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Gunther JR, Chadha AS, Guha S, Raju GS, Maru DM, Munsell MF, Jiang Y, Yang P, Felix E, Clemons M, Mathew GG, Singh PK, Skibber JM, Rodriguez-Bigas MA, Chang GJ, Eng C, Delclos ME, Crane CH, Das P, Krishnan S. A phase II randomized double blinded trial evaluating the efficacy of curcumin with pre-operative chemoradiation for rectal cancer. J Gastrointest Oncol 2022; 13:2938-2950. [PMID: 36636059 PMCID: PMC9830363 DOI: 10.21037/jgo-22-259] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 09/23/2022] [Indexed: 11/18/2022] Open
Abstract
Background In vivo studies demonstrate that curcumin increases radioresponse of colorectal cancers. To demonstrate efficacy in humans, we performed a randomized double-blind study of locally advanced rectal cancer (LARC) patients receiving pre-operative chemoradiation therapy (CRT) ± curcumin. We used pathologic complete response (pCR) rate as a surrogate for clinical outcome. Methods From 2008-2010, LARC patients were randomized to placebo/curcumin in a 1:2 ratio. Patients received CRT [50.4 gray in 28 fractions; capecitabine (825 mg/m2 twice daily)] followed by surgery. Curcumin (4 grams orally, twice daily) or placebo was given throughout CRT and 6 weeks afterward. Toxicity was monitored weekly. Blood samples taken pre- and 1-hour post-ingestion and tissue biopsies (both collected at CRT week 2) were analyzed for pharmacokinetics. The primary outcome was surgical pCR rate. Results Of 22 enrolled patients, 15 received curcumin. Median age was 61 years and the majority were male (n=13; 59%). The median serum curcumin concentrations before (3.04 ng/mL; range, 1.24-18.88 ng/mL) and 1 hour after (3.32 ng/mL; range, 0.84-5.36 ng/mL) curcumin intake did not differ significantly (P=0.33). Serum curcumin concentrations both increased and decreased 1-hour post-administration (range as percentage of baseline: 8.8-258.1%). Twelve curcumin patient tissue biopsies had median curcumin concentration of 33.7 ng/mg tissue (range, 0.1-4,765.7 ng/mg). Two placebo and 1 curcumin patient achieved pCRs (P=0.18). One grade 3 toxicity (infection) was experienced. Conclusions The addition of curcumin to CRT did not increase pCR rates for LARC patients. The unpredictable bioavailability of curcumin contributes to continued uncertainties regarding curcumin efficacy. Trial Registration ClinicalTrials.gov identifier: NCT00745134.
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Affiliation(s)
- Jillian R. Gunther
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Awalpreet S. Chadha
- Department of Internal Medicine, The University of Alabama, Birmingham, AL, USA
| | - Sushovan Guha
- Division of Gastroenterology, Department of Medicine, University of Texas Medical School at Houston, Houston, TX, USA
| | - Gottumukkala S. Raju
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Dipen M. Maru
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mark F. Munsell
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yan Jiang
- Department of Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Peiying Yang
- Department of Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Edd Felix
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marilyn Clemons
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Geena George Mathew
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pankaj K. Singh
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - John M. Skibber
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Miguel A. Rodriguez-Bigas
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - George J. Chang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cathy Eng
- Department of Medical Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Marc E. Delclos
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christopher H. Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sunil Krishnan
- Vivian L. Smith Department of Neurosurgery, UT Health Science Center, Houston, TX, USA
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2
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Holliday EB, Morris VK, Johnson B, Eng C, Ludmir EB, Das P, Minsky BD, Taniguchi C, Smith GL, Koay EJ, Koong AC, Delclos ME, Skibber JM, Rodriguez-Bigas MA, You YN, Bednarski BK, Tillman MM, Chang GJ, Jennings K, Messick CA. Definitive Intensity-Modulated Chemoradiation for Anal Squamous Cell Carcinoma: Outcomes and Toxicity of 428 Patients Treated at a Single Institution. Oncologist 2022; 27:40-47. [PMID: 35305097 PMCID: PMC8842324 DOI: 10.1093/oncolo/oyab006] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 11/16/2021] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Although intensity-modulated radiation therapy (IMRT) is considered the standard of care for the treatment of squamous cell carcinoma of the anus (SCCA), few large series have reported oncologic outcomes and toxicities. In this retrospective report, we aim to describe outcomes and toxicities after IMRT-based chemoradiation (CRT) for the treatment of SCCA, evaluate the impact of dose escalation (>54 Gy), and compare concurrent fluoropyrimidine in combination with either mitomycin or with cisplatin as chemosensitizers.
Methods
Patients treated at The University of Texas MD Anderson Cancer Center between January 1, 2003 and December 31, 2018 with IMRT-based CRT were included. Median time to locoregional recurrence, time to colostomy, and overall survival were estimated using the Kaplan–Meier method.
Results
A total of 428 patients were included; median follow-up was 4.4 years. Three hundred and thirty-four patients (78.0%) were treated with concurrent cisplatin and fluoropyrimidine, and 160 (37.4%) with >54 Gy. Two- and 5-year freedom from locoregional failure, freedom from colostomy failure, and overall survival were 86.5% and 81.2%, respectively, 90.0% and 88.3%, respectively, and 93.6% and 85.8%, respectively. Neither dose escalation nor mitomycin-based concurrent chemotherapy resulted in improved outcomes. Mitomycin-based concurrent chemotherapy was associated with in approximately 2.5 times increased grade 3 or greater acute toxicity. Radiation dose >54 Gy was associated with approximately 2.6 times increased Grade 3 or greater chronic toxicity.
Conclusions
Our results suggest IMRT-based CRT with concurrent fluoropyrimidine and cisplatin is a safe and feasible option for patient with SCCA and may cause less acute toxicity. The role for radiation dose escalation is unclear and requires further study.
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Affiliation(s)
- Emma B Holliday
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Van K Morris
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Benny Johnson
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cathy Eng
- Vanderbilt Ingram Cancer Center, Nashville, TN, USA
| | - Ethan B Ludmir
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bruce D Minsky
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cullen Taniguchi
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Grace L Smith
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eugene J Koay
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Albert C Koong
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marc E Delclos
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - John M Skibber
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Y Nancy You
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Mathew M Tillman
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - George J Chang
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Craig A Messick
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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3
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Augustyn A, Reed VI, Ahmad N, Bhutani MS, Bloom ES, Bowers JR, Chronowski GM, Das P, Holliday EB, Delclos ME, Huey RW, Koay EJ, Lee SS, Nelson CL, Taniguchi CM, Koong AC, Chun SG. Implementation of a stereotactic body radiotherapy program for unresectable pancreatic cancer in an integrated community academic radiation oncology satellite network. Clin Transl Radiat Oncol 2021; 27:147-151. [PMID: 33665384 PMCID: PMC7907676 DOI: 10.1016/j.ctro.2021.02.004] [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: 01/16/2021] [Revised: 02/05/2021] [Accepted: 02/07/2021] [Indexed: 11/18/2022] Open
Abstract
PDSA methodology was used to implement a pancreas SBRT in an academic satellite network. Oncologic outcomes were favorable with no serious adverse events. This technical note provides groundwork for safe establishment of SBRT pancreas programs.
With increasing interest in stereotactic body radiotherapy (SBRT) for unresectable pancreatic cancer, quality improvement (QI) initiatives to develop integrated clinical workflows are crucial to ensure quality assurance (QA) when introducing this challenging technique into radiation practices. Materials/Methods: In 2017, we used the Plan, Do, Study, Act (PDSA) QI methodology to implement a new pancreas SBRT program in an integrated community radiation oncology satellite. A unified integrated information technology infrastructure was used to virtually integrate the planned workflow into the community radiation oncology satellite network (P – Plan/D – Do). This workflow included multiple prospective quality assurance (QA) measures including multidisciplinary evaluation, prospective scrutiny of radiation target delineation, prospective radiation plan evaluation, and monitoring of patient outcomes. Institutional review board approval was obtained to retrospectively study and report outcomes of patients treated in this program (S – Study). Results: There were 12 consecutive patients identified who were treated in this program from 2017 to 2020 with a median follow-up of 27 months. The median survival was 13 months, median local failure free survival was 12 months and median progression free survival was 6 months from SBRT. There were no acute or late Common Terminology Criteria for Adverse Effects (CTCAE) version 5 toxicities ≥ Grade 3. Conclusion: We report the successful implementation of a community pancreas SBRT program involving multiple prospective QA measures, providing the groundwork to safely expand access to pancreas SBRT in our community satellite network (A – Act).
