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Jacobson G, Fluss R, Dany-BenShushan A, Golan T, Meron T, Zimmermann C, Dawson LA, Barry A, Miszczyk M, Buckstein M, Diaz Pardo D, Aguiar A, Hammer L, Dicker AP, Ben-Ailan M, Morag O, Hausner D, Symon Z, Lawrence YR. Coeliac plexus radiosurgery for pain management in patients with advanced cancer : study protocol for a phase II clinical trial. BMJ Open 2022; 12:e050169. [PMID: 35332036 PMCID: PMC8948399 DOI: 10.1136/bmjopen-2021-050169] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Pancreatic cancer is characterised by severe mid-back and epigastric pain caused by tumour invasion of the coeliac nerve plexus. This pain is often poorly managed with standard treatments. This clinical trial investigates a novel approach in which high-dose radiation (radiosurgery) is targeted to the retroperitoneal coeliac plexus nerve bundle. Preliminary results from a single institution pilot trial are promising: pain relief is substantial and side effects minimal. The goals of this study are to validate these findings in an international multisetting, and investigate the impact on quality of life and functional status among patients with terminal cancer. METHODS AND ANALYSIS A single-arm prospective phase II clinical trial. Eligible patients are required to have severe coeliac pain of at least five on the 11-point BPI average pain scale and Eastern Cooperative Oncology Group performance status of two or better. Non-pancreatic cancers invading the coeliac plexus are also eligible. The intervention involves irradiating the coeliac plexus using a single fraction of 25 Gy. The primary endpoint is the complete or partial pain response at 3 weeks. Secondary endpoints include pain at 6 weeks, analgesic use, hope, qualitative of life, caregiver burden and functional outcomes, all measured using validated instruments. The protocol is expected to open at a number of cancer centres across the globe, and a quality assurance programme is included. The protocol requires that 90 evaluable patients" be accrued, based upon the assumption that a third of patients are non-evaluable (e.g. due to death prior to 3-weeks post-treatment assessment, or spontaneous improvement of pain pre-treatment), it is estimated that a total of 120 patients will need to be accrued. Supported by Gateway for Cancer Research and the Israel Cancer Association. ETHICS AND DISSEMINATION Ethic approval for this study has been obtained at eight academic medical centres located across the Middle East, North America and Europe. Results will be disseminated through conference presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER NCT03323489.
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Affiliation(s)
- Galia Jacobson
- Radiation Oncology, Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
- Radiation Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Ronen Fluss
- Gertner Institute, Sheba Mediacal Center, Tel Hashomer, Tel Aviv, Israel
| | - Amira Dany-BenShushan
- Israeli Center for Cardiovascular Research, Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
| | - Talia Golan
- Oncology, Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
- Sackler School of Medicine, Tel aviv University, Tel Aviv, Israel
| | - Tikva Meron
- Oncology, Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Laura A Dawson
- Radiation Oncology, Princess Margaret Hospital Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Aisling Barry
- Radiation Oncology, Princess Margaret Hospital Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Marcin Miszczyk
- IIIrd Radiotherapy and Chemotherapy Department, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | - Michael Buckstein
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Dayssy Diaz Pardo
- Department of Radiation Oncology, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Artur Aguiar
- Radiation Oncology, Portuguese Institute of Oncology of Porto, Porto, Portugal
| | - Liat Hammer
- Radiation Oncology, Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
- Radiatin Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Adam P Dicker
- Radiation Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Maoz Ben-Ailan
- Radiation Oncology, Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
| | - Ofir Morag
- Cancer Pain Unit, Institute of Oncology, Sheba Medical Center, Tel Aviv, Israel
| | - David Hausner
- Cancer Center, Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
| | - Zvi Symon
- Radiation Oncology, Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
- Sackler School of Medicine, Tel aviv University, Tel Aviv, Israel
| | - Yaacov R Lawrence
- Radiation Oncology, Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
- Sackler School of Medicine, Tel aviv University, Tel Aviv, Israel
- Radiation Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Lawrence YR, Hammer L, Morag O, Ben-Ailan M, Alezra D, Margalit O, Halpern N, Boursi B, Shmueli ES, Jacobson G, Amit U, Katzman T, Shefer K, Weiss I, Yanovsky I, Dicker AP, Golan T, Symon Z, Hausner D. Abstract CT147: Celiac plexus radiosurgery a new palliative modality for upper gastrointestinal malignancies - final quality of life results from a proof-of-concept clinical trial. Cancer Res 2019. [DOI: 10.1158/1538-7445.am2019-ct147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Many patients with upper-abdominal malignancies suffer from severe low back / epigastric pain caused by infiltration of the celiac plexus. The celiac plexus is a network of nociceptive nerves, located along the aorta. Contemporary approaches (opioids, celiac plexus chemical neurolysis, systemic chemotherapy) are often inadequate. The celiac plexus has not previously been targeted using radiation. We hypothesized that ablative radiation targeted to the celiac plexus would alleviate pain and improve quality of life (QOL).
