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Braschi EL, Morris CG, Yeung AR, De Leo AN. Impact of Maximum Point Dose Within the Planning Target Volume on Local Control of Nonsmall Cell Lung Cancer Treated With Stereotactic Body Radiotherapy. Am J Clin Oncol 2024; 47:217-222. [PMID: 38148589 DOI: 10.1097/coc.0000000000001081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
BACKGROUND No consensus exists on the maximum dose delivered to the planning target volume (PTV) in the delivery of stereotactic body radiotherapy (SBRT) for primary lung cancer. We investigated whether higher biologically effective doses (BED) within the PTV were associated with improved tumor control. METHODS We reviewed patients with early-stage, node-negative nonsmall cell lung cancer who received curative-intent SBRT between 2005 and 2018. We calculated the maximum BED (maxBED) within the PTV for all patients, analyzing outcomes using the cumulative incidence method and Fine-Gray test statistics to assess prognostic impact. RESULTS We analyzed 171 patients (median age, 70.2; range, 43 to 90 y) with 181 lung nodules. Median follow-up was 2.7 years (range, 0.1 to 12 y) for all patients and 4.2 years (range, 0.2 to 8.4 y) for living patients. Median maximum tumor diameter was 1.9 cm (range, 0.7 to 5.6 cm). Patients received a prescription of 48 or 50 Gy in 4 or 5 fractions, respectively, except for one who received 60 Gy in 5 fractions. Median maxBED was 120 Gy (range, 101 to 171 Gy). There was no difference in the 3-year local control (LC) rate among patients treated with a maxBED<120 Gy versus ≥120 Gy ( P =0.83). CONCLUSIONS No significant differences in LC were observed between patients with early-stage nonsmall cell lung cancer treated with SBRT in 4 or 5 fractions with a maxBED≥120 Gy. However, a higher maxBED trended toward improved LC rates, suggesting a maxBED threshold greater than 120 Gy may be needed to improve LC rates.
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Affiliation(s)
- Erica L Braschi
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL
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De Leo AN, Shah A, Li J, Morris CG, Bova FJ, Friedman WA, Amdur RJ. Stereotactic Radiosurgery for Vestibular Schwannoma With Radiographic Brainstem Compression. Am J Clin Oncol 2024; 47:110-114. [PMID: 37981700 DOI: 10.1097/coc.0000000000001065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
OBJECTIVE The safety of single-treatment stereotactic radiosurgery (SRS) for vestibular schwannoma (VS) with radiographic evidence of brainstem compression but without motor deficit is controversial. Data on linear accelerator (linac)-based SRS in this setting are scarce. We address this with an outcomes report from an unselected series of patients with VS with radiographic brainstem compression treated with linac SRS. METHODS We included 139 patients with unilateral VS (any size) with radiographic brainstem compression (all without serious brainstem neurological deficits). The SRS prescription dose was 12.5 Gy (single fraction) using 6MV linac-produced photon beams, delivered with a multiple arc technique. Inclusion criteria required at least 1 year of radiographic follow-up with magnetic resonance imaging. The primary endpoint was freedom from serious brainstem toxicity (≥grade 3 Common Terminology Criteria for Adverse Events v5); the secondary was freedom from enlargement (tumor progression or any requiring intervention). We assessed serious cranial nerve complications, excluding hearing loss, defined as Common Terminology Criteria for Adverse Events v5 grade 3 toxicity. RESULTS Median magnetic resonance imaging follow-up time was 5 years, and median tumor size was 2.5 cm in greatest axial dimension and 5 ml in volume. The median brainstem D0.03 ml=12.6 Gy and median brainstem V10 Gy=0.4 ml. At 5 years, the actuarial freedom from serious brainstem toxicity was 100%, and freedom from tumor enlargement (requiring surgery and/or due to progression) was 90%. Severe facial nerve damage in patients without tumor enlargement was 0.9%. CONCLUSION Linac-based SRS, as delivered in our series for VS with radiographic brainstem compression, is safe and effective.
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Affiliation(s)
| | | | | | | | - Frank J Bova
- Neurosurgery, University of Florida College of Medicine, Gainesville, FL
| | - William A Friedman
- Neurosurgery, University of Florida College of Medicine, Gainesville, FL
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Drescher NR, Indelicato DJ, Dagan R, Bradley JA, Holtzman AL, Mailhot Vega RB, Aldana PR, Sandler ES, Morris CG, Mendenhall WM. Outcomes following proton therapy for pediatric esthesioneuroblastoma. Pediatr Blood Cancer 2024; 71:e30793. [PMID: 38018357 DOI: 10.1002/pbc.30793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 10/31/2023] [Accepted: 11/18/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Pediatric esthesioneuroblastoma (EN) can infiltrate skull base anatomy, presenting challenges due to high radiation doses and pediatric tissue sensitivity. This study reports outcomes of pediatric EN treated with proton radiotherapy (PT). PROCEDURE Using an IRB-approved prospective outcomes registry, we evaluated patient, tumor, and treatment-related variables impacting disease control and toxicity in pediatric nonmetastatic EN treated with modern multimodality therapy, including PT. RESULTS Fifteen consecutive patients (median age 16) comprising Kadish stage B (n = 2), C (n = 9), and D (n = 4) tumors were assessed, including six with intracranial involvement, four with cranial nerve deficits, and four with cervical lymphadenopathy. Before radiation, two had subtotal and 13 had gross total resections (endoscopic or craniofacial). Two underwent neck dissection. Eleven received chemotherapy before radiation (n = 5), concurrent with radiation (n = 4), or both (n = 2). Median total radiation dose (primary site) was 66 Gy/CGE for gross disease and 54 Gy/CGE (cobalt Gray equivalent) for microscopic disease. Median follow-up was 4.8 years. No patients were lost to follow-up. Five-year disease-free and overall survival rates were 86% (no local or regional recurrences). Two patients developed vertebral metastases and died. Two required a temporary feeding tube for oral mucositis/dysphagia. Late toxicities included symptomatic retinopathy, major reconstructive surgery, cataracts, chronic otitis media, chronic keratoconjunctivitis, hypothyroidism, and in-field basal cell skin cancer. CONCLUSIONS A multimodality approach for pediatric EN results in excellent local control. Despite the moderate-dose PT, serious radiation toxicity was observed; further dose and target volume reductions may benefit select patients. Longer follow-up and comparative data from modern photon series are necessary to fully characterize any relative PT advantage.
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Affiliation(s)
- Nicolette R Drescher
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Daniel J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Roi Dagan
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Adam L Holtzman
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Philipp R Aldana
- Department of Neurosurgery, University of Florida College of Medicine Jacksonville, Jacksonville, Florida, USA
| | - Eric S Sandler
- Department of Pediatrics, Nemours Children's Specialty Clinic, Jacksonville, Florida, USA
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - William M Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
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Gracie J, Holtzman AL, Dagan R, Bryant CM, Morris CG, Mendenhall WM. Impact of mandated drug monitoring on opioid use during highly conformal radiotherapy for oropharynx cancer. Ann Palliat Med 2023; 12:1146-1154. [PMID: 37953218 DOI: 10.21037/apm-23-404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 08/18/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Prescription drug monitoring programs (PDMPs) have proliferated due to increasing opioid-related deaths. We evaluated acute opioid use changes for 64 patients treated with highly conformal radiotherapy (RT) following a state-mandated PDMP. METHODS Patients receiving proton therapy (PT) (n=40), intensity-modulated RT (IMRT) (n=14), or both (n=10) were divided into preintervention (n=26) and postintervention cohorts (n=38); records were reviewed retrospectively under an institutional review board (IRB)-approved tracking protocol. Dosages prescribed during acute therapy (during RT-3 months post-RT) and patient-reported pain (Defense and Veterans Pain Rating Scale) were endpoints. Dosages were treated as responses in Chi-square tests (three-level ordinal response). RESULTS Overall, 72% (n=46) received opioids; of which 22% (n=10) of all patients and 10% (n=2) of opioid-naive patients continued analgesic management 3 months post-RT. Median total doses were 975 and 1,025 morphine milligram equivalents (MME) in pre- and postintervention groups, with no significant differences in MME prescribed (P=0.8) or uncontrolled pain (P=0.3). Statistically significant factors were tonsil primaries (P<0.01) and alcohol use (P=0.02). Uncontrolled pain episodes during and post-RT did not vary per cohort (P=0.19). CONCLUSIONS PDMP use was not associated with management changes in patient-reported acute pain during RT (IMRT or PT). Following highly conformal RT, few patients remained on narcotics 3 months post-RT.
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Affiliation(s)
- Jayden Gracie
- Department of Radiation Oncology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Adam L Holtzman
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Roi Dagan
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Curtis M Bryant
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - William M Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
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5
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Augustin E, Holtzman AL, Dagan R, Bryant CM, Indelicato DJ, Morris CG, Deraniyagala RL, Fernandes R, Bunnell AM, Nedrud SM, Mendenhall WM. Challenging the Role of Subtotal Resection Following Proton Radiotherapy for Adenoid Cystic Carcinoma of the Head and Neck. Int J Radiat Oncol Biol Phys 2023; 117:e563-e564. [PMID: 37785726 DOI: 10.1016/j.ijrobp.2023.06.1885] [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) To report long-term outcomes of patients with adenoid cystic carcinoma (ACC) of the head and neck treated with proton radiotherapy. MATERIALS/METHODS On this IRB-approved, single institutional prospective outcomes registry, 56 patients were included with de novo, nonmetastatic adenoid carcinoma of the head and neck treated with primary (n = 9) or adjuvant proton therapy from June 2007 to December 2021. The cohort had 30 women and 26 men with a median age of 57 years (range, 10-81 years). Twenty-nine percent (n = 16) had intracranial extension, 23% (n = 13) had orbital extension, and 55% (n = 31) had clinical cranial nerve involvement at the time of radiotherapy. Thirty patients underwent gross total resection (GTR), 26 had gross disease at the time of treatment undergoing a subtotal resection (STR) (n = 17) or biopsy alone (n = 9). The median dose to the primary site was 72.6 GyRBE (range, 64-74.4 GyRBE) delivered in either once (n = 19) or twice (n = 37) daily treatments. Thirty patients received either elective nodal irradiation (ENI) in a node negative neck or concurrent chemotherapy. RESULTS With a median follow-up of 6.2 years (range, 0.9 - 14.7 years), the 5-year local-regional control (LRC), disease free survival (DFS), cause-specific survival (CCS) and overall survival (OS) were 88%, 85%, 89%, and 89%, respectively. Cranial extension (p = 0.003) and gross residual tumor (p = 0.0388) were factors associated with decreased LRC. While LRC for those with a GTR was 96%, those with STR or biopsy alone were 81% and 76%, respectively. T-stage (p = 0.0154), cranial extension (p = 0.0056), extent of resection (p = 0.0355), and gross residual tumor (p = 0.0094) were associated with decreased DFS. T-stage (p = 0.0099), extent of surgery (p = 0.029) and gross residual tumor (p.0071) were associated with decreased CCS. The 5-year cumulative incidence of clinically significant late grade ³3 toxicity was 15% and the crude incidence at most recent follow-up was 23% (n = 13). There was no LRC benefit with ENI (p = 0.94). CONCLUSION Proton therapy provides excellent disease control for head and neck ACC with acceptable toxicity. Gross residual disease at the time of treatment and intracranial involvement were significant prognostic features for worse outcomes. STR did not confer benefit over biopsy only at 5-years and may question the role of extensive and morbid operations if GTR is not technically feasible.
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Affiliation(s)
- E Augustin
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
| | - A L Holtzman
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
| | - R Dagan
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
| | - C M Bryant
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
| | - D J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
| | - C G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
| | - R L Deraniyagala
- Department of Radiation Oncology, Oakland University William Beaumont School of Medicine, Auburn Hills, MI
| | - R Fernandes
- Department of Oral and Maxillofacial Surgery, University of Florida College of Medicine Jacksonville, Jacksonville, FL
| | - A M Bunnell
- Department of Oral and Maxillofacial Surgery, University of Florida College of Medicine Jacksonville, Jacksonville, FL
| | - S M Nedrud
- Department of Oral and Maxillofacial Surgery, University of Florida College of Medicine Jacksonville, Jacksonville, FL
| | - W M Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
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Drescher N, Indelicato DJ, Dagan R, Bradley JA, Holtzman AL, Vega RM, Aldana PR, Sandler ES, Morris CG, Mendenhall WM. Pediatric Esthesioneuroblastoma Treated with Proton Radiotherapy. Int J Radiat Oncol Biol Phys 2023; 117:e509-e510. [PMID: 37785594 DOI: 10.1016/j.ijrobp.2023.06.1765] [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) Given its tendency to abut and infiltrate critical skull base anatomy, pediatric esthesioneuroblastoma (EN) presents a local control challenge, particularly given the high dose of radiation historically utilized in adult patients and the sensitivity of developing pediatric normal tissue. The purpose of this study was to report the outcomes of pediatric EN treated with proton radiotherapy. MATERIALS/METHODS Using an IRB-approved, single institutional prospective outcomes registry, we analyzed disease control and toxicity in pediatric patients with non-metastatic EN treated with a multimodality approach, including proton radiotherapy, between March 2008 and March 2022. Of the 15 patients, 8 were female, and 7 were male. The median age was 16 years (range, 3-21 years). Patients were Kadish stage B (n = 2), C (n = 8), and D (n = 5) and Hyams low-grade (n = 9), high-grade (n = 5), and not specified (n = 1). Six patients had intracranial involvement, 4 had cranial nerve deficits, and 4 had positive cervical lymph nodes. Prior to radiation, 2 patients had a subtotal resection and 13 had a gross total resection via either endoscopic (n = 8) or craniofacial (n = 7) approaches. Two patients underwent neck dissection (one unilateral and one bilateral). A total of 11 patients received chemotherapy before (n = 5), concurrent (n = 4) with radiation, or both (n = 2). The median total radiation dose delivered to the primary site was 66 Gy/CGE (range, 59.4-72.8 Gy/CGE) for patients with gross disease and 54 Gy/CGE (range, 54-74.4 Gy/CGE) for patients with microscopic disease. RESULTS With a median follow-up of 4.8 years (range, 0.1-12.2 years), both the 5-year disease free and overall survival rates were 86%. There were no local or regional recurrences. Two patients with Kadish D, high grade tumors developed vertebral metastases and died with disease. Serious acute toxicity included 2 patients requiring a temporary feeding tube for oral mucositis/dysphagia. Serious late toxicity included symptomatic retinopathy (n = 3), major reconstructive surgery (n = 2), cataracts requiring intervention (n = 2), chronic otitis media (n = 2), chronic keratoconjunctivitis (n = 2), hypothyroidism (n = 2), and in-field basal cell skin cancer (n = 1). CONCLUSION A multimodality approach to pediatric EN results in excellent local control. Despite the use of moderate dose proton therapy, serious radiation toxicity was observed and thus select patients may benefit from further dose and target volume reduction. Longer follow-up and comparative data from modern photon series are necessary to fully characterize any relative advantage of proton therapy.