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Affiliation(s)
- Alexander Augustyn
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas, M.D. Anderson Cancer Center, Houston, TX, United States
| | - Valerie I. Reed
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas, M.D. Anderson Cancer Center, Houston, TX, United States
| | - Neelofur Ahmad
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas, M.D. Anderson Cancer Center, Houston, TX, United States
| | - Manoop S. Bhutani
- Department of Gastroenterology, Hepatology and Nutrition, Division of Internal Medicine, The University of Texas, M.D. Anderson Cancer Center, Houston, TX, United States
| | - Elizabeth S. Bloom
- Department of Gastroenterology, Hepatology and Nutrition, Division of Internal Medicine, The University of Texas, M.D. Anderson Cancer Center, Houston, TX, United States
| | - John R. Bowers
- Department of Radiation Oncology, M.D. Anderson Albuquerque, Albuquerque, NM, United States
| | - Gregory M. Chronowski
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas, M.D. Anderson Cancer Center, Houston, TX, United States
| | - Prajnan Das
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas, M.D. Anderson Cancer Center, Houston, TX, United States
| | - Emma B. Holliday
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas, M.D. Anderson Cancer Center, Houston, TX, United States
| | - Marc E. Delclos
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas, M.D. Anderson Cancer Center, Houston, TX, United States
| | - Ryan W. Huey
- Department of Gastrointestinal Medical Oncology, Division of Cancer Medicine, The University of Texas, M.D. Anderson Cancer Center, Houston, TX, United States
| | - Eugene J. Koay
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas, M.D. Anderson Cancer Center, Houston, TX, United States
| | - Sunyoung S. Lee
- Department of Gastrointestinal Medical Oncology, Division of Cancer Medicine, The University of Texas, M.D. Anderson Cancer Center, Houston, TX, United States
| | - Christopher L. Nelson
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas, M.D. Anderson Cancer Center, Houston, TX, United States
| | - Cullen M. Taniguchi
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas, M.D. Anderson Cancer Center, Houston, TX, United States
| | - Albert C. Koong
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas, M.D. Anderson Cancer Center, Houston, TX, United States
| | - Stephen G. Chun
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas, M.D. Anderson Cancer Center, Houston, TX, United States
- Corresponding author.
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4
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Ludmir EB, Adlakha EK, Chun SG, Reed VK, Arzu IY, Ahmad N, Bloom E, Chronowski GM, Delclos ME, Mayo LL, Schlembach PJ, Liao Z, Koong AC, Herman JM, Shah SJ. Enhancing clinical trial enrollment at MD Anderson Cancer Center satellite community campuses. Acta Oncol 2019; 58:1135-1137. [PMID: 30958082 DOI: 10.1080/0284186x.2019.1600019] [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: 10/27/2022]
Affiliation(s)
- Ethan B. Ludmir
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Erica K. Adlakha
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Stephen G. Chun
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Valerie K. Reed
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Isidora Y. Arzu
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Neelofur Ahmad
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elizabeth Bloom
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gregory M. Chronowski
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marc E. Delclos
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lauren L. Mayo
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pamela J. Schlembach
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zhongxing Liao
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Albert C. Koong
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph M. Herman
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shalin J. Shah
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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5
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Gunther JR, Chadha AS, Yang P, Munsell MF, Das P, Delclos ME, Foo WC, Kaur H, Clemons M, Mathew GG, Chang GJ, Rodriguez-Bigas MA, Skibber JM, Bhutani M, Raju GS, Eng C, Guha S, Krishnan S. (S021) A Phase 2 Randomized Double Blinded Study Evaluating the Efficacy of Curcumin With Pre-Operative Chemoradiation for Rectal Cancer. Int J Radiat Oncol Biol Phys 2017. [DOI: 10.1016/j.ijrobp.2017.02.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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6
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Gunther JR, Chadha AS, Shin US, Park IJ, Kattepogu KV, Grant JD, Weksberg DC, Eng C, Kopetz SE, Das P, Delclos ME, Kaur H, Maru DM, Skibber JM, Rodriguez-Bigas MA, You YN, Krishnan S, Chang GJ. Preoperative radiation dose escalation for rectal cancer using a concomitant boost strategy improves tumor downstaging without increasing toxicity: A matched-pair analysis. Adv Radiat Oncol 2017; 2:455-464. [PMID: 29114614 PMCID: PMC5605486 DOI: 10.1016/j.adro.2017.04.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [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: 12/22/2016] [Revised: 12/22/2016] [Accepted: 04/04/2017] [Indexed: 02/08/2023] Open
Abstract
Purpose Pathologic complete response to neoadjuvant chemoradiation therapy (CRT) is associated with improved outcomes for patients with locally advanced rectal cancer (LARC). Increased response rates have been reported with higher radiation doses, but these studies often lack long-term outcome and/or toxicity data. We conducted a case-control analysis of patients with LARC who underwent definitive CRT to determine the efficacy and safety of intensified treatment with a concomitant boost (CB) approach. Methods and materials From 1995 to 2003, a phase 2 protocol examined CRT with 5-fluorouracil and CB radiation therapy (52.5 Gy in 5 weeks) for patients with LARC. Seventy-six protocol patients were matched (case-control approach) for surgery type, tumor (T) stage, and clinical nodal (N) stage with patients who received standard dose (SD) CRT (5-fluorouracil, 45 Gy). A chart review was performed. McNemar's test and Kaplan-Meier analyses were used for statistical analysis. Results The SD and CB groups did not differ in tumor circumferential involvement and length, but the tumors of CB patients were closer to the anal verge (4.7 vs 5.7 cm; P = .02). Although tumor downstaging was higher in the CB cohort (76% vs 51%; P < .01), pathologic complete response rates did not differ (CB, 17.1% vs SD, 15.8%, P = 1.00). The incidence of grade ≥3 radiation-related toxicities was low and similar in both groups (CB, 10% vs SD, 3%, P = .22). Postoperative (anastomotic leak, wound complications/abscess, bleeding) and late (small bowel obstruction, stricture) complication rates did not differ between the groups (P > .05). The median follow-up was 11.9 years. The 5-year local control rates were higher for CB (100.0%) compared with SD (90.0%) patients (P = .01). CB patients had higher rates of 10-year progression-free survival (71.9% vs 57.6%, P < .01) and overall survival (71.6% vs 62.4%, P = .01) compared with SD patients. Conclusions CRT dose escalation for patients with LARC is safe and effective. The improved T-downstaging and local control observed in CB patients should encourage further dose escalation studies.
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Affiliation(s)
- Jillian R Gunther
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Awalpreet S Chadha
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Ui Sup Shin
- Department of Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - In Ja Park
- Department of Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Kiran V Kattepogu
- Department of Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Jonathan D Grant
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - David C Weksberg
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Cathy Eng
- Department of Gastrointestinal Medical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Scott E Kopetz
- Department of Gastrointestinal Medical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Marc E Delclos
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Harmeet Kaur
- Department of Diagnostic Radiology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Dipen M Maru
- Department of Pathology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - John M Skibber
- Department of Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Miguel A Rodriguez-Bigas
- Department of Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Y Nancy You
- Department of Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Sunil Krishnan
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - George J Chang
- Department of Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas.,Department of Health Services Research, The University of Texas, MD Anderson Cancer Center, Houston, Texas
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7
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Tao R, Tsai CJ, Jensen G, Eng C, Kopetz S, Overman MJ, Skibber JM, Rodriguez-Bigas M, Chang GJ, You YQN, Bednarski BK, Minsky BD, Delclos ME, Koay E, Krishnan S, Crane CH, Das P. Hyperfractionated accelerated reirradiation for rectal cancer: An analysis of outcomes and toxicity. Radiother Oncol 2017; 122:146-151. [PMID: 28057329 DOI: 10.1016/j.radonc.2016.12.015] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [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: 09/07/2016] [Revised: 11/28/2016] [Accepted: 12/04/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE To evaluate outcomes and toxicity in patients treated with hyperfractionated pelvic reirradiation for recurrent rectal cancer. MATERIALS AND METHODS 102 patients with recurrent rectal adenocarcinoma were treated with pelvic reirradiation with a hyperfractionated accelerated approach, consisting of 1.5Gy twice daily fractions to a total dose of 30-45Gy (median 39Gy), with the most common total dose 39Gy (n=90, 88%). The median dose of prior pelvic radiation therapy (RT) was 50.4Gy (range: 25-63Gy). RESULTS The median follow-up was 40months for living patients (range, 3-150months). The 3-year freedom from local progression (FFLP) rate was 40% and the 3-year overall survival (OS) rate was 39%. Treatment with surgery was significantly associated with improved FFLP and OS, with 3-year FFLP rate of 49% vs. 30% (P=0.013), and 3-year OS rate of 62% vs. 20% (P<0.0001), compared to those without surgery. The actuarial 3-year rate of grade 3-4 late toxicity was 34%; patients who underwent surgery had a significantly higher rate of grade 3-4 late toxicity compared to those without surgery (54% vs. 16%, P=0.001). CONCLUSIONS This large, retrospective, single-institution study shows that hyperfractionated accelerated reirradiation was well tolerated. The rate of FFLP was promising, given that the study comprised heavily pre-treated patients with recurrences. Rates of FFLP and OS were particularly impressive in patients who underwent both reirradiation and surgery.