Methods: We conducted a single arm prospective clinical trial. Eligible patients had celiac-pain > 4/10 on Numerical Rating Scale (NRS) and completed treatment per protocol with at least one post-treatment visit. The celiac plexus was irradiated from D12 to L2. Radiation was given as either five fractions of 9 Gy or a single-fraction 25 Gy. The primary endpoint was NRS pain 3 weeks post-treatment. Secondary endpoints were toxicity, pain at 6w, analgesic use, and pain interference with daily activities as evaluated by ‘Brief pain assessment short-form’. Analgesic use was not restricted. Here we report results from those who received single fraction treatment.
Results: 19 patients were evaluable. The median age of the study population was 67 yr with a median ECOG of 2, 89% had pancreatic cancer. Patients were a median 8 months from diagnosis, and had received a median of one systemic treatment. Toxicity was limited to grade 1-2. Average pain decreased from 5.9/10 at baseline, to 3.1/10 at 3w, and to 1.8/10 (both p < 0.0001) at 6w post-treatment. Number of rescue analgesic doses decreased from 3.6 (baseline) to 1.9 at 3w and 1.7 at 6w (both p<0.001). Improvement was seen in all domains of pain-interference (table).
Conclusions: Single fraction celiac plexus radiosurgery alleviates pain, and improves quality of life among patients with advanced upper-GI cancer. An international phase II trial is accruing.
Pain interference measuresdomainweek 0 (baseline)week 3p (w0 vs v3)week 6p (w0 vs v6)General Activity7.93.4<0.00012.0<0.0001Mood6.93.6<0.0051.80.0001Walking ability4.21.80.051.00.01Normal Work7.43.4<0.0051.30.0001Relations with other people62.40.0031.70.003Sleep6.93.2<0.0051.80.0001Enjoyment of life8.32.4<0.00011.8<0.0001
Citation Format: Yaacov R. Lawrence, Liat Hammer, Ofir Morag, Maoz Ben-Ailan, Dror Alezra, Ofer Margalit, Naama Halpern, Ben Boursi, Einat Shacham Shmueli, Galia Jacobson, Uri Amit, Tamar Katzman, Kinneret Shefer, Ilana Weiss, Inessa Yanovsky, Adam P. Dicker, Talia Golan, Zvi Symon, David Hausner. Celiac plexus radiosurgery a new palliative modality for upper gastrointestinal malignancies - final quality of life results from a proof-of-concept clinical trial [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr CT147.
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Affiliation(s)
| | | | - Ofir Morag
- 1Sheba Medical Center, Tel HaShomer, Israel
| | | | | | | | | | - Ben Boursi
- 1Sheba Medical Center, Tel HaShomer, Israel
| | | | | | - Uri Amit
- 1Sheba Medical Center, Tel HaShomer, Israel
| | | | | | | | | | | | | | - Zvi Symon
- 1Sheba Medical Center, Tel HaShomer, Israel
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Lawrence YR, Hammer L, Morag O, Ben-Ailan M, Alezra D, Margalit O, Halpern N, Boursi B, Shmueli ES, Jacobson G, Amit U, Katzman T, Shefer K, Weiss I, Yanovsky I, Dicker A, Golan T, Hausner D, Symon Z. Celiac plexus radiosurgery: A new palliative modality for upper gastrointestinal malignancies—Final results of a proof-of-concept clinical trial. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.10098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | - Ben Boursi
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | | | - Uri Amit
- Sheba Medical Center, Ramat Gan, Israel
| | | | | | | | | | - Adam Dicker
- The Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, PA
| | | | - David Hausner
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Zvi Symon
- Sheba Medical Center, Ramat Gan, Israel
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