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Affiliation(s)
- N Drescher
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
| | - D J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
| | - R Dagan
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
| | - J A Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
| | - A L Holtzman
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
| | - R Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
| | - P R Aldana
- Department of Neurosurgery, University of Florida College of Medicine Jacksonville, Jacksonville, FL
| | - E S Sandler
- Department of Pediatrics, Nemours Children's Health, Jacksonville, FL
| | - C G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
| | - W M Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
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Brisson RJ, Indelicato DJ, Vega RM, Aldana PR, Klawinski D, Cassidy V, Morris CG, Bradley JA. Outcomes Following Proton Therapy for Non-Metastatic Central Nervous System Germinoma in Children and Adolescents. Int J Radiat Oncol Biol Phys 2023; 117:e505. [PMID: 37785586 DOI: 10.1016/j.ijrobp.2023.06.1754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Radiation is a key component in the treatment of central nervous system pure germinoma (PG) in children and adolescents. Compared to photons, proton therapy (PT) improves normal tissue sparing and potentially reduces adverse effects, but there are sparse data on long-term patient outcomes. Herein, we present the largest reported single institution experience utilizing PT for the management of PG. MATERIALS/METHODS We performed an IRB-approved retrospective review of a prospective database containing 35 patients with non-metastatic PG treated with PT between July 2007 and September 2021. The median age at treatment was 13 years. All patients had > 6 months of follow up. Two patients were diagnosed based on cerebral spinal fluid B-HCG levels and the remaining 33 patients through histopathology. Eleven patients had bifocal or multifocal intracranial disease. Most patients (n = 31, 88.6%) received induction chemotherapy with carboplatin + etoposide (n = 25, 80.6%) with all demonstrating a radiographic response to neoadjuvant therapy. Twenty-nine were treated with whole ventricular irradiation (WVI) with an involved field (IF) boost, 2 with craniospinal irradiation + WVI + IF, 2 with IF, 1 with CSI + IF, and 1 with whole brain + IF. Among this subgroup, the most common total dose was 30 GyRBE (n = 18, 51.4%). Of the 4 patients that did not receive chemotherapy, 3 received WVI + IF and 1 was treated with CSI + WVI + IF. The total dose in the patients not receiving chemotherapy was 45 GyRBE. Twenty-nine patients were treated with double scattered PT (DS) and 6 patients with pencil beam scanning PT (PBS). We utilized the cumulative incidence method to estimate local control (LC), freedom from distant metastases (FFDM), freedom from progression (FFP), and overall survival (OS). Treatment related toxicity was assessed according to the CTCAEv5. RESULTS Median follow up was 6.2 years (Range: 0.9-15.2 years). The 10-year KM estimates for LC, FFDM, FFP, and OS were 100%, 100%, 100%, and 97% respectively. One patient developed acute lymphocytic leukemia 8 months after treatment and died. The sole ³ grade 3 radiation-related toxicity was a cavernoma with hemorrhage 3.6 years post treatment requiring surgical resection. The most common adverse events were hearing impairment requiring hearing aids (n = 3), hypersomnia requiring medication (n = 3), and new onset endocrinopathy (n = 1). Of the 22 evaluable patients ³18 years old at last follow up, 7 were high school graduates/in college, 8 college graduates, and 5 others gainfully employed. CONCLUSION The use of proton therapy in the multi-modality approach to non-metastatic PG does not compromise local control. Although serious side effects are rare and treatment has minimal impact on survivors' early educational/career trajectory, the 100% cure rate supports further investigation into selective radiation dose and volume de-escalation.
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Affiliation(s)
- R J Brisson
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
| | - D J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
| | - R Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
| | - P R Aldana
- Department of Neurosurgery, University of Florida College of Medicine Jacksonville, Jacksonville, FL
| | - D Klawinski
- Department of Pediatric Hematology/Oncology, Nemours Children's Specialty Care, Jacksonville, FL
| | - V Cassidy
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
| | - C G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
| | - J A Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
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Ashby F, Brisson RJ, Morris CG, Hitchcock KE, Amdur RJ, Mendenhall WM. Radiation Therapy in the Management of Cutaneous Squamous Cell Carcinoma Metastatic to the Parotid: A 50-Year Single Institution Experience. Int J Radiat Oncol Biol Phys 2023; 117:e563. [PMID: 37785725 DOI: 10.1016/j.ijrobp.2023.06.1884] [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) Cutaneous squamous cell carcinoma (cSCC) represents 20% of skin cancers of the head and neck, and metastatic spread to the parotid area lymph nodes (PALN) are found in 1-3% of cases. Herein, we present the updated results of the largest single institution experience using radiation therapy (RT) in the management of patients (pts) with PALN metastases from cSCC in North America. Our hypothesis is the addition of pts treated with modern RT would maintain acceptable efficacy with a favorable toxicity profile. MATERIALS/METHODS With IRB approval, we retrospectively reviewed all pts diagnosed with cSCC metastatic to PALN treated at our institution with >6 months follow up. All pts were staged by the O'Brien staging system. Fifteen pts (10%) were treated preoperatively, 111 (72%) post operatively, and 28 (18%) with RT alone. Most pts were treated with three dimensional conformal RT (3DCRT) or a combination of 3DCRT and electron therapy (n = 112), while 31 pts were treated with intensity modulated RT (IMRT). There were 115 pts treated once daily fractionation and 39 pts being treated twice per day. We estimated disease control and survival, including local (parotid) control (LC), neck control (NC), local-regional control (LRC), distant metastasis free survival (DMFS), cause specific survival (CSS), and overall survival (OS) using the cumulative incidence method. Treatment toxicities were documented per CTCAEv3. RESULTS From November 1969 to December 2019, 154 pts were included. Median age at RT initiation was 66 years (range, 28-89). Fifty-two pts (33.8%) had an unknown location of a primary, while the most common identifiable locations of a primary were the temple, helix, and forehead. Forty-eight percent of pts had P2 or P3 disease with 26 of these pts being N1 or N2. Forty-six percent of pts were current or former smokers. Median follow up for this cohort was 4.9 years (range, <0.1 - 34.0) with 8 pts being lost to follow up. The overall 10-year Kaplan-Meier estimates for LC, NC, LRC, DMFS, CSS, and OS were 82%, 93%, 77%, 92%, 76%, and 31%, respectively. Eighty-one percent of treatment failures occurred within 2 years of treatment. LC was improved with IMRT (100%) compared to non-IMRT (78%) treatment (p = 0.005), with no other outcomes differing between the cohorts. There were 31 treatment complications were reported with 13 being ³ grade 3. CONCLUSION Our results represent the 10-year outcomes for the largest reported single institution experience of RT for cSCC metastatic to PALN showing favorable clinical outcomes with an acceptable toxicity profile. There was improved LC for pts treated with IMRT compared to 3DCRT/electrons; yet these did not translate to significant changes in other clinical outcomes.
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Affiliation(s)
- F Ashby
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL
| | - R J Brisson
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL
| | - C G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL
| | - K E Hitchcock
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL
| | - R J Amdur
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL
| | - W M Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL
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Casper AC, Giap F, Morris CG, Mendenhall NP. Hyperfractionated and Accelerated Reirradiation for Angiosarcoma Following Breast-Conserving Therapy: Long-Term Clinical Outcomes. Int J Radiat Oncol Biol Phys 2023; 117:e167. [PMID: 37784769 DOI: 10.1016/j.ijrobp.2023.06.1004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Radiation-associated angiosarcoma (RAAS) of the breast is a highly aggressive tumor that can occur in women who have undergone breast conserving therapy (BCT). Due to the rare nature of the disease, no consensus exists regarding the optimum management. Historically, local control and disease-specific survival rates have been poor. In our study, we evaluate the long-term outcomes of a novel approach to treatment of this disease using hyperfractionated and accelerated reirradiation (HART). The fractionation scheme was motivated by the idea that rapidly-growing tumors would benefit from hyperfractionation and previously irradiated tissues would handle smaller doses per fraction better. MATERIALS/METHODS With IRB approval, charts were retrospectively reviewed and follow-up was obtained for 15 patients treated with HART for angiosarcoma of the breast which developed after BCT between November 1997 and April 2017. Mean time to diagnosis of RAAS after BCT was 7.6 years (range, 4.3 - 11.0). Seven patients were treated for recurrent angiosarcoma after initial surgical resection and 8 were treated for de novo angiosarcoma. Patients were treated to a median of 60 Gy (range, 43-75) using two (n = 2) or three (n = 13) daily treatments. Mean time to beginning of HART after the diagnosis of angiosarcoma was 1.91 months (0.13-8.84). RESULTS Median follow-up time was 137 months (range, 4.8 - 235.3). Seven patients were alive at the time of follow-up. Fifteen-year cause-specific survival and overall survival rates were 67% (95% CI: 43 - 89%) and 53% (95% CI: 29 - 76%), respectively. Six patients had progression of their disease after HART, none of which were in the radiation field. Two of these patients had evidence of metastatic disease before treatment began. Effects from radiation included skin, musculoskeletal, nerve, and lung toxicities, most of which resolved or were not clinically significant. CONCLUSION This suggests that HART can provide relatively high rates of local control and overall survival for RAAS after BCT. Additionally, it highlights the need for multi-institution trials regarding treatment with HART in this disease. To our knowledge, this study contains the longest follow-up available for patients with RAAS of the breast.
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Affiliation(s)
- A C Casper
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL
| | - F Giap
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL
| | - C G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL
| | - N P Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL
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Mailhot Vega RB, Garcia Robles BE, Morris CG, Buss K, Mejia U, Poitevin A, Chilaca Rosas MF, Perez Villanueva H, Felix Leyva JA, Indelicato DJ, De la Mata D. Analysis of the Pediatric Radiotherapy Landscape in Mexico and a Subsequent Educational e-Contouring Intervention. JCO Glob Oncol 2023; 9:e2200372. [PMID: 37384858 PMCID: PMC10497300 DOI: 10.1200/go.22.00372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 04/26/2023] [Accepted: 05/30/2023] [Indexed: 07/01/2023] Open
Abstract
PURPOSE Mexico and Central America have the highest childhood cancer incidence in the West. Pediatric-specific oncology knowledge contributes to the disparity. We sought to (1) determine the self-identified treatment patterns and needs of Mexican pediatric radiation oncologists and (2) pilot a workshop to improve contouring accuracy. MATERIALS AND METHODS Partnering with local experts and the Sociedad Mexicana de Radioterapeutas (SOMERA), a 35-question survey was designed to ascertain pediatric radiotherapy capacity and distributed through the SOMERA listserv. The most challenging malignancies were selected for workshop. Participants received precontouring and postcontouring homework to assess improvement per the Dice metric. The Wilcoxon sign-rank test was used for comparative statistics. RESULTS Ninety-four radiation oncologists attempted and 79 completed the survey. Forty-four (76%) felt comfortable treating a pediatric patient, and 36 (62%) were familiar with national protocols for pediatric treatment. Most had access to nutrition, rehabilitation, endocrinology, and anesthesia; 14% had access to fertility services and 27% to neurocognitive support; 11% noted no support, and only one respondent had child-life support. The postsurvey contouring workshop was conducted for high-grade glioma, medulloblastoma, and Hodgkin lymphoma. Significant improvements were seen in all target volumes. CONCLUSION We present the first national survey of Mexico's pediatric radiotherapy capacity and Latin American e-contouring educational intervention with preworkshop and postworkshop Dice metrics, noting statistically significant improvement in all target volumes. Participation improved compared with prior experience through SOMERA partnership and Continuing Medical Education incentivization.
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Affiliation(s)
- Raymond B. Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
| | | | - Christopher G. Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
| | - Kara Buss
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
| | - Ulises Mejia
- Instituto Nacional de Cancerología, Hospital Infantil de México, Ciudad de México, México
| | | | | | | | | | - Daniel J. Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
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Jayappa KD, Tran B, Gordon VL, Morris CG, Saha S, Farrington CC, O'Connor CM, Zawacki KP, Isaac KM, Kester M, Bender TP, Williams ME, Portell CA, Weber MJ, Narla G. PP2A modulation overcomes multidrug resistance in chronic lymphocytic leukemia via mPTP-dependent apoptosis. J Clin Invest 2023:155938. [PMID: 37166997 DOI: 10.1172/jci155938] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023] Open
Abstract
Targeted therapies such as venetoclax (Bcl-2 inhibitor) have revolutionized the treatment of chronic lymphocytic leukemia (CLL). We previously reported that persister CLL cells in treated patients overexpress multiple anti-apoptotic proteins and display resistance to pro-apoptotic agents. Here, we demonstrated that multidrug resistant CLL cells in vivo exhibit apoptosis restriction at a premitochondrial level due to insufficient activation of the Bax and Bak proteins. Co-immunoprecipitation analyses with selective BH-domain antagonists revealed that the pleotropic pro-apoptotic protein (Bim) is prevented from activating Bax/Bak by "switching" interactions to other upregulated anti-apoptotic proteins (Mcl-1/Bcl-xL/Bcl-2). Hence, treatments that bypass Bax/Bak restriction are required to deplete these resistant cells in patients. Protein Phosphatase 2A (PP2A) contributes to oncogenesis and treatment resistance. We observed that a small molecule activator of PP2A (SMAP) induced cytotoxicity in multiple cancer cell lines and CLL samples, including multidrug resistant leukemia/lymphoma cells. The SMAP (DT-061) activated apoptosis in multidrug resistant CLL cells through induction of mitochondrial permeability transition pores (mPTP), independent of Bax/Bak. DT-061 inhibited the growth of wild type and Bax/Bak double knockout multidrug resistant CLL cells in a xenograft mouse model. Collectively, we discovered multidrug resistant CLL cells in patients, and validated a pharmacologically tractable pathway to deplete this reservoir.