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Affiliation(s)
- Randa Tao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA; Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, USA.
| | - Chiaojung Jillian Tsai
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA; Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Garrett Jensen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Cathy Eng
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Scott Kopetz
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Michael J Overman
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - John M Skibber
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Miguel Rodriguez-Bigas
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - George J Chang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Yi-Qian Nancy You
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Brian K Bednarski
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Bruce D Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Marc E Delclos
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Eugene Koay
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Sunil Krishnan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Christopher H Crane
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA; Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
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8
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Chadha AS, Liu G, Chen HC, Das P, Minsky BD, Mahmood U, Delclos ME, Suh Y, Sawakuchi GO, Beddar S, Katz MH, Fleming JB, Javle MM, Varadhachary GR, Wolff RA, Crane CH, Wang X, Thames H, Krishnan S. Does Unintentional Splenic Radiation Predict Outcomes After Pancreatic Cancer Radiation Therapy? Int J Radiat Oncol Biol Phys 2016; 97:323-332. [PMID: 28068240 DOI: 10.1016/j.ijrobp.2016.10.046] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 10/26/2016] [Accepted: 10/31/2016] [Indexed: 12/16/2022]
Abstract
PURPOSE To determine whether severity of lymphopenia is dependent on radiation dose and fractional volume of spleen irradiated unintentionally during definitive chemoradiation (CRT) in patients with locally advanced pancreatic cancer (LAPC). METHODS 177 patients with LAPC received induction chemotherapy (mainly gemcitabine-based regimens) followed by CRT (median 50.4 Gy with concurrent capecitabine) from January 2006 to December 2012. Absolute lymphocyte count (ALC) was recorded at baseline, before CRT, and 2 to 10 weeks after CRT. Splenic dose-volume histogram (DVH) parameters were reported as mean splenic dose (MSD) and percentage of splenic volume receiving at least 5- (V5), 10- (V10), 15- (V15), and 20-Gy (V20) dose. Overall survival (OS) was analyzed with use of the Cox model, and development of post-CRT severe lymphopenia (ALC <0.5 K/UL) was assessed by multivariate logistic regression with use of baseline and treatment factors. RESULTS The median post-CRT ALC (0.68 K/UL; range, 0.13-2.72) was significantly lower than both baseline ALC (1.42 K/UL; range, 0.34-3.97; P<.0001) and pre-CRT ALC (1.32 K/UL, range 0.36-4.82; P<.0001). Post-CRT ALC <0.5 K/UL was associated with inferior OS on univariate analysis (median, 11.1 vs 15.3 months; P=.01) and multivariate analysis (hazard ratio = 1.66, P=.01). MSD (9.8 vs 6 Gy, P=.03), median V10 (32.6 vs 16%, P=.04), V15 (23.2 vs 9.5%, P=.03), and V20 (15.4 vs 4.6%, P=.02) were significantly higher in patients with severe lymphopenia than in those without. On multivariate analysis, postinduction lymphopenia (P<.001; odds ratio [OR] = 5.25) and MSD (P=.002; OR= 3.42) were independent predictors for the development of severe post-CRT lymphopenia. CONCLUSION Severe post-CRT lymphopenia is an independent predictor of poor OS in LAPC patients receiving CRT. Higher splenic doses increase the risk for the development of severe post-CRT lymphopenia. When clinically indicated, assessment of splenic DVHs before the acceptance of treatment plans may minimize the risk of severe post-CRT lymphopenia.
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Affiliation(s)
- Awalpreet S Chadha
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Guan Liu
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hsiang-Chun Chen
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Bruce D Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Usama Mahmood
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Marc E Delclos
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yelin Suh
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Gabriel O Sawakuchi
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas; Graduate School of Biomedical Sciences, The University of Texas, Houston, Texas
| | - Sam Beddar
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matthew H Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason B Fleming
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Milind M Javle
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Gauri R Varadhachary
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Robert A Wolff
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Christopher H Crane
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Xuemei Wang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Howard Thames
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sunil Krishnan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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9
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Chadha AS, Skinner HD, Gunther JR, Munsell MF, Das P, Minsky BD, Delclos ME, Chatterjee D, Wang H, Clemons M, George G, Singh PK, Katz MH, Fleming JB, Javle MM, Wolff RA, Varadhachary GR, Crane CH, Krishnan S. Phase I Trial of Consolidative Radiotherapy with Concurrent Bevacizumab, Erlotinib and Capecitabine for Unresectable Pancreatic Cancer. PLoS One 2016; 11:e0156910. [PMID: 27336466 PMCID: PMC4919049 DOI: 10.1371/journal.pone.0156910] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 05/20/2016] [Indexed: 01/06/2023] Open
Abstract
Purpose To determine the safety, tolerability and maximum tolerated dose (MTD) of addition of erlotinib to bevacizumab and capecitabine-based definitive chemoradiation (CRT) in unresectable pancreatic cancer. Methods Seventeen patients with CT-staged, biopsy-proven unresectable pancreatic cancer were enrolled between 3/2008 and 10/2010. Prior chemotherapy was permitted. Two patients each were enrolled at dose levels (DLs) 1–4 and 9 patients at DL 5. All patients received 50.4 Gy (GTV only) in 28 fractions with concurrent capecitabine, bevacizumab and erlotinib. Dose of each drug was escalated in 5 DLs using the continual reassessment method. Bevacizumab was escalated from 5mg/Kg q2weeks (DLs 1–4) to 10mg/Kg q2weeks (DL 5); daily erlotinib from 100mg/day (DLs 1–2) to 150 mg/Kg (DLs 3–5); and capecitabine from 400mg/m2 twice daily on days of radiation (DL 1) to 650mg/m2 (DLs 2–3) to 825 mg/m2 (DLs 4–5). Reassessment for potential resection was performed 6–8 weeks later. Results Sixteen patients received gemcitabine-based chemotherapy prior to CRT. With a median clinical follow-up of 10 months, no grade 3 toxicities were observed in DLs 1–4. Three (33%) patients at DL 5 developed a grade 3 acute toxicity (2 diarrhea, 1 rash). No grade 4 or 5 toxicities were seen. DL 4 was selected as the MTD; therefore, the recommended doses in combination with radiation are: bevacizumab, 5mg/Kg q2weeks; erlotinib, 150 mg/Kg daily; and capecitabine, 825mg/m2 BID. Median survival was 17.4 months. Of the five patients who underwent resection, 4 were originally deemed locally advanced and 1 was borderline resectable. Three patients had excellent pathological response (2 complete response and 20% viable tumor) at surgery, and the 2 patients with complete response are still alive at 61 and 67 months of follow up with no local or distant failures. Conclusions This chemoradiation regimen at the recommended dose levels is safe and tolerable for patients with unresectable pancreatic cancer and merits further evaluation.
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Affiliation(s)
- Awalpreet S. Chadha
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Heath D. Skinner
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Jillian R. Gunther
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Mark F. Munsell
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Bruce D. Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Marc E. Delclos
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Deyali Chatterjee
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Huamin Wang
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Marilyn Clemons
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Geena George
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Pankaj K. Singh
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Matthew H. Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Jason B. Fleming
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Milind M. Javle
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Robert A. Wolff
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Gauri R. Varadhachary
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Christopher H. Crane
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Sunil Krishnan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
- * E-mail:
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10
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Thaker NG, Sturdevant L, Jhingran A, Das P, Delclos ME, Gunn GB, McAleer MF, Tereffe W, Choi SL, Frank SJ, Simeone WJ, Martinez W, Hahn SM, Famiglietti R, Kuban DA. Assessing the Quality of a Radiation Oncology Case-Based, Peer-Review Program in an Integrated Academic and Community Cancer Center Network. J Oncol Pract 2016; 12:e476-86. [DOI: 10.1200/jop.2015.005983] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Purpose: Academic centers increasingly find a need to define a comprehensive peer-review program that can translate high-quality radiation therapy (RT) to community network sites. In this study, we describe the initial results of a quarterly quality audit program that aims to improve RT peer-review and provider educational processes across community sites. Materials and Methods: An electronic tool was used by community-based certified member (CM) sites to enter clinical treatment information about patients undergoing peer review. At least 10% of the patient load for each CM physician was selected for audit on a quarterly basis by expert academic faculty. Quality metrics included the review of the management plan, technical plan, and other indicators. RT was scored as being concordant or nonconcordant with institutional guidelines, national standards, or expert judgment. Results: A total of 719 patients were entered into the peer-review database by the first four CM sites. Of 14% of patients audited, 17% (18 of 104) were deemed nonconcordant. Nonconcordance rates were lowest in prevalent disease sites, such as breast (16%), colorectal (14%), and lung (12%), whereas rates were highest in lymphoma (50%), brain (44%), and gynecology (27%). Deficiencies included incomplete staging work-up, incorrect target and normal tissue delineation, and nonadherence to accepted dose-volume constraints. Conclusion: Given the high rate of nonconcordance, we recommend prospective, pre-RT peer review of all patients, and, in particular, expert review of patients that are from low-volume or complex disease sites. An integrated approach to peer review holds a promise of improving the quality, safety, and value of cancer therapy in the community setting.
