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