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Affiliation(s)
- Kallesh D Jayappa
- Department of Microbiology, Immunology, and Cancer Biology, University of Virginia School of Medicine, Charlottesville, United States of America
| | - Brian Tran
- Division of Genetic Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, United States of America
| | - Vicki L Gordon
- Department of Microbiology, Immunology, and Cancer Biology, University of Virginia School of Medicine, Charlottesville, United States of America
| | - Christopher G Morris
- Department of Microbiology, Immunology, and Cancer Biology, University of Virginia School of Medicine, Charlottesville, United States of America
| | - Shekhar Saha
- Department of Biochemistry and Molecular Genetics, University of Virginia School of Medicine, Charlottesville, United States of America
| | - Caroline C Farrington
- Division of Genetic Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, United States of America
| | - Caitlin M O'Connor
- Division of Genetic Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, United States of America
| | - Kaitin P Zawacki
- Division of Genetic Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, United States of America
| | - Krista M Isaac
- Division of Hematology/Oncology, University of Virginia School of Medicine, Charlottesville, United States of America
| | - Mark Kester
- Department of Pharmacology, University of Virginia School of Medicine, Charlottesville, United States of America
| | - Timothy P Bender
- Department of Microbiology, Immunology, and Cancer Biology, University of Virginia School of Medicine, Charlottesville, United States of America
| | - Michael E Williams
- Division of Hematology/Oncology, University of Virginia School of Medicine, Charlottesville, United States of America
| | - Craig A Portell
- Division of Hematology/Oncology, University of Virginia School of Medicine, Charlottesville, United States of America
| | - Michael J Weber
- Department of Microbiology, Immunology, and Cancer Biology, University of Virginia School of Medicine, Charlottesville, United States of America
| | - Goutham Narla
- Division of Genetic Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, United States of America
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Gracie J, Fortune EC, Morris CG, Leach DF, Mendenhall WM. Radiation Treatment for Cancer of the Anal Margin. Am J Clin Oncol 2023; 46:167-171. [PMID: 36820471 DOI: 10.1097/coc.0000000000000986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
OBJECTIVE To identify best treatment practices by examining outcomes of anal margin cancer patients treated with radiotherapy. METHODS Relevant literature was compared with 38 patients at our institution treated 1979 to 2019 with curative radiotherapy. Median age was 51. Four patients had T1, 22 had T2, and 12 had T3 disease based on the American Joint Committee on Cancer (AJCC) staging at time of diagnosis. Nodal staging distribution was: N0=33; N1=2; N2=2; N3=1. Median radiation dose was 56 Gy/30 fractions. Five received nodal radiation for node positivity, 29 received elective nodal radiation, and 29 had perineal boost. Twenty-seven received concurrent chemotherapy. RESULTS Three patients experienced isolated local recurrence, 2 had isolated inguinal node recurrences, and 2 developed distant metastases, 1 of whom also had local and regional recurrence. Ten-year disease-free survival (DFS), cause-specific survival, and overall survival were 87%, 92%, and 68%, respectively. One patient did not complete radiation, and 4 had unexpected treatment breaks. Two received salvage abdominoperineal resections. At last follow-up, 17 were alive with no evidence of disease, 2 were alive with anal margin cancer present, 3 had died with anal margin cancer present at 11, 18, and 21 months from radiation therapy, and 16 had died from intercurrent disease. Median follow-up was 6.6 years (range 0.9 to 29.0 y). Age ≥51 was associated with worse locoregional control ( P =0.018) and DFS ( P =0.0233), males had worse DFS ( P =0.0311), and HIV-positive patients had worse overall survival ( P =0.006). CONCLUSIONS Radiation provides high locoregional control of anal margin cancer with good long-term outcomes.
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Affiliation(s)
- Jayden Gracie
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL
| | - E Charles Fortune
- Department of Radiation Oncology, John B. Amos Cancer Center, Piedmont Columbus Regional, Columbus, GA
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL
| | - Daniel F Leach
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL
- Department of Internal Medicine, Southeast Health, Dothan, AL
| | - William M Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL
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Witek ME, Morris CG, Alexander GS, Dontu P, Koroulakis AI, Regine WF, Mendenhall WM. Multi-institutional study of clinical outcomes of patients with head and neck cancer presenting with cN3 disease. Head Neck 2023; 45:1149-1155. [PMID: 36855018 DOI: 10.1002/hed.27326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 02/02/2023] [Accepted: 02/10/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND To evaluate disease control, toxicities, and variables associated with clinical outcomes for patients with head and neck squamous cell carcinoma and clinical N3 disease (HNSCC N3) treated with definitive chemoradiation therapy. METHODS We performed a retrospective review of patients with HNSCC N3 treated at two high-volume academic centers between 1996 and 2019. RESULTS We identified 85 patients with a median follow-up of 2.8 years. Five-year overall survival, regional control, and freedom from distant metastases rates were 38%, 80%, and 80%, respectively. Severe complications were identified in 19% of patients. CONCLUSIONS Favorable regional control is achievable with definitive chemoradiation therapy for patients with HNSCC N3 disease. Distant metastases are a common pattern of failure and should be a focus of prospective study.
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Affiliation(s)
- Matthew E Witek
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Gregory S Alexander
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Pragnya Dontu
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Antony I Koroulakis
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - William F Regine
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - William M Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida, USA
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14
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Holtzman AL, Glassman GE, Dagan R, Rao D, Fiester PJ, Tavanaieour D, Morris CG, Indelicato DJ, Mendenhall WM. Long-term outcomes of fractionated proton beam therapy for benign or radiographic intracranial meningioma. J Neurooncol 2023; 161:481-489. [PMID: 36692832 DOI: 10.1007/s11060-022-04207-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 12/02/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE Benign intracranial meningioma is one of the most common primary brain neoplasms. Proton therapy has been increasingly utilized for nonoperative management of this neoplasm, yet few long-term outcomes studies exist. METHODS The medical records of a total of 59 patients with 64 lesions were reviewed under a prospective outcomes tracking protocol for histologically proven or radiographically benign meningioma. The patients were treated with proton therapy at the University of Florida Proton Therapy Institute between 2007 and 2019 and given a median dose of 50.4 GyRBE at 1.8 GyRBE (relative biological effectiveness) (range 48.6-61.2 GyRBE) in once-daily treatments. RESULTS With a median clinical and imaging follow-up of 6.3 and 4.7 years, the rates of 5-year actuarial local progression and cumulative incidence of grade 3 or greater toxicity were 6% (95% confidence interval [CI] 1%-14%), and 2% (95% CI < 1%-15%), respectively. Two patients experienced local progression after 5 years. The 5-year actuarial overall survival rate was 87% (95% CI 74-94%). CONCLUSION Fractionated PBT up to 50.4 GyRBE is a safe and highly effective therapy for treating benign intracranial meningioma.
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Affiliation(s)
- Adam L Holtzman
- Department of Radiation Oncology, University of Florida College of Medicine, 2015 North Jefferson Street, Jacksonville, FL, 32206, USA.
| | | | - Roi Dagan
- Department of Radiation Oncology, University of Florida College of Medicine, 2015 North Jefferson Street, Jacksonville, FL, 32206, USA
| | - Dinesh Rao
- Department of Radiology, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
| | - Peter J Fiester
- Department of Radiology, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
| | - Daryoush Tavanaieour
- Department of Neurosurgery, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, 2015 North Jefferson Street, Jacksonville, FL, 32206, USA
| | - Daniel J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, 2015 North Jefferson Street, Jacksonville, FL, 32206, USA
| | - William M Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, 2015 North Jefferson Street, Jacksonville, FL, 32206, USA
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15
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Culbert MM, Parekh A, Shah A, Morris CG, Amdur RJ. Predictors of an Academic Career in Radiation Oncology 5 to 10 Years After Residency. Am J Clin Oncol 2023; 46:45-49. [PMID: 36468664 DOI: 10.1097/coc.0000000000000965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To report the percentage of resident graduates in the modern era who establish careers in academic radiation oncology 5 to 10 years after residency. MATERIALS AND METHODS The study population included 1147 radiation oncologists who completed residency between 2011 and 2017 and were practicing radiation oncologists in 2021. RESULTS The percentage of 2011-2017 graduates with an academic career in 2021 (5 to 10 y after residency): Holman Pathway resident: Yes, 74% versus No, 43% ( P <0.05); PhD degree before residency: Yes, 67% versus No, 38% ( P <0.05), Doximity top-10 ranked residency program: Yes, 66% versus No, 37% ( P <0.05).Logistic regression multivariate analysis confirmed PhD and Doximity top-10 as strong independent predictors for all endpoints.Regarding gender, no significant differences were observed for all 4 endpoints in the percentage of women versus men establishing academic careers at the 5-year to 10-year post-residency time point. CONCLUSION Since 2011, at least one-third (~35%) of radiation oncology residents have gone into academic medicine and are academically productive 5 to 10 years after residency. Holman Pathway, PhD degree, or Doximity top-10 residency program approximately doubles the probability of an academic career. Moreover, radiation oncology is on track to achieve gender equity in academic medicine.
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Affiliation(s)
- Matthew M Culbert
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL
| | - Akash Parekh
- Department of Radiation Oncology, Boston University School of Medicine, Boston, MA
| | - Anjay Shah
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL
| | - Robert J Amdur
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL
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16
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Bradley JA, Liang X, Mailhot Vega RB, Liu C, Brooks ED, Burchianti T, Viviers E, Dagan R, Oladeru OT, Morris CG, Mendenhall NP. Incidence of Rib Fracture following Treatment with Proton Therapy for Breast Cancer. Int J Part Ther 2023; 9:269-278. [PMID: 37169006 PMCID: PMC10166011 DOI: 10.14338/ijpt-22-00034.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 01/30/2023] [Indexed: 05/13/2023] Open
Abstract
Purpose To determine the rib fracture rate in a cohort of patients with breast cancer treated with proton therapy. Patient and Methods From a prospective database, we identified 225 patients treated with proton therapy between 2012 and 2020 (223 women; 2 men). Clinical and dosimetric data were extracted, the cumulative incidence method assessed rib fracture rate, and Fine-Gray tests assessed prognostic significance of select variables. In-field rib fracture was defined as a fracture that occurred in a rib located within the 10% isodose line. Out-of-field rib fracture was defined as a fracture occurring in a rib location outside of the 10% isodose line. Results Of the patients, 74% had left-sided breast cancer; 5%, bilateral; and 21%, right-sided. Dual-energy x-ray absorptiometry scans showed normality in 20%, osteopenia in 34%, and osteoporosis in 6% (test not performed in 40%). Additionally, 57% received an aromatase inhibitor. Target volumes were breast ± internal mammary nodes (IMNs) (16%), breast and comprehensive regional lymphatics (32%), chest wall ± IMNs (1%), and chest wall/comprehensive regional lymphatics (51%). Passive-scattered proton therapy was used for 41% of patients, 58% underwent pencil-beam scanning (PBS), and 1% underwent a combination (passive scattering/PBS), with 85% of patients receiving a boost. Median follow-up was 3.1 years, with 97% having >12-month follow-up. The 3-year cumulative in-field rib fracture incidence was 3.7%. Eight patients developed in-field rib fractures (1 symptomatic, 7 imaging identified) for a 0.4% symptomatic rib fracture rate. Median time from radiation completion to rib fracture identification was 1.8 years (fractures were identified within 2.2 years for 7 of 8 patients). No variables were associated with rib fracture on univariate analysis. Three fractures developed outside the radiation field (0.9% cumulative incidence of out-of-field rib fracture). Conclusion In this series of patients with breast cancer treated with proton therapy, the 3-year rib fracture rates remain low (in-field 3.7%; symptomatic 0.4%). As in photon therapy, the asymptomatic rate may be underestimated owing to a lack of routine surveillance imaging. However, patients experiencing symptomatic rib fractures after proton therapy for breast cancer are rare.
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Affiliation(s)
- Julie A. Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | | | - Raymond B. Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Chunbo Liu
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Eric D. Brooks
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Teena Burchianti
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Emma Viviers
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Roi Dagan
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Oluwadamilola T. Oladeru
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Christopher G. Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Nancy P. Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
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Rutenberg MS, Hoppe BS, Starr JS, Awad Z, Thomas M, Morris CG, Johnson P, Henderson RH, Jones JC, Gharia B, Bowers S, Wolfsen HC, Krishnan S, Ko SJ, Babiker HM, Nichols RC. Proton Therapy With Concurrent Chemotherapy for Thoracic Esophageal Cancer: Toxicity, Disease Control, and Survival Outcomes. Int J Part Ther 2022; 9:18-29. [PMID: 36721483 PMCID: PMC9875824 DOI: 10.14338/ijpt-22-00021.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 09/26/2022] [Indexed: 12/23/2022] Open
Abstract
Purpose When treating esophageal cancer with radiation therapy, it is critical to limit the dose to surrounding structures, such as the lung and/or heart, as much as possible. Proton radiation therapy allows a reduced radiation dose to both the heart and lungs, potentially reducing the risk of cardiopulmonary toxicity. Here, we report disease control, survival, and toxicity outcomes among patients with esophageal cancer treated with proton radiation therapy and concurrent chemotherapy (chemoradiation therapy; CRT) with or without surgery. Materials and Methods We enrolled 17 patients with thoracic esophageal carcinoma on a prospective registry between 2010 and 2021. Patients received proton therapy to a median dose of 50.4-GyRBE (range, 50.4-64.8) in 1.8-Gy fractions.Acute and late toxicities were graded per the Common Terminology Criteria for Adverse Events, version 4.0 (US National Cancer Institute, Bethesda, Maryland). In addition, disease control, patterns of failure, and survival outcomes were collected. Results Nine patients received preoperative CRT, and 8 received definitive CRT. Overall, 88% of patients had adenocarcinoma, and 12% had squamous cell carcinoma. With a median follow-up of 2.1 years (range, 0.5-9.4), the 3-year local progression-free, disease-free, and overall survival rates were 85%, 66%, and 55%, respectively. Two patients (1 with adenocarcinoma and 1 with squamous cell carcinoma) recurred at the primary site after refusing surgery after a complete clinical response to CRT. The most common acute nonhematologic and hematologic toxicities, respectively, were grades 1 to 3 esophagitis and grades 1 to 4 leukopenia, both affecting 82% of patients. No acute cardiopulmonary toxicities were observed in the absence of surgical resection. Reagarding surgical complications, 3 postoperative cardiopulmonary complications occurred as follows: 1 grade 1 pleural effusion, 1 grade 3 pleural effusion, and 1 grade 2 anastomotic leak. Two severe late CRT toxicities occurred: 1 grade 5 tracheoesophageal fistula and 1 grade 3 esophageal stenosis requiring a feeding tube. Conclusion Proton radiation therapy is a safe, effective treatment for esophageal cancer with increasing evidence supporting its role in reducing cardiopulmonary toxicity.