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Affiliation(s)
| | | | - Anuja Jhingran
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Prajnan Das
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Marc E. Delclos
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Gary B. Gunn
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Welela Tereffe
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Steven J. Frank
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Wendi Martinez
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Stephen M. Hahn
- The University of Texas MD Anderson Cancer Center, Houston, TX
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11
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Krishnan S, Chadha AS, Suh Y, Chen HC, Rao A, Das P, Minsky BD, Mahmood U, Delclos ME, Sawakuchi GO, Beddar S, Katz MH, Fleming JB, Javle MM, Varadhachary GR, Wolff RA, Crane CH. Focal Radiation Therapy Dose Escalation Improves Overall Survival in Locally Advanced Pancreatic Cancer Patients Receiving Induction Chemotherapy and Consolidative Chemoradiation. Int J Radiat Oncol Biol Phys 2015; 94:755-65. [PMID: 26972648 DOI: 10.1016/j.ijrobp.2015.12.003] [Citation(s) in RCA: 234] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 11/16/2015] [Accepted: 12/04/2015] [Indexed: 12/18/2022]
Abstract
PURPOSE To review outcomes of locally advanced pancreatic cancer (LAPC) patients treated with dose-escalated intensity modulated radiation therapy (IMRT) with curative intent. METHODS AND MATERIALS A total of 200 patients with LAPC were treated with induction chemotherapy followed by chemoradiation between 2006 and 2014. Of these, 47 (24%) having tumors >1 cm from the luminal organs were selected for dose-escalated IMRT (biologically effective dose [BED] >70 Gy) using a simultaneous integrated boost technique, inspiration breath hold, and computed tomographic image guidance. Fractionation was optimized for coverage of gross tumor and luminal organ sparing. A 2- to 5-mm margin around the gross tumor volume was treated using a simultaneous integrated boost with a microscopic dose. Overall survival (OS), recurrence-free survival (RFS), local-regional and distant RFS, and time to local-regional and distant recurrence, calculated from start of chemoradiation, were the outcomes of interest. RESULTS Median radiation dose was 50.4 Gy (BED = 59.47 Gy) with a concurrent capecitabine-based (86%) regimen. Patients who received BED >70 Gy had a superior OS (17.8 vs 15.0 months, P=.03), which was preserved throughout the follow-up period, with estimated OS rates at 2 years of 36% versus 19% and at 3 years of 31% versus 9% along with improved local-regional RFS (10.2 vs 6.2 months, P=.05) as compared with those receiving BED ≤70 Gy. Degree of gross tumor volume coverage did not seem to affect outcomes. No additional toxicity was observed in the high-dose group. Higher dose (BED) was the only predictor of improved OS on multivariate analysis. CONCLUSION Radiation dose escalation during consolidative chemoradiation therapy after induction chemotherapy for LAPC patients improves OS and local-regional RFS.
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Affiliation(s)
- Sunil Krishnan
- Department of Radiation Oncology, The University of Texas, Houston, Texas.
| | - Awalpreet S Chadha
- Department of Radiation Oncology, The University of Texas, Houston, Texas
| | - Yelin Suh
- Department of Radiation Physics, The University of Texas, Houston, Texas
| | - Hsiang-Chun Chen
- Department of Biostatistics, MD Anderson Cancer Center, Houston, Texas
| | - Arvind Rao
- Department of Bioinformatics and Computational Biology, MD Anderson Cancer Center, Houston, Texas
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas, Houston, Texas
| | - Bruce D Minsky
- Department of Radiation Oncology, The University of Texas, Houston, Texas
| | - Usama Mahmood
- Department of Radiation Oncology, The University of Texas, Houston, Texas
| | - Marc E Delclos
- Department of Radiation Oncology, The University of Texas, Houston, Texas
| | - Gabriel O Sawakuchi
- Department of Radiation Physics, The University of Texas, Houston, Texas; Graduate School of Biomedical Sciences, The University of Texas, Houston, Texas
| | - Sam Beddar
- Department of Radiation Physics, The University of Texas, Houston, Texas
| | - Matthew H Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason B Fleming
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Milind M Javle
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Gauri R Varadhachary
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Robert A Wolff
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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12
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Tang Y, Crane CH, Eng C, Minsky BD, Delclos ME, Krishnan S, Malatek D, Gould MS, Das P. Quality of life after intensity-modulated radiation therapy for anal cancer. ACTA ACUST UNITED AC 2015. [DOI: 10.1007/s13566-015-0209-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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13
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Chadha AS, Kocak-Uzel E, Das P, Minsky BD, Delclos ME, Mahmood U, Guha S, Ahmad M, Varadhachary GR, Javle M, Katz MH, Fleming JB, Wolff RA, Crane CH, Krishnan S. Paraneoplastic thrombocytosis independently predicts poor prognosis in patients with locally advanced pancreatic cancer. Acta Oncol 2015; 54:971-8. [PMID: 25608822 DOI: 10.3109/0284186x.2014.1000466] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND AND AIMS Platelets are believed to promote tumor growth and metastasis but their prognostic role in locally advanced pancreatic cancer (LAPC) remains largely unknown. We assessed whether pretreatment platelet counts independently predict survival outcomes in patients with LAPC treated with chemoradiation (CRT). METHODS We retrospectively reviewed the MD Anderson pancreatic cancer database and identified 199 patients with LAPC treated with CRT between 2006 and 2012. Induction chemotherapy was used prior to consolidative CRT in 177 (89%) patients. Median radiation dose was 50.4 Gy. Concurrent radiosensitizers were gemcitabine-based (13%) or capecitabine-based (84%) regimens. Actuarial univariate and multivariate statistical methods were used to determine significant prognostic factors for overall survival (OS) and progression-free survival (PFS) calculated from the start of treatment. RESULTS Median follow-up was 9.9 months. Median OS and PFS durations were 17.7 and 10.7 months, respectively. On univariate analysis, platelet count > 300 K/μl, KPS ≤ 80, ≥ 5% weight loss and pretreatment CA19-9 above the median were associated with inferior OS or PFS. Median OS was lower in patients with platelet count > 300 K/μl compared to patients with platelet count ≤ 300 K/μl (10.2 vs. 19 months; p = 0.0002). Corresponding median PFS times were 7.8 months and 11.1 months (p = 0.004), respectively. On multivariate analysis, platelet count > 300 K/μl (p = 0.012), ≥ 5% weight loss (p = 0.002) and elevated pretreatment CA19-9 (p = 0.005) were independent prognostic factors for OS. Platelet count > 300 K/μl (p = 0.03) and KPS ≤ 80 (p = 0.05) independently predicted PFS. CONCLUSIONS Our analysis suggests that pretreatment thrombocytosis independently predicts inferior OS and PFS in LAPC.
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Affiliation(s)
- Awalpreet S. Chadha
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, Texas, USA
| | - Esengul Kocak-Uzel
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, Texas, USA
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, Texas, USA
| | - Bruce D. Minsky
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, Texas, USA
| | - Marc E. Delclos
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, Texas, USA
| | - Usama Mahmood
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, Texas, USA
| | - Sushovan Guha
- Division of Gastroenterology, Hepatology and Nutrition University of Texas Health Science Center and Medical School at Houston, Houston, Texas, USA
| | - Mediha Ahmad
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, Texas, USA
| | - Gauri R. Varadhachary
- Department of Gastrointestinal Medical Oncology, The University of Texas M D Anderson Cancer Center, Houston, Texas
| | - Milind Javle
- Department of Gastrointestinal Medical Oncology, The University of Texas M D Anderson Cancer Center, Houston, Texas
| | - Matthew H. Katz
- Department of Surgical Oncology, The University of Texas M D Anderson Cancer Center, Houston, Texas
| | - Jason B. Fleming
- Department of Surgical Oncology, The University of Texas M D Anderson Cancer Center, Houston, Texas
| | - Robert A. Wolff
- Department of Gastrointestinal Medical Oncology, The University of Texas M D Anderson Cancer Center, Houston, Texas
| | - Christopher H. Crane
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, Texas, USA
| | - Sunil Krishnan
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, Texas, USA
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Hyngstrom JR, Tzeng CWD, Beddar S, Das P, Krishnan S, Delclos ME, Crane CH, Chang GJ, You YN, Feig BW, Skibber JM, Rodriguez-Bigas MA. Intraoperative radiation therapy for locally advanced primary and recurrent colorectal cancer: ten-year institutional experience. J Surg Oncol 2014; 109:652-8. [PMID: 24510523 DOI: 10.1002/jso.23570] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [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: 11/12/2013] [Accepted: 01/14/2014] [Indexed: 12/28/2022]
Abstract
BACKGROUND We evaluated the role of intraoperative radiation therapy (IORT) during radical resection of locally advanced colorectal cancer (CRC). METHODS We retrospectively evaluated all patients with CRC treated with IORT at our institution from 2001 to 2010. IORT was delivered using high-dose-rate brachytherapy (median 12.5-Gy). We analyzed factors associated with postoperative morbidity, local control (LC), and overall survival (OS). RESULTS One hundred patients were evaluated with 70% received IORT for recurrent tumors. R0 resection rate was 58%. Postoperative Grade ≥3 complications (33%) were independently associated with transfusions ≥3 units packed red blood cells (P = 0.016) and body mass index (BMI) ≥35 (P = 0.0499). Eighty-two patients underwent external beam radiation therapy (EBRT) before IORT. Five-year LC was 94%, for primary and 56%, for recurrent tumors, respectively (P = 0.007). Microscopic positive (R1) margins were not associated with LC (P = 0.316). BMI ≥30 (P = 0.048) and post-discharge complications (P = 0.041) were independent risk factors for worse LC. Median post-IORT OS was 67.7 (95% CI 51.1-84.3) months for all patients. CONCLUSION For patients with primary or recurrent locally advanced CRC, treatment with radical surgery and IORT achieved excellent LC outcomes irrespective of microscopic margin status. IORT may be indicated for tumors suspected to have close or positive microscopic margins.
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Affiliation(s)
- John R Hyngstrom
- Section of Surgical Oncology, Department of Surgery, University of Utah, Salt Lake City, Utah
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15
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Das P, Eng C, Rodriguez-Bigas MA, Chang GJ, Skibber JM, You YN, Maru DM, Munsell MF, Clemons MV, Kopetz SE, Garrett CR, Shureiqi I, Delclos ME, Krishnan S, Crane CH. Preoperative radiation therapy with concurrent capecitabine, bevacizumab, and erlotinib for rectal cancer: a phase 1 trial. Int J Radiat Oncol Biol Phys 2013; 88:301-5. [PMID: 24315563 DOI: 10.1016/j.ijrobp.2013.10.034] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 10/23/2013] [Accepted: 10/24/2013] [Indexed: 12/18/2022]
Abstract
PURPOSE The goal of this phase 1 trial was to determine the maximum tolerated dose (MTD) of concurrent capecitabine, bevacizumab, and erlotinib with preoperative radiation therapy for rectal cancer. METHODS AND MATERIALS Patients with clinical stage II to III rectal adenocarcinoma, within 12 cm from the anal verge, were treated in 4 escalating dose levels, using the continual reassessment method. Patients received preoperative radiation therapy with concurrent bevacizumab (5 mg/kg intravenously every 2 weeks), erlotinib, and capecitabine. Capecitabine dose was increased from 650 mg/m(2) to 825 mg/m(2) orally twice daily on the days of radiation therapy; erlotinib dose was increased from 50 mg orally daily in weeks 1 to 3, to 50 mg daily in weeks 1 to 6, to 100 mg daily in weeks 1 to 6. Patients underwent surgery at least 9 weeks after the last dose of bevacizumab. RESULTS A total of 19 patients were enrolled, and 18 patients were considered evaluable. No patient had grade 4 acute toxicity, and 1 patient had grade 3 acute toxicity (hypertension). The MTD was not reached. All 18 evaluable patients underwent surgery, with low anterior resection in 7 (39%), proctectomy with coloanal anastomosis in 4 patients (22%), posterior pelvic exenteration in 1 (6%), and abdominoperineal resection in 6 (33%). Of the 18 patients, 8 (44%) had pathologic complete response, and 1 had complete response of the primary tumor with positive nodes. Three patients (17%) had grade 3 postoperative complications (ileus, small bowel obstruction, and infection). With a median follow-up of 34 months, 1 patient developed distant metastasis, and no patient had local recurrence or died. The 3-year disease-free survival was 94%. CONCLUSIONS The combination of preoperative radiation therapy with concurrent capecitabine, bevacizumab, and erlotinib was well tolerated. The pathologic complete response rate appears promising and may warrant further investigation.
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Affiliation(s)
- Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - Cathy Eng
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Miguel A Rodriguez-Bigas
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - George J Chang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - John M Skibber
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Y Nancy You
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Dipen M Maru
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mark F Munsell
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Marilyn V Clemons
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Scott E Kopetz
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Christopher R Garrett
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Imad Shureiqi
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Marc E Delclos
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sunil Krishnan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Christopher H Crane
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Das P, Abboud MT, Haque W, Javle M, Kaseb A, Curley SA, Vauthey JN, Aloia TA, Beddar AS, Delclos ME, Krishnan S, Crane CH. Gastric bleeding after radiation therapy for intrahepatic cholangiocarcinoma. Pract Radiat Oncol 2013; 3:344-8. [PMID: 24674408 DOI: 10.1016/j.prro.2012.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Revised: 10/10/2012] [Accepted: 11/05/2012] [Indexed: 12/17/2022]
Abstract
PURPOSE The goal of this study was to determine the incidence and risk factors associated with gastric bleeding in patients treated with radiation therapy for intrahepatic cholangiocarcinoma. METHODS AND MATERIALS Between November 2002 and December 2008, 33 patients with intrahepatic cholangiocarcinoma were treated with radiation therapy to the primary site. Twenty-nine (88%) patients were previously treated with chemotherapy, including gemcitabine and cisplatin in 19 patients. The median dose of radiation therapy was 50.4 Gy (range, 35-70 Gy). Twenty-seven (82%) patients received concurrent therapy, with capecitabine in 26 and bevacizumab in 1 patient. RESULTS Nine of the 33 patients developed gastric bleeding, with a 1-year actuarial rate of 36%. Of these 9 patients, 7 presented with bleeding symptoms and 2 presented with anemia. All 9 patients were documented to have gastritis on endoscopy. The absolute and percent volumes of stomach receiving 40 and 50 Gy were significantly associated with the risk of gastric bleeding. CONCLUSIONS Patients with intrahepatic cholangiocarcinoma have a significant risk of developing gastric bleeding after radiation therapy. Hence, the volume of stomach exposed to radiation therapy should be minimized in patients receiving radiation therapy for intrahepatic cholangiocarcinoma.
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Affiliation(s)
- Prajnan Das
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - Mirna T Abboud
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Waqar Haque
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Milind Javle
- Department of Gastrointestinal Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ahmed Kaseb
- Department of Gastrointestinal Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Steven A Curley
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Thomas A Aloia
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - A Sam Beddar
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Marc E Delclos
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sunil Krishnan
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Christopher H Crane
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
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Kelly P, Das P, Pinnix CC, Beddar S, Briere T, Pham M, Krishnan S, Delclos ME, Crane CH. Duodenal toxicity after fractionated chemoradiation for unresectable pancreatic cancer. Int J Radiat Oncol Biol Phys 2013; 85:e143-9. [PMID: 23200173 DOI: 10.1016/j.ijrobp.2012.09.035] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Revised: 09/10/2012] [Accepted: 09/30/2012] [Indexed: 02/03/2023]
Abstract
PURPOSE Improving local control is critical to improving survival and quality of life for patients with locally advanced unresectable pancreatic cancer (LAPC). However, previous attempts at radiation dose escalation have been limited by duodenal toxicity. In order to guide future studies, we analyzed the clinical and dosimetric factors associated with duodenal toxicity in patients undergoing fractionated chemoradiation for LAPC. METHODS AND MATERIALS Medical records and treatment plans of 106 patients with LAPC who were treated with chemoradiation between July 2005 and June 2010 at our institution were reviewed. All patients received neoadjuvant and concurrent chemotherapy. Seventy-eight patients were treated with conventional radiation to 50.4 Gy in 28 fractions; 28 patients received dose-escalated radiation therapy (range, 57.5-75.4 Gy in 28-39 fractions). Treatment-related toxicity was graded according to Common Terminology Criteria for Adverse Events, version 4.0. Univariate and multivariate analyses were performed to assess prognostic influence of clinical, pathologic, and treatment-related factors by using Kaplan-Meier and Cox regression methods. RESULTS Twenty patients had treatment-related duodenal toxicity events, such as duodenal inflammation, ulceration, and bleeding. Four patients had grade 1 events, 8 had grade 2, 6 had grade 3, 1 had grade 4, and 1 had grade 5. On univariate analysis, a toxicity grade ≥2 was associated with tumor location, low platelet count, an absolute volume (cm(3)) receiving a dose of at least 55 Gy (V(55 Gy) > 1 cm(3)), and a maximum point dose >60 Gy. Of these factors, only V(55 Gy) ≥1 cm(3) was associated with duodenal toxicity on multivariate analysis (hazard ratio, 6.7; range, 2.0-18.8; P=.002). CONCLUSIONS This study demonstrates that a duodenal V(55 Gy) >1 cm(3) is an important dosimetric predictor of grade 2 or greater duodenal toxicity and establishes it as a dosimetric constraint when treating patients with unresectable pancreatic cancer with concurrent chemoradiation.