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Affiliation(s)
| | - Bradford S. Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Jason S. Starr
- Division of Hematology/Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Ziad Awad
- Department of Surgery, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Mathew Thomas
- Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Christopher G. Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Perry Johnson
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Randal H. Henderson
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Jeremy C. Jones
- Division of Hematology/Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Bharatsinh Gharia
- Department of Medicine, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Steven Bowers
- Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Herbert C. Wolfsen
- Department of Gastroenterology and Hepatology, Mayo Clinic Jacksonville, FL, USA
| | - Sunil Krishnan
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Stephen J. Ko
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Hani M. Babiker
- Division of Hematology/Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Romaine C. Nichols
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
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18
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Chong MWS, Argent SP, Moreau F, Trenholme WJF, Morris CG, Lewis W, Easun TL, Schröder M. A Coordination Network Featuring Two Distinct Copper(II) Coordination Environments for Highly Selective Acetylene Adsorption. Chemistry 2022; 28:e202201188. [PMID: 35762497 PMCID: PMC9545019 DOI: 10.1002/chem.202201188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Indexed: 11/24/2022]
Abstract
Single crystals of 2D coordination network {Cu2 L2 ⋅ (DMF)3 (H2 O)3 }n (1-DMF) were prepared by reaction of commercial reagents 3-formyl-4-hydroxybenzoic acid (H2 L) and Cu(NO3 )2 in dimethylformamide (DMF). The single-crystal structure shows two distinct Cu(II) coordination environments arising from the separate coordination of Cu(II) cations to the carboxylate and salicylaldehydato moieties on the linker, with 1D channels running through the structure. Flexibility is exhibited on solvent exchange with ethanol and tetrahydrofuran, while porosity and the unique overall connectivity of the structure are retained. The activated material exhibits type I gas sorption behaviour and a BET surface area of 950 m2 g-1 (N2 , 77 K). Notably, the framework adsorbs negligible quantities of CH4 compared with CO2 and the C2 Hn hydrocarbons. It exhibits exceptional selectivity for C2 H2 /CH4 and C2 H2 /C2 Hn , which has applicability in separation technologies for the isolation of C2 H2 .
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Affiliation(s)
| | - Stephen P. Argent
- School of ChemistryUniversity of NottinghamUniversity ParkNottinghamNG7 2RDUK
| | - Florian Moreau
- School of ChemistryUniversity of NottinghamUniversity ParkNottinghamNG7 2RDUK
- School of ChemistryThe University of ManchesterOxford RoadManchesterM13 9PLUK
| | - William J. F. Trenholme
- School of ChemistryUniversity of NottinghamUniversity ParkNottinghamNG7 2RDUK
- School of ChemistryThe University of ManchesterOxford RoadManchesterM13 9PLUK
| | - Christopher G. Morris
- School of ChemistryUniversity of NottinghamUniversity ParkNottinghamNG7 2RDUK
- School of ChemistryThe University of ManchesterOxford RoadManchesterM13 9PLUK
| | - William Lewis
- School of ChemistryUniversity of NottinghamUniversity ParkNottinghamNG7 2RDUK
| | - Timothy L. Easun
- School of ChemistryCardiff UniversityMain Building, Park PlaceCardiffCF10 3ATUK
| | - Martin Schröder
- School of ChemistryUniversity of NottinghamUniversity ParkNottinghamNG7 2RDUK
- School of ChemistryThe University of ManchesterOxford RoadManchesterM13 9PLUK
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de Leo AN, Dagan R, Morris CG, Holtzman AL, Hitchcock KE, Bryant CM, Amdur RJ, Mendenhall WM. Early-stage vocal cord cancer treated with hypofractionated radiotherapy to the larynx with or without concurrent chemotherapy. Head Neck 2022; 44:2513-2521. [PMID: 35950338 DOI: 10.1002/hed.27165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/17/2022] [Accepted: 07/15/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND We report outcomes among patients with T2 and select T3 glottic squamous cell carcinoma (SCC) treated with radiotherapy. METHODS We reviewed T2 and T3 (only paraglottic space invasion) N0 M0 glottic SCC patients treated with curative-intent hypofractionated larynx radiotherapy, with or without concurrent systemic therapy. RESULTS Of 71 patients, those who received concurrent chemotherapy (23/71; 32%) had worse prognostic factors, including impaired cord mobility (70% vs. 40%, p = 0.02) and larger median gross tumor volume (3.0 vs. 1.6 cm3 , p = 0.003). Over a median follow-up of 3.8 years, 2-year local control among patients with impaired cord mobility appeared higher for those who received chemotherapy (88% vs. 61%, p = 0.12), but the difference was not statistically significant. Acute and late toxicity rates were not higher among patients who received chemotherapy. CONCLUSIONS The addition of concurrent platinum-based chemotherapy to hypofractionated larynx radiotherapy among patients with early-stage glottic SCC with impaired cord mobility appears safe and worthy of additional investigation.
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Affiliation(s)
- Alexandra N de Leo
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida, USA.,Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, USA
| | - Roi Dagan
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida, USA.,Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, USA
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida, USA.,Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, USA
| | - Adam L Holtzman
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida, USA.,Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, USA
| | - Kathryn E Hitchcock
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida, USA.,Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, USA
| | - Curtis M Bryant
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida, USA.,Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, USA
| | - Robert J Amdur
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida, USA.,Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, USA
| | - William M Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida, USA.,Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, USA
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Holtzman AL, Rutenberg MS, De Leo AN, Rao D, Patel J, Morris CG, Indelicato DJ, Mendenhall WM. The incidence of brainstem toxicity following high-dose conformal proton therapy for adult skull-base malignancies. Acta Oncol 2022; 61:1026-1031. [PMID: 35897132 DOI: 10.1080/0284186x.2022.2101900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Dose escalation for skull-based malignancies often presents risks to critical adjacent neural structures, including the brainstem. We report the incidence of brainstem toxicity following fractionated high-dose conformal proton therapy and associated dosimetric parameters. MATERIAL AND METHODS We performed a single-institution review of patients with skull-base chordoma or chondrosarcoma who were treated with proton therapy between February 2007 and January 2020 on a prospective outcomes-tracking protocol. The primary endpoint was grade ≥2 brainstem toxicity. No patients received concurrent chemotherapy, and brainstem toxicity was censored for analysis if it coincided with local disease progression. RESULTS We analyzed 163 patients who received a minimum of 45 GyRBE to 0.03 cm3 of the brainstem. Patients were treated to a median total dose of 73.8 (range 64.5-74.4) GyRBE at 1.8 GyRBE per fraction with 17 patients undergoing twice-daily treatment at 1.2 GyRBE per fraction. With a median follow-up of 4 years, the 5-year cumulative incidence of grade ≥2 brainstem injury was 1.3% (95% CI 0.25-4.3%). There was one grade 2, one grade 3, and no grade 4 or 5 events, with all patients recovering function with medical management. CONCLUSION In delivering curative-intent radiotherapy for skull-base chordoma and chondrosarcoma in adults, small volumes of the brainstem can safely receive at least 64 GyRBE with minimal risk of serious brainstem injury.
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Affiliation(s)
- Adam L Holtzman
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | | | - Alexandra N De Leo
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Dinesh Rao
- Department of Radiology, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
| | - Jeet Patel
- Department of Radiology, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Daniel J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - William M Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
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21
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Giap F, O'steen L, Liu IC, Spiguel LE, Shaw CM, Morris CG, Mailhot Vega RB, Lightsey JL, Bradley JA, Mendenhall NP, Okunieff PG, Lockney NA. Intraoperative radiation therapy for early-stage breast cancer: a single-institution experience. Rep Pract Oncol Radiother 2022; 27:666-676. [PMID: 36196411 PMCID: PMC9521704 DOI: 10.5603/rpor.a2022.0075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 06/21/2022] [Indexed: 11/25/2022] Open
Abstract
Background To assess outcomes and toxicity after low-energy intraoperative radiotherapy (IORT) for early-stage breast cancer (ESBC). Materials and methods We reviewed patients with unilateral ESBC treated with breast-conserving surgery and 50-kV IORT at our institution. Patients were prescribed 20 Gy to the surface of the spherical applicator, fitted to the surgical cavity during surgery. Patients who did not meet institutional guidelines for IORT alone on final pathology were recommended adjuvant treatment, including additional surgery and/or external-beam radiation therapy (EBRT). We analyzed ipsilateral breast tumor recurrence, overall survival, recurrence-free survival and toxicity. Results Among 201 patients (median follow-up, 5.1 years; median age, 67 years), 88% were Her2 negative and ER positive and/or PR positive, 98% had invasive ductal carcinoma, 87% had grade 1 or 2, and 95% had clinical T1 disease. Most had pathological stage T1 (93%) N0 (95%) disease. Mean IORT applicator dose at 1-cm depth was 6.3 Gy. Post-IORT treatment included additional surgery, 10%; EBRT, 11%; adjuvant chemotherapy, 9%; and adjuvant hormonal therapy, 74%. Median total EBRT dose was 42.4 (range, 40.05–63) Gy and median dose per fraction was 2.65 Gy. At 5 years, the cumulative incidence of ipsilateral breast tumor recurrence was 2.7%, the overall survival rate was 95% with no breast cancer-related deaths, and the recurrence-free survival rate was 96%. For patients who were deemed unsuitable for postoperative IORT alone and did not receive recommended risk-adapted EBRT, the IBTR rate was 4.7% versus 1.7% (p = 0.23) for patients who were either suitable for IORT alone or unsuitable and received adjuvant EBRT. Cosmetic toxicity data was available for 83%, with 7% experiencing grade 3 breast toxicity and no grade 4–5 toxicity. Conclusions IORT for select patients with ESBC results in acceptable outcomes in regard to ipsilateral breast tumor recurrence and toxicity.
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22
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Padgett M, Kharod SM, Mercado CE, Morris CG, Rutenberg MS, Nichols RC. Patterns-of-care disparities among uninsured versus insured patients with anorectal carcinoma referred for radiotherapy at an Urban Safety-Net Hospital. J Gastrointest Oncol 2022; 13:1081-1085. [PMID: 35837158 PMCID: PMC9274027 DOI: 10.21037/jgo-21-592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 03/17/2022] [Indexed: 08/30/2023] Open
Abstract
BACKGROUND To compare patterns-of-care and clinical outcomes among uninsured versus insured patients (IPs) with anorectal malignancies referred for radiotherapy at an urban safety-net hospital. This topic is important because uninsured patients (UPs) in the US often have limited access to health care, which can result in worse health outcomes. METHODS We reviewed the medical records of 59 patients with biopsy-proven, non-metastatic anal and rectal cancers who received curative-intent primary or neoadjuvant/adjuvant radiotherapy between May 2002 and August 2012. Data regarding patient and disease characteristics, weight loss, insurance status at symptom onset, date of first therapeutic intervention, and survival status at last follow-up, were collected and analyzed. RESULTS The percentage of IPs presenting with T4 tumors was 7% versus 40% among the uninsured (P=0.005). The median interval between first symptom onset and diagnosis date was 89 (range, 0-1,428) days for IPs and 221 (range, 0-1,576) days for UPs (P=0.01). The median interval between first symptom onset and treatment initiation was 172 (range, 9-1,498) days for IPs and 302 (range, 35-1,624 days) days for UPs (P=0.01). The 5-year overall survival rate was 59% for the entire cohort, 62% for the insured patients, and 55% for the uninsured patients (P=0.76). CONCLUSIONS Differences in health insurance status demonstrated various disparities in patterns-of-care, including significant delay in diagnosis, more advanced-stage disease at presentation, and treatment initiation delays among UPs. Nevertheless, overall survival at 5 years was not statistically significant between the insured and the uninsured.
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Affiliation(s)
- Michael Padgett
- University of Florida College of Medicine, Department of Radiation Oncology, Jacksonville, FL, USA
| | - Shivam M. Kharod
- University of Florida College of Medicine, Department of Radiation Oncology, Jacksonville, FL, USA
| | - Catherine E. Mercado
- Orlando Health Cancer Institute, Department of Radiation Oncology, Orlando, FL, USA
| | - Christopher G. Morris
- University of Florida College of Medicine, Department of Radiation Oncology, Jacksonville, FL, USA
| | - Michael S. Rutenberg
- University of Florida College of Medicine, Department of Radiation Oncology, Jacksonville, FL, USA
| | - Romaine C. Nichols
- University of Florida College of Medicine, Department of Radiation Oncology, Jacksonville, FL, USA
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Rapp CT, Rutenberg MS, Morris CG, Nichols RC. Dose-escalated proton therapy with elective nodal irradiation and concomitant chemotherapy for unresectable, borderline resectable, or medically inoperable pancreatic cancer: a phase II trial. J Gastrointest Oncol 2022; 13:1395-1401. [PMID: 35837200 PMCID: PMC9274025 DOI: 10.21037/jgo-21-593] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 04/13/2022] [Indexed: 08/30/2023] Open
Abstract
BACKGROUND To report outcomes of a phase II single-institution trial of dose-escalated proton radiotherapy with elective nodal irradiation (ENI) and concomitant chemotherapy for patients with unresectable, borderline resectable, or medically inoperable pancreatic adenocarcinoma. METHODS Patients received 40.5 GyRBE in 18 fractions to the gross disease and elective nodal volumes followed by 22.5 GyRBE as a 10-fraction boost to the gross disease for a cumulative dose of 63 GyRBE over 28 fractions. Oral capecitabine (1,000 mg taken orally twice daily) was given on radiation treatment days. The primary objective of this study was to improve the proportion surviving to at least 1 year from the historical rate of 50% to 75%. Secondary objectives included assessing gastrointestinal (GI) toxicity and weight loss during treatment, and evaluating the safety of subsequent surgical resection. This single-institution study was closed to accrual early after the opening of the multicenter PAN009-18 trial by the Proton Collaborative Group (PCG), which follows a similar protocol. RESULTS At enrollment, 10 (67%) patients had unresectable disease, 3 (20%) had borderline-resectable disease, and 2 (13%) refused surgery. All 15 patients successfully completed radiation therapy as prescribed. With regard to toxicity, a single patient experienced grade 3 nausea requiring cessation of capecitabine, which ultimately resolved by treatment completion. The median percentage weight loss during treatment was -3.0% (range, -9.6% to +12.0%). Two (13%) initially borderline patients ultimately underwent R0 resection: their total operating room times were 267 and 410 minutes, and blood loss was 700 and 400 mL, respectively. Neither patient experienced intraoperative or postoperative complications. Both were discharged on postoperative day 6. The median follow-up was 0.93 years (range, 0.21 to 2.14 years). The 1-year overall survival (OS) rate was 47%. Three enrolled patients are currently alive: 2 with no evidence of disease and 1 with stable disease. CONCLUSIONS The primary objective of 1-year OS of 75% was not reached. Proton therapy was well-tolerated. Patients undergoing surgery did not experience operative or perioperative complications, suggesting that patients with borderline resectable or even resectable disease may benefit from neoadjuvant proton therapy. The PCG will test this premise as patients accrue to the multicenter PAN009-18 trial. TRIAL REGISTRATION NCT02598349.
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Affiliation(s)
- Cooper T. Rapp
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | | | - Christopher G. Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
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Holtzman AL, Bates JE, Morris CG, Rutenberg MS, Indelicato DJ, Tavanaiepour D, Mendenhall WM. Impact of Type of Treatment Center and Access to Care on Mortality and Survival for Skull Base Chordoma and Chondrosarcoma. Skull Base Surg 2022; 83:328-338. [DOI: 10.1055/s-0040-1722228] [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: 04/09/2020] [Accepted: 10/04/2020] [Indexed: 10/22/2022]
Abstract
Abstract
Introduction In adults with skull base chordoma or chondrosarcoma, the impact of treatment center and access to care have not been well described in regard to perioperative mortality and survival.
Methods A query of the National Cancer Database (NCDB) and review of 1,102 adults—488 with chordomas and 614 with chondrosarcomas—was performed. The Kaplan–Meier's product limit method and chi-square analysis, respectively, assessed overall survival and 30-day (30D) and 90-day (90D) mortalities.
Results For 925 patients who had surgery and available mortality data, the 30D and 90D mortality rates were 0.9 and 1.5%. Lower education level (p = 0.0185) and treatment at a nonacademic facility (p = 0.016) were associated with increased risk of 90-day mortality. Median follow-up was 52 months and analysis was dichotomized by histology. For those with skull base chordoma, patients from a larger metro size (p = 0.002), age below the median 52 years (p ≤ 0.001), and private insurance (<0.001) were associated with prolonged survival, whereas for skull base chondrosarcoma, the factors were treatment at an academic medical center (p = 0.001), high-volume center (p = 0.007), age below the median 52 years (p ≤ 0.001), higher income (p = 0.043), higher education (p = 0.017), and private insurance (p ≤ 0.001). Comparing high-, medium-, and low-volume centers, high-volume centers were most likely to be academic, deliver radiotherapy, escalate doses >70 Gy, and utilize proton radiotherapy consistent across both disease subsets.
Conclusion Higher educational attainment and treatment at an academic facility were associated with decreased 90D mortality for patients with skull base chordoma and chondrosarcoma. For those with skull base chordoma, larger metro size, younger age, and private insurance were associated with prolonged survival; for those with chondrosarcoma, it was treatment at a high-volume or academic medical center, younger age, higher income or education, and private insurance.
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Affiliation(s)
- Adam L. Holtzman
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - James E. Bates
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Christopher G. Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Michael S. Rutenberg
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Daniel J. Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Daryoush Tavanaiepour
- Department of Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - William M. Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, United States
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Fortune EC, Mercado CE, Drew PA, Morris CG, Amdur RJ. Adjuvant I-131 therapy for T0-3 N1b M0 differentiated thyroid cancer with many (≥ 5) positive nodes. Rep Pract Oncol Radiother 2022; 27:121-124. [PMID: 35402034 PMCID: PMC8989455 DOI: 10.5603/rpor.a2022.0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 11/20/2021] [Indexed: 11/25/2022] Open
Abstract
Background In patients with well-differentiated thyroid cancer, there is controversy about the prognostic importance of a large number of positive neck nodes and the potential value of radioiodine therapy. The purpose of this study was to evaluate this issue in the group of patients for whom it is most clinically important - those with classic histology and favorable T and M stage. Materials and methods Twenty-five patients met the following inclusion criteria: classic histology of papillary or follicular thyroid carcinoma treated with total thyroidectomy and neck dissection followed by adjuvant I-131 treatment in our department between January 1, 2003, and December 31, 2013; adult age of > 21 years; and American Joint Committee on Cancer (AJCC ) stage (8th edition) of T0-3, N1b with ≥ 5 positive nodes, and M0. Results The median positive node number was 10 (range, 5-31). The median adjuvant I-131 dose was 158 mCi (range, 150-219 mCi). The median follow-up in patients without recurrence after treatment was 7.3 years. The 10-year actuarial rates were favorable: overall survival, 100%; freedom from visible recurrence, 82%; and visible or biochemical recurrence, 72%. Conclusion Recurrence was infrequent in our study population with ≥ 5 positive nodes following moderate-dose adjuvant I-131 treatment. These results are valuable in directing initial adjuvant therapy and follow-up intensity. Our results do not inform the question of the use of postoperative thyroglobulin (Tg) level to select N1b patients for low-dose I-131 treatment.
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Affiliation(s)
- E Charles Fortune
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida, United States
| | - Catherine E Mercado
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida, United States
| | - Peter A Drew
- Department of Pathology, University of Florida College of Medicine, Gainesville, Florida, United States
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida, United States
| | - Robert J Amdur
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida, United States
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Henderson RH, Bryant CM, Nichols RC, Mendenhall WM, Hoppe BS, Su Z, Morris CG, Mendenhall NP. Five- and seven-year outcomes for image-guided moderately accelerated hypofractionated proton therapy for prostate cancer. Acta Oncol 2022; 61:468-477. [PMID: 34965846 DOI: 10.1080/0284186x.2021.2016948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND To report 5- and 7-year outcomes after image-guided moderately accelerated hypofractionated proton therapy (AHPT) for prostate cancer. MATERIAL AND METHODS We reviewed the first 582 prostate cancer patients enrolled on prospective outcomes tracking trial and treated with double-scattered moderately AHPT between 2008 and 2015. 269 patients had low-risk (LR) and 313 had intermediate-risk (IR) disease, including 149 with favorable intermediate-risk (FIR) and 164 with unfavorable intermediate-risk (UIR) disease. LR patients received a median 70.0GyRBE (2.5GyRBE/fraction) and IR patients received a median of 72.5 GyRBE. Seventeen patients (UIR, n = 12) received androgen deprivation therapy (ADT) for a median of 6 months. Toxicities were graded per the CTCAE, v4.0, and patient-reported quality-of-life data were reviewed. RESULTS Median follow-up was 8.0 years (0.9-12.2). The 5- and 7-year rates of freedom from biochemical progression (FFBP) overall and in the LR and IR subsets, respectively, were 96.8/95.2%, 98.8/98.8%, and 95.0/91.9%. For the FIR and UIR subsets, they were 97.2/95.2% and 93.1/88.8%. Actuarial 5- and 7-year rates of late CTCAE, v4.0, grade 2 gastrointestinal (GI), grade 3 GI, and grade 3 genitourinary (GU) toxicities were 9.9%/11.2%, 1.4/1.4% and 1.3/2.1%, respectively. No grade ≥4 GI or GU toxicities occurred. The mean (standard deviation, SD) IPSS and EPIC Composite bowel function and bother scores were 7 (SD = 5), 97 (SD = 7), and 94 (SD = 6), respectively at baseline, 7 (SD = 5), 92 (SD = 13), and 92 (SD = 9) at the 5-year follow-up, and 7 (SD = 5), 93 (SD = 12), and 92 (SD = 10) at the 7-year follow-up. CONCLUSION Image-guided AHPT 5- and 7-year outcomes show high efficacy, minimal physician-assessed toxicity, and excellent patient-reported outcomes in this cohort.
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Affiliation(s)
- Randal H. Henderson
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Curtis M. Bryant
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - R. Charles Nichols
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - William M. Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Bradford S. Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Zhong Su
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Christopher G. Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Nancy P. Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
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Hoppe BS, Nichols RC, Flampouri S, Pankuch M, Morris CG, Pham DC, Mohindra P, Hartsell WF, Mohammed N, Chon BH, Kestin LL, Simone CB. Chemoradiation with Hypofractionated Proton Therapy in Stage II-III Non-Small Cell Lung Cancer: A YYY Phase 1/2 Trial. Int J Radiat Oncol Biol Phys 2022; 113:732-741. [PMID: 35306151 DOI: 10.1016/j.ijrobp.2022.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 02/23/2022] [Accepted: 03/04/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Hypofractionated radiotherapy has been safely implemented into the treatment of early-stage non-small cell lung cancer (NSCLC), but not locally advanced (LA-) NSCLC due to prohibitive toxicities with photon therapy. Proton therapy, however, may allow for safe delivery of hypofractionated radiotherapy. We sought to determine whether hypofractionated proton therapy with concurrent chemotherapy improves overall survival. METHODS & MATERIALS The YYY conducted a phase 1/2 single-arm nonrandomized prospective multicenter trial from 2013 through 2018. Thirty-two patients were consented; 28 were eligible for on-study treatment. Patients had AJCCv7 stage II or III unresectable NSCLC and received hypofractionated proton therapy at 2.5-4 Gy per fraction to a total 60 Gy with concurrent platin-based doublet chemotherapy. The primary outcome was 1-year overall survival comparable to that reported for RTOG 9410 of 62%. RESULTS The trial closed early due to slow accrual, in part, from a competing trial, NRG 1308. Median patient age was 70 (range, 50-86) years. Patients were predominantly male (N=20), white (N=23), and prior smokers (N=27). Most had stage III NSCLC (N=22), 50% of whom had adenocarcinoma. After a median follow-up of 31 months, the 1- and 3-year overall survival rates were 89% and 49%, and progression-free survival rates were 58% and 32%, respectively. No acute grade 3 or higher esophagitis occurred. Only 14% developed a grade 3 or higher radiation-related pulmonary toxicity. CONCLUSION Hypofractionated proton therapy delivered at 2.5-3.53 Gy per fraction to a total 60 Gy with concurrent chemotherapy provides promising survival and additional examination through larger studies may be warranted.
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Affiliation(s)
- Bradford S Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida.
| | - Romaine C Nichols
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Stella Flampouri
- Department of Radiation Oncology, Winship Cancer Institute at Emory University, Atlanta, Georgia
| | - Mark Pankuch
- Northwestern Medicine Proton Center, Warrenville, Illinois
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Dat C Pham
- Baptist MD Anderson Cancer Center, Jacksonville, Florida
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine and Maryland Proton Treatment Center, Baltimore, Maryland
| | | | | | - Brian H Chon
- ProCure Proton Therapy Center, Somerset, New Jersey
| | - Larry L Kestin
- MHP Radiation Oncology Institute/GenesisCare USA, Farmington Hills, Michigan
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center and New York Proton Center, New York, New York
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Rutenberg MS, Holtzman AL, Indelicato DJ, Huh S, Rao D, Fiester PJ, Morris CG, Tavanaiepour D, Amdur RJ. Disease Control after Radiotherapy for Adult Craniopharyngioma: Clinical Outcomes from a Large Single-Institution Series. J Neurooncol 2022; 157:425-433. [DOI: 10.1007/s11060-022-03983-z] [Citation(s) in RCA: 1] [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: 02/01/2022] [Accepted: 03/05/2022] [Indexed: 10/18/2022]
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Drescher NR, Amdur RJ, Morris CG, Shaw CM, Dziegielewski PT, Mendenhall WM. Postoperative Radiotherapy for Cutaneous Melanoma in Patients at High Risk of Local-Regional Recurrence after Surgery Alone. Cancer Invest 2022; 40:348-353. [PMID: 35100059 DOI: 10.1080/07357907.2022.2033986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
We evaluated outcomes in 131 patients with cutaneous melanoma (median follow-up, 3.6 years) considered at high risk of recurrence after surgery alone treated with surgery and postoperative radiotherapy. Eligible patients had one or more of the following: recurrence after surgery, positive lymph nodes, extracapsular extension, incomplete regional node dissection, microscopically positive margins, gross residual disease, or in-transit metastases. 102 patients received hypofractionated radiotherapy and 29 had conventional fractionation. 10-year outcomes were: in-field local-regional control, 87%; local regional control, 72%; distant metastasis-free survival, 48%; cause-specific survival, 44%; and overall survival, 31%. Three patients experienced acute toxicities while 6 experienced late toxicities.
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Affiliation(s)
- Nicolette R Drescher
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Robert J Amdur
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Christiana M Shaw
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Peter T Dziegielewski
- Department of Otolaryngology, University of Florida College of Medicine, Gainesville, FL, USA
| | - William M Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
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Indelicato DJ, Mailhot Vega RB, Viviers E, Morris CG, Bradfield SM, Gibbs CP, Bradley JA. Modern Therapy for Chest Wall Ewing Sarcoma: An Update of the XXX Experience. Int J Radiat Oncol Biol Phys 2022; 113:345-354. [DOI: 10.1016/j.ijrobp.2022.02.011] [Citation(s) in RCA: 1] [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: 08/17/2021] [Revised: 02/03/2022] [Accepted: 02/06/2022] [Indexed: 12/25/2022]
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Indelicato DJ, Vega RBM, Viviers E, Morris CG, Bradfield SM, Ranalli NJ, Bradley JA. Modern Therapy for Spinal and Paraspinal Ewing Sarcoma: An Update of the XXX Experience. Int J Radiat Oncol Biol Phys 2022; 113:161-165. [PMID: 35033584 DOI: 10.1016/j.ijrobp.2022.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 01/04/2022] [Accepted: 01/07/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE In 2010, we published a comprehensive review of our institutional outcomes treating children with spinal and paraspinal Ewing sarcoma using photon therapy. Multimodality therapy was associated with fair disease control but also with serious toxicity, including a 37% rate of Grade ≥3 toxicity. We therefore sought to assess our more recent experience treating children with more modern technology and treatment regimens. METHODS AND MATERIALS Between 2010 and 2021, 32 pediatric patients with nonmetastatic spinal and paraspinal Ewing sarcoma were treated at XXX and enrolled in a retrospective outcome study. Median age at diagnosis was 9.8 (range, 2.1-21.8) years old. Three, 22, and 7 tumors arose within the cervical, thoracic, and lumbar spine regions, respectively. Median maximum tumor diameter was 5 (range, 3-19) cm. At diagnosis, 28/32 patients had motor, bowel, or bladder deficits. Chemotherapy was delivered per contemporary North American and European interval-compressed regimens. Before radiotherapy, 14 patients underwent gross total resection while 18 underwent a biopsy or subtotal resection with cord decompression. All patients were treated with proton therapy; 6 with hardware stabilization also received a component of intensity-modulated photon therapy. Median prescription dose was 50.4 (range, 45-54) GyRBE. Median maximum dose to the spinal cord was 50.2 (range, 0-54.9) GyRBE. RESULTS With a median follow-up of 4.1 (range, 0.7 - 9.4) years, the 5-year local control, progression-free survival, and overall survival rates were 92%, 79%, and 85%, respectively. Ten of 30 living patients have residual motor, bowel, or bladder deficits. Overall, 22% of patients experienced CTCAE grade 3 late toxicity related to multimodality treatment: kyphosis (n=4), esophagitis (n=2) and chronic kidney disease (n=1). No patients developed grade ≥4 toxicity, new neurologic deficits, or second malignancy. CONCLUSION Modern treatment advances may offer an improved therapeutic ratio for pediatric spinal and paraspinal Ewing sarcoma. With appropriate management, most patients can be cured with recovery of long-term neurologic function and modest side-effects.