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Affiliation(s)
- Patrick Kelly
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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18
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Skinner HD, Crane CH, Garrett CR, Eng C, Chang GJ, Skibber JM, Rodriguez-Bigas MA, Kelly P, Sandulache VC, Delclos ME, Krishnan S, Das P. Metformin use and improved response to therapy in rectal cancer. Cancer Med 2013; 2:99-107. [PMID: 24133632 PMCID: PMC3797563 DOI: 10.1002/cam4.54] [Citation(s) in RCA: 74] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Revised: 11/22/2012] [Accepted: 12/08/2012] [Indexed: 12/16/2022] Open
Abstract
Locally advanced rectal cancer is commonly treated with chemoradiation prior to total mesorectal excision (TME). Studies suggest that metformin may be an effective chemopreventive agent in this disease as well as a possible adjunct to current therapy. In this study, we examined the effect of metformin use on pathologic complete response (pCR) rates and outcomes in rectal cancer. The charts of 482 patients with locally advanced rectal adenocarcinoma treated from 1996 to 2009 with chemoradiation and TME were reviewed. Median radiation dose was 50.4 Gy (range 19.8–63). Nearly, all patients were treated with concurrent 5-fluorouracil-based chemotherapy (98%) followed by adjuvant chemotherapy (81.3%). Patients were categorized as nondiabetic (422), diabetic not taking metformin (40), or diabetic taking metformin (20). No significant differences between groups were found in clinical tumor classification, nodal classification, tumor distance from the anal verge or circumferential extent, pretreatment carcinoembryonic antigen level, or pathologic differentiation. pCR rates were 16.6% for nondiabetics, 7.5% for diabetics not using metformin, and 35% for diabetics taking metformin, with metformin users having significantly higher pCR rates than either nondiabetics (P = 0.03) or diabetics not using metformin (P = 0.007). Metformin use was significantly associated with pCR rate on univariate (P = 0.05) and multivariate (P = 0.01) analyses. Furthermore, patients taking metformin had significantly increased disease-free (P = 0.013) and overall survival (P = 0.008) compared with other diabetic patients. Metformin use is associated with significantly higher pCR rates as well as improved survival. These promising data warrant further prospective study.
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Affiliation(s)
- Heath D Skinner
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center Houston, Texas, 77030
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Briere TM, Crane CH, Beddar S, Bhosale P, Mok H, Delclos ME, Krishnan S, Das P. Reproducibility and genital sparing with a vaginal dilator used for female anal cancer patients. Radiother Oncol 2012; 104:161-6. [DOI: 10.1016/j.radonc.2012.05.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Revised: 02/06/2012] [Accepted: 05/20/2012] [Indexed: 11/16/2022]
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20
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Suzuki A, Xiao L, Taketa T, Blum MA, Matamoros A, Chien PL, Mansfield PF, Fournier KF, Weston B, Lee JH, Bhutani MS, Estrella JS, Delclos ME, Krishnan S, Das P, Ajani JA. Localized gastric cancer treated with chemoradation without surgery: UTMD Anderson Cancer Center experience. Oncology 2012; 82:347-51. [PMID: 22677933 DOI: 10.1159/000338318] [Citation(s) in RCA: 6] [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] [Received: 03/06/2012] [Accepted: 03/06/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND In patients with localized gastric cancer (LGC) who are unfit for surgery, decline surgery, or have unresectable cancer, chemoradiotherapy may provide palliation; however, data in the literature are sparse. METHODS We identified 66 LGC patients who had definitive chemoradiation but no surgery. All patients had baseline and postchemoradiation staging including an endoscopic biopsy. Multiple statistical methods were used to analyze outcomes. RESULTS Most patients were men and most had stage III or IV cancer. Five patients were surgery eligible but declined to have surgery. The median follow-up time was 33.9 months (95% CI 18.3-49.6). The median survival time (MST) for 66 patients was only 14.5 months (95% CI 10.8-19.7) and the median relapse-free survival (RFS) was 5.03 months (95% CI 4.67-6.40). The estimated overall survival (OS) and RFS rates at 3 years were 22.6% (95% CI 13.7-37.3) and 7.7% (95% CI 3.2-18.6), respectively. Twenty-three (35%) patients who achieved a clinical complete response (cCR; negative postchemoradiation biopsy and no progression by imaging) fared better than those who achieved less than cCR (<cCR) [cCR: MST 30.7 months (95% CI 20.4-NA); <cCR: MST 10.6 months (95% CI 8.43-14.9); p < 001]. In multivariate analysis, cCR was the only independent prognosticator for OS [hazard ratio (HR) = 0.32, p < 0.0012] and RFS (HR = 0.12, p < 0.0001). CONCLUSION Our data demonstrate that in the absence of surgery, outcomes with definitive chemoradiation are only modest. A third of the patients achieved cCR and had a longer OS and RFS than those who achieved <cCR.
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Affiliation(s)
- Akihiro Suzuki
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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21
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Chakravarty T, Crane CH, Ajani JA, Mansfield PF, Briere TM, Beddar AS, Mok H, Reed VK, Krishnan S, Delclos ME, Das P. Intensity-Modulated Radiation Therapy With Concurrent Chemotherapy as Preoperative Treatment for Localized Gastric Adenocarcinoma. Int J Radiat Oncol Biol Phys 2012; 83:581-6. [DOI: 10.1016/j.ijrobp.2011.07.035] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Revised: 06/20/2011] [Accepted: 07/14/2011] [Indexed: 01/25/2023]
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22
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Kelly P, Das P, Varadhachary GR, Fontanilla HP, Krishnan S, Delclos ME, Jhingran A, Eifel PJ, Crane CH. Role of definitive radiation therapy in carcinoma of unknown primary in the abdomen and pelvis. Int J Radiat Oncol Biol Phys 2012; 82:2012-7. [PMID: 21640510 DOI: 10.1016/j.ijrobp.2011.03.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Revised: 03/09/2011] [Accepted: 03/17/2011] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Carcinoma of unknown primary (CUP) in the abdomen and pelvis is a heterogeneous group of cancers with no standard treatment. Considered by many to be incurable, these patients are often treated with chemotherapy alone. In this study, we determined the effectiveness of radiation therapy in combination with chemotherapy in patients with CUP in the abdomen and pelvis. PATIENTS AND METHODS Medical records were reviewed for 37 patients with CUP treated with radiation therapy for disease located in the soft tissues and/or nodal basins of the abdomen and pelvis at the University of Texas M.D. Anderson Cancer between 2002 and 2009. All patients underwent chemotherapy, either before or concurrent with radiation therapy. Patients were selected for radiation therapy on the basis of histologic type, disease extent, and prior therapy response. Twenty patients underwent definitive radiation therapy (defined as radiation therapy targeting all known disease sites with at least 45 Gy) and 17 patients underwent palliative radiation therapy. Only 6 patients had surgical resection of their disease. Patient and treatment characteristics were extracted and the endpoints of local disease control, progression-free survival (PFS), overall survival (OS), and treatment-related toxicity incidence were analyzed. RESULTS The 2-year PFS and OS rates for the entire cohort were 32% and 57%, respectively. However, in patients treated with definitive radiation therapy, the rates were 48% and 76%, and 7 patients lived more than 3 years after treatment with no evidence of disease progression. Nevertheless, radiation-associated toxicity was significant in this cohort, as 40% experienced Grade 2 or higher late toxicities. CONCLUSIONS The use of definitive radiation therapy should be considered in selected patients with CUP in the soft tissues or nodal basins of the abdomen and pelvis.
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Affiliation(s)
- Patrick Kelly
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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23
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Skinner HD, Javle MM, Wolff RA, Clemons MV, Munsell MF, Delclos ME, Fleming JB, Das P, Crane CH, Krishnan S. Phase I trial of radiotherapy with concurrent bevacizumab, erlotinib, and capecitabine for locally advanced pancreatic cancer (LAPC). J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.4_suppl.254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
254 Background: The addition of bevacizumab to capecitabine-based chemoradiotherapy (CRT) for LAPC has been shown to be safe. The aim of this study was to determine the safety, tolerability and maximum tolerated dose (MTD) of the addition of erlotinib to this treatment regimen. Methods: Seventeen patients with CT-staged biopsy-proven non-metastatic unresectable LAPC were enrolled between March 2008 and October 2010. Prior chemotherapy was permitted. All patients received 50.4 Gy (GTV only) in 28 fractions with concurrent capecitabine, bevacizumab and erlotinib. Dose was escalated using a continual reassessment method. Two patients each were enrolled at dose levels (DLs) 1-4 and 9 patients at DL 5. Bevacizumab was escalated from 5mg/Kg every two weeks (DLs 1-4) to 10mg/Kg (DL 5); erlotinib from 100 mg/day (DLs 1-2) to 150 mg/day (DLs 3-5); and capecitabine from 400mg/m2 twice daily on days of radiation (DL 1) to 600mg/m2 (DLs 2-3) to 825 mg/m2 (DLs 4-5). Reassessment for potential resection was performed 6-8 weeks later. Results: With a median follow-up of 10 months (range 3-23), no grade 3 toxicities were observed in DLs 1-4. Three (33%) patients at DL 5 developed a grade 3 acute toxicity (2 diarrheas and 1 rash). No grade 4 or 5 toxicities were seen. DL 4, with a posterior probability of 0.122 of dose limiting toxicity, was selected as the MTD. Median survival was 19.4 months and time to distant progression was 9.8 months. Patients treated at DLs 4 and 5 had a median survival of 24 months. Of 5 patients who underwent margin-negative resections, 4 were originally deemed unresectable and 1 was borderline; 4 were treated at DLs 4 or 5 (36% of patients treated at these DLs); 3 patients had excellent pathological responses (complete response, 5% viable tumor, and 20% viable tumor) at pancreatectomy and are alive at 13, 21 and 22 months respectively with no local or distant failures. Conclusions: The combination of erlotinib, bevacizumab and capecitabine with radiotherapy for LAPC is safe and tolerable. Both the promising survival and the high rate of resectability at the higher dose levels suggest that this strategy of dual inhibition of growth factor receptor pathways during CRT warrants continued evaluation.
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Affiliation(s)
| | - Milind M. Javle
- University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Robert A. Wolff
- University of Texas M. D. Anderson Cancer Center, Houston, TX
| | | | - Mark F. Munsell
- University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Marc E. Delclos
- University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Jason B Fleming
- University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Prajnan Das
- University of Texas M. D. Anderson Cancer Center, Houston, TX
| | | | - Sunil Krishnan
- University of Texas M. D. Anderson Cancer Center, Houston, TX
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24
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Mitchell MP, Abboud M, Crane CH, Eng C, Chang GJ, Rodriguez-Bigas MA, Skibber JM, You YN, Beddar S, Krishnan S, Delclos ME, Das P. Intensity-modulated radiation therapy (IMRT) with concurrent chemotherapy for anal cancer: A large single-institution experience. J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.4_suppl.661] [Citation(s) in RCA: 2] [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: 11/20/2022] Open
Abstract
661 Background: IMRT for squamous cell anal carcinoma enables sparing of normal tissues potentially leading to decreased toxicity. We evaluated toxicity, local control and survival in anal cancer patients treated with IMRT and concurrent chemotherapy. Methods: Between March 2007 and January 2011, 65 patients were treated at our institution with IMRT and concurrent chemotherapy for newly diagnosed, localized squamous cell carcinoma of the anal canal. Radiotherapy was delivered with a simultaneous integrated boost technique, with dose based on the T stage. The median total dose to the primary tumor was 54 Gy (range 50 – 58.8 Gy) and the median dose to the pelvis was 45 Gy (range 40.5-50.4 Gy) delivered in 25-29 fractions. The concurrent chemotherapy regimens were 5-fluorouracil (5-FU) and cisplatin (75%), capecitabine and oxaliplatin (11%), 5-FU and mitomycin C (MMC) (5%), cisplatin and MMC (2%), capecitabine and cisplatin (2%), capecitabine and MMC (2%), and 5-FU given alone due to other co morbidities (5%). Results: Median age at diagnosis was 57 years (range 35-80). The patient population was 71% female. The percentage of patients with stage I, II, IIIA, and IIIB disease were 12%, 28%, 14% and 42%, respectively. Stage was Tx in 5%. 8% of patients were HIV positive. Grade 3 gastrointestinal toxicity occurred in 9% and moist desquamation beyond the perianal area occurred in 17%. 91% of patients completed treatment without a break. The median follow-up was 19 months (range 1 to 49 months). The 2-year local control was 93%. Four patients had a local recurrence, of which two underwent salvage APR, one refused surgery, and one patient, who also had metastatic disease, received chemotherapy. Four patients developed metastasis. The 2 year distant control was 93%. There were two deaths due to the development of metastatic disease. The 2-year overall and disease-free survival were 96% and 89%, respectively. Conclusions: Concurrent IMRT and chemotherapy was well tolerated with low rates of acute toxicity, and excellent local control, disease-free survival and overall survival. Our results compare favorably with other published data despite a higher proportion of patients with advanced disease.
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Affiliation(s)
- Melissa Pulfer Mitchell
- University of Texas M. D. Anderson Cancer Center, Houston, TX; Methodist Hospital, Houston, TX
| | - Mirna Abboud
- University of Texas M. D. Anderson Cancer Center, Houston, TX; Methodist Hospital, Houston, TX
| | - Christopher H. Crane
- University of Texas M. D. Anderson Cancer Center, Houston, TX; Methodist Hospital, Houston, TX
| | - Cathy Eng
- University of Texas M. D. Anderson Cancer Center, Houston, TX; Methodist Hospital, Houston, TX
| | - George J. Chang
- University of Texas M. D. Anderson Cancer Center, Houston, TX; Methodist Hospital, Houston, TX
| | | | - John Michael Skibber
- University of Texas M. D. Anderson Cancer Center, Houston, TX; Methodist Hospital, Houston, TX
| | - Y. Nancy You
- University of Texas M. D. Anderson Cancer Center, Houston, TX; Methodist Hospital, Houston, TX
| | - Sam Beddar
- University of Texas M. D. Anderson Cancer Center, Houston, TX; Methodist Hospital, Houston, TX
| | - Sunil Krishnan
- University of Texas M. D. Anderson Cancer Center, Houston, TX; Methodist Hospital, Houston, TX
| | - Marc E. Delclos
- University of Texas M. D. Anderson Cancer Center, Houston, TX; Methodist Hospital, Houston, TX
| | - Prajnan Das
- University of Texas M. D. Anderson Cancer Center, Houston, TX; Methodist Hospital, Houston, TX
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Das P, Eng C, Rodriguez-Bigas MA, Chang GJ, Skibber JM, Maru D, Munsell MF, Clemons MV, Kopetz S, Garrett CR, Shureiqi I, Krishnan S, Delclos ME, Crane CH. Preoperative radiation therapy with concurrent capecitabine, bevacizumab, and erlotinib for rectal adenocarcinoma: A phase I trial. J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.4_suppl.544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
544 Background: The goal of this phase I trial was to determine the maximal tolerated dose (MTD) of concurrent capecitabine, bevacizumab and erlotinib with preoperative radiation therapy (RT) for rectal cancer, with a secondary objective of evaluating pathologic complete response (pCR). Methods: Eligibility criteria included patients with clinical stage II-III rectal adenocarcinoma within 12 cm from the anal verge. Exclusion criteria included uncontrolled hypertension, recent myocardial infarction or angina, coagulopathy, impaired renal function, and history of gastrointestinal perforation. Patients were treated in cohorts of 2, in 4 escalating dose levels (DL), using the continual reassessment method, as shown in the table. Patients underwent surgery at least 9 weeks after the last dose of bevacizumab. Results: Nineteen patients were enrolled in the study: 1 withdrew early because of insurance issues and was non-evaluable. The clinical stage was T3N0 in 3, T3N1 in 13, T3N2 in 1 and T4N0 in 1 patient. No patient had grade 4-5 acute toxicity; 1 patient had grade 3 acute toxicity (hypertension, DL 2) during or within 4 weeks after RT. The MTD was not reached; the probability of dose limiting toxicity at DL 4 was 0.15. All 18 evaluable patients underwent surgery, with low anterior resection in 7 (39%), proctectomy with coloanal anastomosis in 5 (28%), and abdominoperineal resection in 6 (33%) patients. Eight patients (44%) had pCR, and an additional 8 (44%) had ≤ 10% viable tumor in the surgical specimen. Fifteen patients (83%) had T downstaging. Three patients developed grade 3 post-operative complications (ileus, small bowel obstruction and infection). After a median follow-up of 21 months (range 9-39 months), no patient had local recurrence, but 1 patient developed distant metastasis. Conclusions: The combination of preoperative RT with concurrent capecitabine, bevacizumab and erlotinib was well tolerated. The pCR rate of 44% is promising and warrants further investigation. [Table: see text]
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Affiliation(s)
- Prajnan Das
- University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Cathy Eng
- University of Texas M. D. Anderson Cancer Center, Houston, TX
| | | | - George J. Chang
- University of Texas M. D. Anderson Cancer Center, Houston, TX
| | | | - Dipen Maru
- University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Mark F. Munsell
- University of Texas M. D. Anderson Cancer Center, Houston, TX
| | | | - Scott Kopetz
- University of Texas M. D. Anderson Cancer Center, Houston, TX
| | | | - Imad Shureiqi
- University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Sunil Krishnan
- University of Texas M. D. Anderson Cancer Center, Houston, TX
| | - Marc E. Delclos
- University of Texas M. D. Anderson Cancer Center, Houston, TX
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26
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Skinner HD, Sharp HJ, Kaseb AO, Javle MM, Vauthey JN, Abdalla EK, Delclos ME, Das P, Crane CH, Krishnan S. Radiation treatment outcomes for unresectable hepatocellular carcinoma. Acta Oncol 2011; 50:1191-8. [PMID: 21793641 DOI: 10.3109/0284186x.2011.592147] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Hepatocellular carcinoma is one of the most common cancers worldwide. Data regarding the use of radiotherapy is limited in patients from populations without endemic viral hepatitis. We examine the outcomes for patients treated with radiotherapy in the modern era at a single institution. MATERIAL AND METHODS A total of 29 patients with localized hepatocellular carcinoma treated from 2000-2010 were reviewed. Patients with metastatic disease at the time of radiation were excluded. Median radiation dose was 50 Gy (range 30 to 75 Gy) with a median biologically effective dose of 80.6 (range 60 to 138.6). Median tumor size at the time of radiation was 5.2 cm (range 2 to 25 cm). RESULTS Eighty three percent of all patients had either stable disease or a partial response to radiation, based on RECIST criteria. Median change in tumor size following radiation was -17% (range -73.5 to 177.8%). Estimated one-year overall survival and in-field progression-free survival rates for the study population were 56% and 79%, respectively. One-year overall survival in patients treated to a biologically effective dose <75 was significantly lower than in patients treated to a biologically effective dose ≥75 (18% vs. 69%). One-year in-field progression-free survival rate (60% vs. 88%) and biochemical progression-free survival duration (median 6.5 vs. 1.6 months) were also significantly improved in patients treated to a biologically effective dose ≥75. Grade 3 toxicity was seen in 13.8% of patients. DISCUSSION In a population without endemic viral hepatitis, unresectable hepatocellular carcinoma demonstrates significant response to radiotherapy with minimal toxicity. Furthermore, our findings suggest that increased biologically effective dose is associated with improved survival and local tumor control.