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Affiliation(s)
- Daniel J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL.
| | - Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
| | - Emma Viviers
- University of Florida Health Proton Therapy Institute, Jacksonville, FL
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
| | - Scott M Bradfield
- Department of Pediatrics, Nemours Children's Specialty Care, Jacksonville, FL
| | - Nathan J Ranalli
- Department of Neurosurgery, University of Florida College of Medicine Jacksonville, Jacksonville, FL
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL
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Braschi EL, Kharod SM, Morris CG, Spiguel AR, Gibbs CP, Scarborough MT, Zlotecki RA. Reirradiation in Conservative Salvage of Recurrent Soft-tissue Sarcoma: An Analysis of Treatment Efficacy and Toxicities. Am J Clin Oncol 2021; 44:624-628. [PMID: 34753882 DOI: 10.1097/coc.0000000000000874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Compared with radical resection alone, perioperative radiation therapy (RT) combined with neurovascular preserving surgery is the standard for the management of virgin soft-tissue sarcomas. Yet, the optimal management of a local recurrence remains unclear. We report outcomes of patients with locally recurrent soft-tissue sarcoma treated with resection and reirradiation at the University of Florida. MATERIALS AND METHODS We reviewed the records of patients treated with primary conservative surgery and radiation for soft-tissue sarcoma followed by salvage resection and reirradiation for a local recurrence at our institution. RESULTS We analyzed 23 patients treated between 1976 and 2014 (median follow-up, 46 mo). Tumor sites included: proximal extremity, 11 patients; trunk, 6; distal extremity, 5; and head and neck, 1. All patients had conservative gross total resection of their recurrent tumor, without amputation. For reirradiation, 16 patients received external-beam RT alone, 6 received external-beam RT and brachytherapy, and 1 received brachytherapy alone. Two patients received chemotherapy. After retreatment, the 5-year overall survival, cause-specific survival, local control, and distant control rates were 39%, 42%, 46%, and 60%, respectively. Ten patients experienced local recurrences, 1 experienced regional recurrence, and 9 developed distant metastases. Retreatment-related complications ranged from delayed wound healing to limb amputation; 8 patients required amputation. Only 3 patients remained disease-free at last follow-up. No statistically significant associations were found between treatment factors (eg, RT dose) and local control. CONCLUSIONS Achieving local control of recurrent soft-tissue sarcoma is challenging. Treatment with reoperation and reirradiation can lead to debilitating complications affecting function and quality of life.
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Affiliation(s)
| | | | | | - Andre R Spiguel
- Orthopaedics and Rehabilitation, University of Florida College of Medicine, Gainesville, FL
| | - Charles P Gibbs
- Orthopaedics and Rehabilitation, University of Florida College of Medicine, Gainesville, FL
| | - Mark T Scarborough
- Orthopaedics and Rehabilitation, University of Florida College of Medicine, Gainesville, FL
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Mendenhall NP, Rausch Osian SM, Bryant CM, Hoppe BS, Morris CG. What men want: Results from a national survey on decision making for prostate cancer treatment and research participation. Clin Transl Sci 2021; 14:2314-2326. [PMID: 34379363 PMCID: PMC8604236 DOI: 10.1111/cts.13090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/07/2021] [Accepted: 05/09/2021] [Indexed: 11/30/2022] Open
Abstract
Data comparing outcomes in prostate cancer and factors affecting treatment choice are sparse. To inform the design of a comparative effectiveness clinical trial, we engaged patients in developing a 28‐question survey about decision making on treatment and research participation and dispersed it among men greater than or equal to 50 years of age. The 1046 respondents ranked long‐term clinical outcomes as most important in making treatment decisions, specific functional outcomes as slightly less important, and duration, location, and cost of treatment as least important. Treatment choice was strongly impacted by side effect profile. Responses to whether the subject would agree to participation in a randomized trial between two types of radiation with minimal differences in outcomes were “yes” in 15%, “no” in 39%, and “undecided” in 46%. Responses to whether the subject would agree to participation in a randomized trial between two treatment durations with similar outcomes were yes in 36%, no in 24%, and undecided in 40%. Findings suggest many potential patients have strong treatment preferences and are averse to randomization, particularly when outcomes of importance may be affected. Patient engagement in study design and novel nonrandomized trial designs may offer a path to increase clinical trial success.
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Affiliation(s)
- Nancy P Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, Florida, USA
| | | | - Curtis M Bryant
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, Florida, USA
| | - Bradford S Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, Florida, USA
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Lockney NA, Henderson RH, Swarts SG, Zhang Z, Zhang B, Li J, Zlotecki RA, Morris CG, Casey-Sawicki KA, Okunieff PG. Measuring Radiation Toxicity Using Circulating Cell-Free DNA in Prostate Cancer Patients. Int J Part Ther 2021; 8:28-35. [PMID: 35127973 PMCID: PMC8768895 DOI: 10.14338/ijpt-d-21-00008] [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: 02/10/2021] [Accepted: 05/20/2021] [Indexed: 11/27/2022] Open
Abstract
Background After radiation therapy (RT), circulating plasma cell-free DNA (cfDNA) released in response to RT damage to tissue can be measured within hours. We examined for a correlation between cfDNA measured during the first week of therapy and early and late gastrointestinal (GI) and genitourinary (GU) toxicity. Material and Methods Patients were eligible for enrollment if they planned to receive proton or photon RT for nonmetastatic prostate cancer in the setting of an intact prostate or after prostatectomy. Blood was collected before treatment and on sequential treatment days for the first full week of therapy. Toxicity assessments were performed at baseline, weekly during RT, and 6 months and 12 months after RT. Data were analyzed to examine correlations among patient-reported GI and GU toxicities. Results Fifty-four patients were evaluable for this study. Four (7%) and 3 (6%) patients experienced acute and late grade 2 GI toxicity, respectively. Twenty-two (41%) and 18 (35%) patients experienced acute and late grade 2 GU toxicity, respectively. No patients developed grade 3 or higher toxicity. Grade 2 acute GI toxicity, but not grade 2 acute GU toxicity, was significantly correlated with pre-RT cfDNA levels and on all days 1, 2, 3, 4, and 5 of RT (P < .005). Grade 2 late GI toxicity, but not GU toxicity, was significantly correlated with pre-RT cfDNA levels (P = .021). Conclusions Based on this preliminary study, cfDNA levels can potentially predict the subset of patients destined to develop GI toxicity during prostate cancer treatment. Given that the toxicity profiles of the various fractionations and modalities are highly similar, the data support the expectation that cfDNA could provide a biological estimate to complement the dose-volume histogram. A test of this hypothesis is under evaluation in a National Cancer Institute–funded multi-institutional study.
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Affiliation(s)
- Natalie A. Lockney
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Randal H. Henderson
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Steven G. Swarts
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Zhenhuan Zhang
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Bingrong Zhang
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Jennifer Li
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Robert A. Zlotecki
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Christopher G. Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | | | - Paul G. Okunieff
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
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Mendenhall WM, Brooks ED, Smith S, Morris CG, Bryant CB, Henderson RH, Nichols RC, McIntyre K, Klein SL, Mendenhall NP. Insurance Approval for Definitive Proton Therapy for Prostate Cancer. Int J Part Ther 2021; 8:36-42. [PMID: 35127974 PMCID: PMC8768894 DOI: 10.14338/ijpt-21-00002.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 05/29/2021] [Indexed: 11/21/2022] Open
Abstract
Purpose To determine factors that influence insurance approval for definitive proton therapy (PT) for prostate cancer. Materials and Methods Between 2014 and 2018, 1592 insured patients with localized prostate cancer were evaluated and recommended to undergo definitive PT; 547 patients (34.4%) had commercial insurance, whereas 1045 patients (65.6%) had Medicare/Medicaid. Of those with Medicare, 164 patients (15.7%) had Medicare alone; 677 (64.8%) had supplemental plans; and 204 (19.5%) had secondary commercial insurance. Insurance that “covered” PT for prostate cancer implied that it was an indication designated in the coverage policy. “Not covered” means that the insurance policy did not list prostate cancer as an indication for PT. Of all 1592 patients, 1263 (79.3%) belonged to plans that covered PT per policy. However, approval for PT was still required via medical review for 619 patients (38.9%), comparative dosimetry for 56 patients (3.5%), peer-to-peer discussion for 234 patients (14.7%), and administrative law judge hearings for 3 patients (<0.1%). Multivariate analyses of factors affecting approval were conducted, including risk group (low/intermediate versus high), insurance type (commercial versus Medicare/Medicaid), whether PT was included as a covered benefit under the plan (covered versus not covered), and time period (2014-16 versus 2017 versus 2018). Results On multivariate analysis, factors affecting PT approval for prostate treatment included coverage of PT per policy (97.1% had approval with insurance that covered PT versus 48.6% whose insurance did not cover PT; P < .001); insurance type (32.5% had approval with commercial insurance versus 97.4% with Medicare; P < .001); and time, with 877/987 patients (88.9%) approved between 2014 and 2016, 255/312 patients (81.7%) approved during 2017, and 255/293 patients (87.0%) approved thereafter (P = .02). Clinical factors, including risk group, had no bearing on insurance approval (P = .44). Conclusion Proton insurance approval for prostate cancer has decreased, is most influenced by the type of insurance a patient belongs to, and is unrelated to clinical factors (risk group) in this study. More work is needed to help navigate appropriate access to care and to assist patients seeking definitive PT for prostate cancer treatment.
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Affiliation(s)
- William M. Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Eric D. Brooks
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Stephanie Smith
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Christopher G. Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Curtis B. Bryant
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Randal H. Henderson
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Romaine C. Nichols
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Kathy McIntyre
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Stuart L. Klein
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Nancy P. Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
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Bates JE, Terezakis S, Morris CG, Rao AD, Sehgal S, Kumar R, Mailhot Vega RB, Mendenhall NP, Hoppe BS. Comparative Effectiveness of Proton Therapy versus Photon Radiotherapy in Adolescents and Young Adults for Classical Hodgkin Lymphoma. Int J Part Ther 2021; 8:21-27. [PMID: 35127972 PMCID: PMC8768899 DOI: 10.14338/ijpt-21-00011.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/11/2021] [Indexed: 12/04/2022] Open
Abstract
Purpose Early stage (stages I-II) classical Hodgkin lymphoma (cHL) is a highly curable disease typically diagnosed in adolescents and young adults (AYAs). Proton therapy can also reduce the late toxicity burden in this population, but data on its comparative efficacy with photon radiotherapy in this population are sparse. We assessed outcomes in AYAs with cHL in a multi-institution retrospective review. Materials and Methods We identified 94 patients aged 15 to 40 years with stages I and II cHL treated with radiotherapy as part of their initial treatment between 2008 and 2017. We used Kaplan-Meier analyses and log-rank testing to evaluate survival differences between groups of patients. Results A total of 91 patients were included in the analysis. The 2-year progression-free survival (PFS) rate was 89%. Of the 12 patients who experienced progression after radiotherapy, 4 occurred out-of-field, 2 occurred in-field, and 6 experienced both in- and out-of-field progression. There was no significant difference in 2-year PFS among AYA patients by radiotherapy dose received (≥ 30 Gy, 91%; < 30 Gy, 86%; P = .82). Likewise, there was no difference in 2-year PFS among patients who received either proton or photon radiotherapy (proton, 94%; photon, 83%; P = .07). Conclusion Our cohort of AYA patients had comparable outcomes regardless of radiotherapy dose or modality used. For patients with significant risk of radiation-induced late effects, proton therapy is a reasonable treatment modality.
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Affiliation(s)
- James E. Bates
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Stephanie Terezakis
- Department of Radiation Oncology, University of Minnesota, Minneapolis, MN, USA
| | - Christopher G. Morris
- Department of Radiation Oncology, University of Florida, Gainesville, FL, USA
- University of Florida Proton Therapy Institute, Jacksonville, FL, USA
| | - Avani D. Rao
- Department of Radiation Oncology and Molecular Radiation Science, Johns Hopkins University, Baltimore, MD, USA
| | - Shuchi Sehgal
- Department of Radiation Oncology and Molecular Radiation Science, Johns Hopkins University, Baltimore, MD, USA
| | - Rahul Kumar
- School of Medical Sciences & Research, Sharda University, Greater Noida, India
| | | | - Nancy P. Mendenhall
- Department of Radiation Oncology, University of Florida, Gainesville, FL, USA
- University of Florida Proton Therapy Institute, Jacksonville, FL, USA
| | - Bradford S. Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
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Indelicato DJ, Ioakeim-Ioannidou M, Bradley JA, Mailhot-Vega RB, Morris CG, Tarbell NJ, Yock T, MacDonald SM. Proton Therapy for Pediatric Ependymoma: Mature Results From a Bicentric Study. Int J Radiat Oncol Biol Phys 2021; 110:815-820. [DOI: 10.1016/j.ijrobp.2021.01.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/17/2020] [Accepted: 01/20/2021] [Indexed: 01/15/2023]
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Indelicato DJ, Bates JE, Mailhot Vega RB, Rotondo RL, Hoppe BS, Morris CG, Looi WS, Sandler ES, Aldana PR, Bradley JA. Second tumor risk in children treated with proton therapy. Pediatr Blood Cancer 2021; 68:e28941. [PMID: 33565257 DOI: 10.1002/pbc.28941] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [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: 12/16/2020] [Revised: 01/11/2021] [Accepted: 01/12/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Out-of-field neutron dissemination during double-scattered proton therapy has raised concerns of increased second malignancies, disproportionally affecting pediatric patients due to the proportion of body exposed to scatter dose and inherent radiosensitivity of developing tissue. We sought to provide empiric data on the incidence of early second tumors. METHODS Between 2006 and 2019, 1713 consecutive children underwent double-scattered proton therapy. Median age at treatment was 9.1 years; 371 were ≤3 years old. Thirty-seven patients (2.2%) had tumor predisposition syndromes. Median prescription dose was 54 Gy (range 15-75.6). Median follow-up was 3.3 years (range 0.1-12.8), including 6587 total person-years. Five hundred forty-nine patients had ≥5 years of follow-up. A second tumor was defined as any solid neoplasm throughout the body. RESULTS Eleven patients developed second tumors; the 5- and 10-year cumulative incidences were 0.8% (95% CI, 0.4-1.9%) and 3.1% (95% CI, 1.5-6.2%), respectively. Using age- and gender-specific data from the Surveillance, Epidemiology, and End Results (SEER) program, the standardized incidence ratio was 13.5; the absolute excess risk was 1.5/1000 person-years. All but one patient who developed second tumors were irradiated at ≤5 years old (p < .0005). There was also a statistically significant correlation between patients with tumor predisposition syndromes and second tumors (p < .0001). Excluding patients with tumor predisposition syndromes, 5- and 10-year rates were 0.6% (95% CI, 0.2-1.7%) and 1.7% (95% CI, 0.7-4.0%), respectively, with all five malignant second tumors occurring in the high-dose region. CONCLUSION Second tumors are rare within the decade following double-scattered proton therapy, particularly among children irradiated at >5 years old and those without tumor predisposition syndrome.
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Affiliation(s)
- Daniel J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - James E Bates
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Ronny L Rotondo
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Bradford S Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Wen S Looi
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Eric S Sandler
- Department of Pediatrics, Nemours Children's Specialty Clinic, Jacksonville, Florida, USA
| | - Philipp R Aldana
- Department of Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, USA
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Holtzman AL, Rotondo RL, Rutenberg MS, Indelicato DJ, De Leo A, Rao D, Patel J, Morris CG, Mendenhall WM. Clinical Outcomes Following Dose-Escalated Proton Therapy for Skull-Base Chordoma. Int J Part Ther 2021; 8:179-188. [PMID: 34285945 PMCID: PMC8270096 DOI: 10.14338/ijpt-20-00066.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 10/04/2020] [Indexed: 11/21/2022] Open
Abstract
Purpose To evaluate the effectiveness of external-beam proton therapy (PT) on local control and survival in patients with skull-base chordoma. Materials and Methods We reviewed the medical records of patients with skull-base chordoma treated with definitive or adjuvant high-dose PT and updated their follow-up when feasible. We assessed overall survival, disease-specific survival, local control, and freedom from distant metastasis. Radiotherapy toxicities were scored using the Common Terminology Criteria for Adverse Events, version 4.0. Results A total 112 patients were analyzed, of whom 105 (94%) received PT and 7 (6%) received combined proton-photon therapy between 2007 and 2019. Eighty-seven patients (78%) underwent a subtotal resection, 22 (20%) a gross total resection, and 3 (3%) a biopsy alone. The median radiotherapy dose was 73.8 Gy radiobiologic equivalent (GyRBE; range, 69.6-74.4). Ninety patients (80%) had gross disease at radiotherapy and 7 (6%) were treated for locally recurrent disease following surgery. Median follow-up was 4.4 years (range, 0.4-12.6); for living patients, it was 4.6 years (range, 0.4-12.6), and for deceased patients, 4.1 years (range, 1.2-11.2). At 5 years after radiotherapy, the actuarial overall survival, disease-specific survival, local control, and freedom from distant metastasis rates were 78% (n = 87), 83% (n = 93), 74% (n = 83), and 99% (n = 111), respectively. The median time to local progression was 2.4 years (range, 0.8-7). Local control and disease-specific survival by resection status was 95% versus 70% (P = 0.28) and 100% versus 80% (P = 0.06) for gross total, versus subtotal, resection or biopsy alone, respectively. There were no serious acute toxicities (grade ≥ 3) related to radiotherapy. Conclusion High-dose PT alone or after surgical resection for skull-base chordoma reaffirms the favorable 5-year actuarial local control rate compared with conventional techniques with acceptable late-complication–free survival. Outcomes following gross total resection and adjuvant PT were excellent. Further follow-up of this cohort is necessary to better characterize long-term disease control and late toxicities.
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Affiliation(s)
- Adam L Holtzman
- Department of Radiation Oncology University of Florida College of Medicine, Jacksonville, FL, USA
| | - Ronny L Rotondo
- Department of Radiation Oncology, University of Kansas, Kansas City, KS, USA
| | - Michael S Rutenberg
- Department of Radiation Oncology University of Florida College of Medicine, Jacksonville, FL, USA
| | - Daniel J Indelicato
- Department of Radiation Oncology University of Florida College of Medicine, Jacksonville, FL, USA
| | - Alexandra De Leo
- Department of Radiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Dinesh Rao
- Department of Radiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Jeet Patel
- Department of Radiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Christopher G Morris
- Department of Radiation Oncology University of Florida College of Medicine, Jacksonville, FL, USA
| | - William M Mendenhall
- Department of Radiation Oncology University of Florida College of Medicine, Jacksonville, FL, USA
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Dagan R, Uezono H, Bryant C, Holtzman AL, Morris CG, Mendenhall WM. Long-term Outcomes from Proton Therapy for Sinonasal Cancers. Int J Part Ther 2021; 8:200-212. [PMID: 34285947 PMCID: PMC8270098 DOI: 10.14338/ijpt-20-00068.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 11/20/2020] [Indexed: 02/03/2023] Open
Abstract
PURPOSE To report long-term disease control, survival, and toxicity after proton therapy for sinonasal cancer. PATIENTS AND METHODS We reviewed 143 cases of adults with nonmetastatic sinonasal cancers treated with primary (18%; n = 26) or adjuvant (82%; n = 117) proton therapy. The most common histologies were squamous cell carcinoma (29%; n = 42), olfactory neuroblastoma (23%; n = 33), and adenoid cystic carcinoma (16%; n = 23). Patients had predominantly advanced-stage disease (T3, 24%, n = 35; T4, 66%, n = 94) and high-grade histology (52%; n = 74). Surgery included endoscopic resection alone (50%) with craniotomy (10%) or open resection (40%), and 31% had gross disease present at radiotherapy. Most (91%) received high-dose (median, 73.6 Gy radiobiological equivalent [GyRBE]; 84% >70 GyRBE) passive-scatter proton therapy using accelerated hyperfractionation (1.2 GyRBE twice daily) and concurrent chemotherapy (70%). Univariate and multivariate models assessed prognostic factors. Grade 3+ toxicities were recorded per Common Terminology Criteria, version 4. Median follow-up was 3.4 years (range, 0.1-12.5 years) overall and 4.9 years (range, 0.9-12.5 years) for living patients. RESULTS The 5-year outcomes were as follows: local control (LC), 80%; neck control, 96%; local-regional control, 78%; freedom from distant metastases, 71%; and disease-free survival, 62%; cause-specific survival, 64%; and overall survival, 59%. Surgery improved LC, but only with gross total resection (5-year LC 87% versus subtotal resection 62.9%, and biopsy alone 55% (P < 0.001). Gross residual disease was the only significant prognostic factor for local-regional control on multivariate analysis. High-grade, T4, and local recurrence were associated with decreased overall survival. Late (G3+) toxicity occurred in 22% (32 of 143), including central nervous system necrosis and vision loss in 6% (9 of 143) and 3.5% (5 of 143), respectively. CONCLUSION Proton therapy after gross-total resection provides excellent long-term LC in patients with locally advanced, high-grade sinonasal cancer. Moreover, LC remains strongly associated with long-term survival. With gross disease, about 60% of patients had long-term LC with proton therapy and induction or concurrent chemotherapy.
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Affiliation(s)
- Roi Dagan
- From the Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Haruka Uezono
- From the Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Curtis Bryant
- From the Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Adam L. Holtzman
- From the Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Christopher G. Morris
- From the Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - William M. Mendenhall
- From the Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
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De Leo AN, Mendenhall WM, Dagan R, Hitchcock KE, Dziegielewski PT, Morris CG, Amdur RJ. Sparing the Larynx and Hypopharynx With Radiation Therapy for Squamous Cell Carcinoma of Unknown Primary Site and Predominant Adenopathy in Level IIA. Pract Radiat Oncol 2021; 11:366-373. [PMID: 34175470 DOI: 10.1016/j.prro.2021.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 06/04/2021] [Accepted: 06/16/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE There is controversy about the need to target the mucosa of the larynx and hypopharynx during radiation therapy (RT) for squamous cell carcinoma of an unknown primary site (SCCA-UP). By 1997, the policy in our department was to target only the oropharynx and nasopharynx in patients with SCCA-UP metastatic to the level II cervical nodes. The purpose of this study was to report the rate of cancer recurrence in the larynx or hypopharynx using an approach that excluded these areas from the RT target volumes. METHODS AND MATERIALS The inclusion criteria for this study were RT in our department for SCCA-UP between January 1, 1997, and December 31, 2019; no history of surgery that could disrupt the cervical lymphatics; predominant adenopathy in level IIA; and neck stage N1-2c. We excluded N3 because the incidental dose to the larynx and hypopharynx is usually high in patients with a >6-cm nodal conglomerate. RESULTS The study population was comprised of 50 patients with a median follow-up after RT of 7.1 years. No patient developed recurrent cancer in a mucosal site (0/50), 2% (1/50) developed a neck recurrence in a high-dose area with synchronous distant metastases, and 2% (1/50) developed distant metastases with no evidence of local or regional recurrence. CONCLUSIONS When delivering RT for SCCA-UP metastatic predominantly to level IIA, it is not necessary to target the mucosa of the larynx or hypopharynx. The extent to which the incidental RT dose to these areas contributes to cancer control is not evaluated in this study.
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Liu IC, Holtzman AL, Rotondo RL, Indelicato DJ, Gururangan S, Cavaliere R, Carter B, Morris CG, Tavanaiepour D, Rutenberg MS. Proton therapy for adult medulloblastoma: Acute toxicity and disease control outcomes. J Neurooncol 2021; 153:467-476. [PMID: 34105033 DOI: 10.1007/s11060-021-03783-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 06/03/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE We report disease control, survival outcomes, and treatment-related toxicity among adult medulloblastoma patients who received proton craniospinal irradiation (CSI) as part of multimodality therapy. METHODS We reviewed 20 adults with medulloblastoma (≥ 22 years old) who received postoperative proton CSI ± chemotherapy between 2008 and 2020. Patient, disease, and treatment details and prospectively obtained patient-reported acute CSI toxicities were collected. Acute hematologic data were analyzed. RESULTS Median age at diagnosis was 27 years; 45% of patients had high-risk disease; 75% received chemotherapy, most (65%) after CSI. Eight (40%) patients received concurrent vincristine with radiotherapy. Median CSI dose was 36GyE with a median tumor bed boost of 54GyE. Median duration of radiotherapy was 44 days. No acute ≥ grade 3 gastrointestinal or hematologic toxicities attributable to CSI occurred. Grade 2 nausea and vomiting affected 25% and 5% of patients, respectively, while 36% developed acute grade 2 hematologic toxicity (36% grade 2 leukopenia and 7% grade 2 neutropenia). Those receiving concurrent chemotherapy with CSI had a 38% rate of grade 2 hematologic toxicity compared to 33% among those not receiving concurrent chemotherapy. Among patients receiving adjuvant chemotherapy (n = 13), 100% completed ≥ 4 cycles and 85% completed all planned cycles. With a median follow-up of 3.1 years, 4-year actuarial local control, disease-free survival, and overall survival rates were 90%, 90%, and 95%, respectively. CONCLUSIONS Proton CSI in adult medulloblastoma patients is very well tolerated and shows promising disease control and survival outcomes. These data support the standard use of proton CSI for adult medulloblastoma.
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Affiliation(s)
- I-Chia Liu
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, 2015 North Jefferson Street, Jacksonville, FL, 32206, USA
| | - Adam L Holtzman
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, 2015 North Jefferson Street, Jacksonville, FL, 32206, USA
| | - Ronny L Rotondo
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Daniel J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, 2015 North Jefferson Street, Jacksonville, FL, 32206, USA
| | - Sridharan Gururangan
- Department of Neurosurgery and the Preston A. Wells Jr. Center for Brain Tumor Therapy, University of Florida College of Medicine, Gainesville, FL, USA
| | | | - Bridgette Carter
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, 2015 North Jefferson Street, Jacksonville, FL, 32206, USA
| | - Daryoush Tavanaiepour
- Department of Neurosurgery, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
| | - Michael S Rutenberg
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, 2015 North Jefferson Street, Jacksonville, FL, 32206, USA.
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Indelicato DJ, Rotondo RL, Mailhot Vega RB, Holtzman AL, Looi WS, Morris CG, Sandler ES, Aldana PR, Bradley JA. Local Control After Proton Therapy for Pediatric Chordoma. Int J Radiat Oncol Biol Phys 2021; 109:1406-1413. [PMID: 33253819 DOI: 10.1016/j.ijrobp.2020.11.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 11/10/2020] [Accepted: 11/18/2020] [Indexed: 11/20/2022]
Abstract
PURPOSE Due to the location and high dose required for disease control, pediatric chordomas are theoretically well-suited for treatment with proton therapy, but their low incidence limits the clinical outcome data available in the literature. We sought to report the efficacy and toxicity of proton therapy among a single-institution cohort. METHODS AND MATERIALS Between 2008 and 2019, 29 patients with a median age of 14.8 years (range, 3.8-21.8) received passive-scattered proton therapy for nonmetastatic chordoma. No patient received prior irradiation. Twenty-four tumors arose in the clivus/cervical spine region and 5 in the lumbosacral spine. Twenty-six tumors demonstrated classic well-differentiated histology and 3 were dedifferentiated or not otherwise specified. Approximately half of the tumors underwent specialized testing: 14 were brachyury-positive and 10 retained INI-1. Three patients had locally recurrent tumors after surgery alone (n = 2) or surgery + chemotherapy (n = 1), and 17 patients had gross disease at the time of radiation. The median radiation dose was 73.8 Gy relative biological effectivness (range, 69-75.6). RESULTS With a median follow-up of 4.3 years (range, 1.0-10.7), the 5-year estimates of local control, progression-free survival, and overall survival rates were 85%, 82%, and 86%, respectively. No disease progression was observed beyond 3 years. Excluding 3 patients with dedifferentiated/not-otherwise-specified chordoma, the 5-year local control, progression-free survival, and overall survival rates were 92%, 92%, and 91%, respectively. Serious toxicities included 3 patients with hardware failure or related infection requiring revision surgery, 2 patients with hormone deficiency, and 2 patients with Eustachian tube dysfunction causing chronic otitis media. No patient experienced brain stem injury, myelopathy, vision loss, or hearing loss after radiation. CONCLUSIONS In pediatric patients with chordoma, proton therapy is associated with a low risk of serious toxicity and high efficacy, particularly in well-differentiated tumors. Complete resection may be unnecessary for local control, and destabilizing operations requiring instrumentation may result in additional complications after therapy.
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Affiliation(s)
- Daniel J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida.
| | - Ronny L Rotondo
- Department of Radiation Oncology, University of Kansas, Kansas City, Kansas
| | - Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Adam L Holtzman
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Wen S Looi
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Eric S Sandler
- Department of Pediatrics, Nemours Childrens Specialty Clinic, Jacksonville, Florida
| | - Philipp R Aldana
- Department of Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
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Kharod SM, Mercado CE, Morris CG, Bryant CM, Mendenhall NP, Mendenhall WM, Nichols RC, Hoppe BS, Liang X, Su Z, Li Z, Henderson RH. Postoperative or Salvage Proton Radiotherapy for Prostate Cancer After Radical Prostatectomy. Int J Part Ther 2021; 7:52-64. [PMID: 33829073 PMCID: PMC8019576 DOI: 10.14338/ijpt-20-00021.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 01/08/2021] [Indexed: 12/02/2022] Open
Abstract
Purpose Postprostatectomy radiation improves disease control, but limited data exist regarding outcomes, toxicities, and patient-reported quality of life with proton therapy. Method and Materials The first 102 patients who were enrolled on an outcome tracking protocol between 2006 and 2017 and treated with double-scattered proton therapy after prostatectomy were retrospectively reviewed. Eleven (11%) received adjuvant radiation, while 91 (89%) received salvage radiation. Seventy-four received double-scattered proton therapy to the prostate bed only. Twenty-eight received a double-scattered proton therapy prostate-bed boost after prostate-bed and pelvic-node treatment. Eleven adjuvant patients received a median dose of 66.6 GyRBE (range, 66.0-70.2). Ninety-one salvage patients received a median dose of 70.2 GyRBE (range, 66.0-78.0). Forty-five patients received androgen deprivation therapy for a median 9 months (range, 1-30). Toxicities were scored using Common Terminology Criteria for Adverse Events v4.0 criteria, and patient-reported quality-of-life data were reviewed. Results The median follow-up was 5.5 years (range, 0.8-11.4 years). Five-year biochemical relapse-free and distant metastases-free survival rates were 72% and 91% for adjuvant patients, 57% and 97% for salvage patients, and 57% and 97% overall. Acute and late grade 3 or higher genitourinary toxicity rates were 1% and 7%. No patients had grade 3 or higher gastrointestinal toxicity. Acute and late grade 2 gastrointestinal toxicities were 5% and 2%. The mean values and SDs of the International Prostate Symptom Score, International Index of Erectile Function, and Expanded Prostate Cancer Index Composite bowel function and bother were 7.5 (SD = 5.9), 10.2 (SD = 8.3), 92.8 (SD = 11.1), and 91.2 (SD = 6.4), respectively, at baseline, and 12.1 (SD = 9.1), 10.1 (SD = 6.7), 87.3 (SD = 18), and 86.7 (SD = 13.8) at the 5-year follow-up. Conclusion High-dose postprostatectomy proton therapy provides effective long-term biochemical control and freedom from metastasis, with low acute and long-term gastrointestinal and genitourinary toxicity.
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Affiliation(s)
- Shivam M Kharod
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | | | - Christopher G Morris
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Curtis M Bryant
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Nancy P Mendenhall
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - William M Mendenhall
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - R Charles Nichols
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Bradford S Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Xiaoying Liang
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Zhong Su
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Zuofeng Li
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Randal H Henderson
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
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Looi WS, Indelicato DJ, Mailhot Vega RB, Morris CG, Sandler E, Aldana PR, Bradley JA. Outcomes following limited-volume proton therapy for multifocal spinal myxopapillary ependymoma. Pediatr Blood Cancer 2021; 68:e28820. [PMID: 33226179 DOI: 10.1002/pbc.28820] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/03/2020] [Accepted: 11/04/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE Spinal myxopapillary ependymoma (MPE) often presents with a multifocal distribution, complicating attempts at resection. There remains no standard approach to irradiating these patients. We report disease control and toxicity in pediatric patients with multifocal spinal MPE treated with limited-volume proton therapy. MATERIALS/METHODS Twelve patients (≤21 years old) with multifocal spinal MPE were treated between 2009 and 2018 with limited-volume brain-sparing proton therapy. Median age was 13.5 years (range, 7-21). Radiotherapy was given as adjuvant therapy after primary surgery in five patients (42%) and for recurrence in seven (58%). No patient received prior radiation. Eleven patients (92%) had evidence of gross disease at radiotherapy. Eleven patients received 54 GyRBE; one received 50.4 GyRBE. Treatment toxicity was graded per the CTCAEv4.0. We estimated disease control and survival using the Kaplan-Meier product-limit method. RESULTS The median follow-up was 3.6 years (range, 1.8-10.6). The five-year actuarial rates of local control, progression-free survival, and overall survival were 100%, 92%, and 100%, respectively. One patient experienced an out-of-field recurrence in the spine superior to the irradiated region. No patients developed in-field recurrences. Following surgery and irradiation, one patient developed grade three spinal kyphosis and one patient developed grade 2 unilateral L5 neuropathy. CONCLUSION 54 GyRBE to a limited volume appears effective for disseminated spinal MPE in both the primary and salvage settings, sparing children the toxicity of full craniospinal irradiation. Compared with historical reports, this approach using proton therapy improves the therapeutic ratio, resulting in minimal side effects and high rates of disease control.
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Affiliation(s)
- Wen Shen Looi
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Daniel J Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Raymond B Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Eric Sandler
- Department of Pediatrics, Nemours Children's Specialty Clinic, Jacksonville, Florida
| | - Philipp R Aldana
- Department of Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
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O'steen L, Lockney NA, Morris CG, Johnson-Mallard V, Pereira D, Amdur RJ. A Prospective Randomized Trial of the Influence of Music on Anxiety in Patients Starting Radiation Therapy for Cancer. Int J Radiat Oncol Biol Phys 2021; 109:670-674. [PMID: 33121861 DOI: 10.1016/j.ijrobp.2020.09.048] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/11/2020] [Accepted: 09/21/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE One of the most downloaded articles in 2017 from the International Journal of Radiation Oncology, Biology, and Physics was a study suggesting that music therapy during radiation therapy (RT) simulation substantially reduces anxiety. To further evaluate the potential of music's clinical efficacy in the context of radiation therapy, we conducted a randomized trial evaluating the influence of genre-based music chosen by the study participant on anxiety during the first RT treatment session with a method that is applicable to routine clinical practice. METHODS AND MATERIALS We conducted a prospective randomized trial of music versus no music during the first RT treatment for cancer. We limited the study to women because prior studies document a higher rate of anxiety in female patients with cancer. Anxiety was evaluated before and after the first RT treatment using the State-Trait Anxiety Inventory (STAI) and Symptom Distress Thermometer (SDT). Patients randomized to music had their preferred genre of music played from a web-based application while in the treatment vault. RESULTS In the study, 102 females were enrolled (51 with and 51 without music). Baseline high anxiety score before RT was recorded in 48% of patients using the STAI and 58% using the SDT. The percent decrease in mean STAI score was 16% with music versus 10% without music (P = .2197). The mean SDT percent changes were a 13% decrease with music versus a 2% increase without music (P = .3298). CONCLUSIONS This study documents that high anxiety is common in women receiving RT for cancer and that music, as used in this study, does not reduce anxiety to a meaningful degree.
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Affiliation(s)
- Lillie O'steen
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - Natalie A Lockney
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida
| | | | - Deidre Pereira
- Department of Clinical and Health Psychology, University of Florida College of Public Health and Health Professions, Gainesville, Florida
| | - Robert J Amdur
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida.
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Lockney NA, Henderson R, Swarts SG, Zhang Z, Zhang B, Li J, Zlotecki RA, Morris CG, Casey-Sawicki K, Okunieff P. Circulating Cell-Free DNA Correlates with Body Integral Dose and Radiation Modality in Prostate Cancer. Int J Part Ther 2020; 7:21-30. [PMID: 33274254 PMCID: PMC7707322 DOI: 10.14338/ijpt-20-00033.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 07/10/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose The RadTox assay measures circulating cell-free DNA released in response to radiotherapy (RT)-induced tissue damage. The primary objectives for this clinical trial were to determine whether cell-free DNA numbers measured by the RadTox assay are (1) correlated with body integral dose, (2) lower with proton RT compared with photon RT, and (3) higher with larger prostate cancer RT fields. Patients and Methods Patients planned to receive proton or photon RT for nonmetastatic prostate cancer in the setting of an intact prostate or postprostatectomy were eligible for the trial. Plasma was collected pre-RT and at 5 additional daily collection points beginning 24 hours after the initiation of RT. Data from 54 evaluable patients were analyzed to examine any correlations among RadTox scores with body-integral dose, RT modality (photon versus proton), and RT field size (prostate or prostate bed versus whole pelvis). Results Body integral dose was significantly associated with the peak post-RT RadTox score (P = .04). Patients who received photon RT had a significant increase in peak post-RT RadTox score (P = .04), average post-RT RadTox score (P = .04), and day-2 RadTox score (all minus the pre-RT values for each patient) as compared with patients who received proton RT. Field size was not significantly associated with RadTox score. Conclusion RadTox is correlated with body integral dose and correctly predicts which patients receive proton versus photon RT. Data collection remains ongoing for patient-reported RT toxicity outcomes to determine whether RadTox scores are correlated with toxicity.
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Affiliation(s)
- Natalie A Lockney
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Randal Henderson
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Steven G Swarts
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Zhenhuan Zhang
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Bingrong Zhang
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Jennifer Li
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Robert A Zlotecki
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Katherine Casey-Sawicki
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
| | - Paul Okunieff
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville and Jacksonville, FL, USA
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Kharod SM, Nichols RC, Henderson RH, Morris CG, Pham DC, Seeram VK, Jones LM, Antonio-Miranda M, Siragusa DA, Li Z, Flampouri S, Hoppe BS. Image-Guided Hypofractionated Proton Therapy in Early-Stage Non-Small Cell Lung Cancer: A Phase 2 Study. Int J Part Ther 2020; 7:1-10. [PMID: 33274252 PMCID: PMC7707327 DOI: 10.14338/ijpt-20-00013.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 07/28/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose Due to the excellent outcomes with image-guided stereotactic body radiotherapy for patients with early-stage non–small cell lung cancer (NSCLC) and the low treatment-related toxicities using proton therapy (PT), we investigated treatment outcomes and toxicities when delivering hypofractionated PT. Materials and Methods Between 2009 and 2018, 22 patients with T1 to T2 N0M0 NSCLC (45% T1, 55% T2) received image-guided hypofractionated PT. The median age at diagnosis was 72 years (range, 58-90). Patients underwent 4-dimensional computed tomography simulation following fiducial marker placement, and daily image guidance was performed. Nine patients (41%) were treated with 48 GyRBE in 4 fractions for peripheral lesions, and 13 patients (59%) were treated with 60 GyRBE in 10 fractions for central lesions. Patients were assessed for CTCAEv4 toxicities with computed tomography imaging for tumor assessment. The primary endpoint was grade 3 to 5 toxicity at 1 year. Results The median follow-up for all patients was 3.5 years (range, 0.2-8.8 years). The overall survival rates at 3 and 5 years were 81% and 49%, respectively. Cause-specific survival rates at 3 and 5 years were 100% and 75%, respectively. The 3-year local, regional, and distant control rates were 86%, 85%, and 95%, respectively. Four patients experienced in-field recurrences between 18 and 45 months after treatment. One patient (5%) developed a late grade 3 bronchial stricture requiring hospitalization and stent. Conclusion Image-guided hypofractionated PT for early-stage NSCLC provides promising local control and long-term survival with a low likelihood of toxicity. Regional nodal and distant relapses remain a problem.
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Affiliation(s)
- Shivam M Kharod
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - R Charles Nichols
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Randal H Henderson
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Dat C Pham
- Department of Medicine, Division of Hematology and Medical Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Vandana K Seeram
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Lisa M Jones
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, College of Medicine, Jacksonville, FL, USA
| | | | - Daniel A Siragusa
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Zuofeng Li
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Stella Flampouri
- Department of Radiation Oncology, Emory Proton Therapy Center, Atlanta, GA, USA
| | - Bradford S Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
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Kharod SM, Nichols RC, Henderson RH, Morris CG, Pham DC, Seeram VK, Jones LM, Antonio-Miranda M, Huh S, Li Z, Hoppe BS. Image-guided hypofractionated double-scattering proton therapy in the management of centrally-located early-stage non-small cell lung cancer. Acta Oncol 2020; 59:1164-1170. [PMID: 32394776 DOI: 10.1080/0284186x.2020.1759821] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The treatment of centrally-located early-stage non-small cell lung cancer (NSCLC) with image-guided stereotactic body radiotherapy (SBRT) is challenging due to the proximity of critical normal structures to the tumor target. The purpose of this study was to report the results of our experience in treating centrally-located early-stage NSCLC with hypofractionated proton therapy (PT). MATERIAL AND METHODS Between 2009 and 2018, 23 patients with T1-T2N0M0 NSCLC (T1, 46%; T2, 54%) were treated with image-guided hypofractionated double-scattering PT. The median age at the time of treatment was 74 years (range, 58-88). Patients underwent 4-dimensional computed tomography (CT) simulation following fiducial marker placement, and daily image guidance was performed. All patients were treated with 60 GyRBE in 10 fractions. Patients were assessed for CTCAEv4 toxicities weekly during treatment, and at regular follow-up intervals with CT imaging for tumor assessment. Overall survival, cause-specific survival, local control, regional control, and metastases-free survival were evaluated using cumulative incidence with competing risks. RESULTS Median follow-up for all patients was 3.2 years (range, 0.2-9.2 years). Overall survival rates at 3 and 5 years were 81% and 50% (95% CI, 27-79%), respectively. Cause-specific survival rates at 3 and 5 years were 81% and 71% (95% CI, 46-92%). The 3-year local, regional, and distant control rates were 90%, 81%, and 87%, respectively. Three patients (13%) experienced local recurrences as their first recurrence, at a median time of 28 months from completion of radiation (range, 18-61 months). Two patients (9%) experienced late grade 3 toxicities, including 1 patient who developed a bronchial stricture that required stent placement. CONCLUSION Image-guided hypofractionated PT for centrally-located early-stage NSCLC provides excellent local control with low rates of grade ≥3 toxicities. For tumors in sensitive locations, PT may provide safer treatment than photon-based treatments due to its dosimetric advantages.
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Affiliation(s)
- Shivam M. Kharod
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - R. Charles Nichols
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Randal H. Henderson
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Christopher G. Morris
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Dat C. Pham
- Department of Medicine, Division of Hematology and Medical Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Vandana K. Seeram
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Lisa M. Jones
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, College of Medicine, Jacksonville, FL, USA
| | | | - Soon Huh
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Zuofeng Li
- Department of Radiation Oncology, University of Florida, College of Medicine, Jacksonville, FL, USA
| | - Bradford S. Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
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Abstract
PURPOSE Radiotherapy-related visual decline is a significant concern in survivors of childhood cancer; however, data establishing the dose-response relationship between dose to the optic apparatus and visual acuity decline in children are sparse. We aimed to determine this relationship in a cohort of children treated with proton therapy. MATERIAL AND METHODS We identified 458 children with 875 eyes at risk treated with proton therapy for intracranial malignancy between December 2006 and September 2018. Eyes were considered at risk if either the ipsilateral optic nerve or optic chiasm received ≥30 GyRBE to 0.1 cm3. Kaplan-Meier and Normal Tissue Complication Probability modeling was used to establish the relationship between radiotherapy dose and risk of visual decline. RESULTS Excluding children with tumor progression, no patient experienced complete vision loss. The actuarial 5-year rate of any visual acuity decline was 2.6% (95% confidence interval [CI]: 1.5%-4.6%). The dose to 0.1 cm3 of the ipsilateral optic nerve or optic chiasm resulting in a 1%, 5%, and 10% risk of acuity decline were 52.7 GyRBE, 56.6 GyRBE, and 58.3 GyRBE. Visual decline was only seen in children with primary tumors of the optic pathway or suprasellar region. CONCLUSIONS Visual acuity decline following radiotherapy for intracranial malignancies in children is rare. A dose of approximately 56 GyRBE to 0.1 cm3 results in an approximately 5% risk of visual acuity decline for children with suprasellar or optic pathway tumors. A dose to 0.1 cm3 of 56 GyRBE appears to be safe for children with tumors elsewhere in the brain.
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Affiliation(s)
- James E. Bates
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Daniel J. Indelicato
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Christopher G. Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Ronny L. Rotondo
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Julie A. Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
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