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Affiliation(s)
- Heath D Skinner
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, 77030, USA
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Das P, Cantor SB, Parker CL, Zampieri JB, Baschnagel A, Eng C, Delclos ME, Krishnan S, Janjan NA, Crane CH. Long-term quality of life after radiotherapy for the treatment of anal cancer. Cancer 2010; 116:822-9. [PMID: 20041481 PMCID: PMC6455911 DOI: 10.1002/cncr.24906] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Radiotherapy is the current standard of care for patients with localized squamous cell cancer of the anal canal. The goal of the current study was to evaluate long-term quality of life (QoL) in patients after this treatment. METHODS Questionnaires were mailed to 80 patients treated with definitive radiotherapy, with or without concurrent chemotherapy, for anal cancer, with a minimum 2-year interval after the completion of radiotherapy. The questionnaire included the Functional Assessment of Cancer Therapy-Colorectal (FACT-C), the Medical Outcomes Study (MOS) Sexual Problems Scale, and questions regarding demographic characteristics and comorbidities. RESULTS A total of 32 (40%) patients completed the questionnaire. There were no significant differences noted with regard to clinical and demographic characteristics between the survey responders and nonresponders. Among the 32 responders, the median dose of radiotherapy was 55 Grays (Gy), and 97% had received concurrent chemotherapy. The median interval between radiotherapy and survey participation was 5 years (range, 3-13 years). The median total FACT-C score was 108 (range, 47-128), of a maximum (best possible) score of 136. Patients who reported depression or anxiety and younger patients were found to have significantly lower total FACT-C scores. The median scores on the Physical, Social/Family, Emotional, Functional, and Colorectal subscales of the FACT-C were 20, 23, 21, 22, and 21, respectively, of maximum (best possible) scores of 28, 28, 24, 28, and 28, respectively. The median score on the MOS Sexual Problems Scale was 67 (range, 0-100), of a maximum (worst possible) score of 100. CONCLUSIONS Patients treated with radiotherapy for anal cancer reported acceptable overall QoL scores, but poor sexual function scores. Investigations are warranted into more modern radiation techniques that could potentially reduce late toxicity from radiotherapy.
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Affiliation(s)
- Prajnan Das
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston1515 Holcombe Boulevard, Unit 97, Houston, TX 77030, USA.
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Haque W, Crane CH, Krishnan S, Delclos ME, Javle M, Garrett CR, Wolff RA, Das P. Reirradiation to the abdomen for gastrointestinal malignancies. Radiat Oncol 2009; 4:55. [PMID: 19922641 PMCID: PMC2787526 DOI: 10.1186/1748-717x-4-55] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [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: 07/06/2009] [Accepted: 11/18/2009] [Indexed: 11/25/2022] Open
Abstract
Background Reirradiation to the abdomen could potentially play a role in palliation of symptoms or local control in patients with gastrointestinal malignancies. Our goal was to retrospectively determine rates of toxicity, freedom from local progression and overall survival in gastrointestinal cancer patients treated with reirradiation to the abdomen. Methods Between November 2002 and September 2008, 13 patients with a prior history of abdominal radiotherapy (median dose 45 Gy) were treated with reirradiation for recurrent or metastatic gastrointestinal malignancies. The median interval between the two courses of radiotherapy was 26 months. Patients were treated with a hyperfractionated accelerated regimen, using 1.5 Gy fractions twice daily, with a median dose of 30 Gy (range 24-48 Gy). Concurrent chemotherapy was administered to 8 (62%) patients. Results The 1-year rate of freedom from local progression was 50%, and the median duration of freedom from local progression was 14 months. The 1-year rate of overall survival was 62%, and the median duration of overall survival was 14 months. One patient developed grade 3 acute toxicity (abdominal pain and gastrointestinal bleeding), requiring hospitalization during radiotherapy; subsequently, that patient experienced a grade 4 late toxicity (gastrointestinal bleeding). No other patients developed grade 3-4 acute or late toxicity or required hospitalization during radiotherapy. Conclusion Hyperfractionated accelerated reirradiation to the abdomen was well-tolerated with low rates of acute and late toxicity. Reirradiation could play a role in providing a limited duration of local control in gastrointestinal cancer patients with a history of prior abdominal radiotherapy.
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Affiliation(s)
- Waqar Haque
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA.
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Callender GG, Das P, Rodriguez-Bigas MA, Skibber JM, Crane CH, Krishnan S, Delclos ME, Feig BW. Local excision after preoperative chemoradiation results in an equivalent outcome to total mesorectal excision in selected patients with T3 rectal cancer. Ann Surg Oncol 2009; 17:441-7. [PMID: 19847569 DOI: 10.1245/s10434-009-0735-7] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND We previously reported 26 patients who underwent preoperative chemoradiotherapy (CXRT) for T3 rectal cancer and were subsequently offered full-thickness local excision (LE) as an alternative to total mesorectal excision (TME). At nearly 4 years' follow-up, no difference in outcome was observed. This study compares outcomes in a larger cohort of patients and reevaluates the original 26 patients after longer follow-up. METHODS Retrospective review was performed of patients who underwent preoperative CXRT (radiation doses of 45, 50.4, or 52.5 Gy with concurrent 5-fluorouracil-based chemotherapy) followed by surgery for T3 rectal cancer. Forty-seven patients underwent LE (Kraske [n = 6] or transanal excision [n = 41]). 473 patients underwent TME (abdominoperineal resection [n = 141] or low anterior resection [n = 332]). Local recurrence, disease-free survival (DFS), disease-specific survival, and overall survival (OS) rates were compared. RESULTS Median follow-up was 63 months for the LE group and 59 months for the TME group. Twenty-three LE patients (49%) had a complete response to CXRT, 17 (36%) had microscopic residual disease, and 7 (15%) had gross residual disease, compared with 108 (23%), 89 (19%), and 276 (58%) TME patients, respectively. There was no significant difference between the 10-year actuarial local recurrence rate for the LE group versus the TME group (10.6% and 7.6%, respectively; P = .52), and no significant difference in DFS, disease-specific survival, or OS rates between groups. CONCLUSIONS In selected patients who demonstrate an excellent response to preoperative CXRT for T3 rectal cancer, full-thickness LE offers comparable local control, DFS, and OS to that achieved with proctectomy and TME.
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Affiliation(s)
- Glenda G Callender
- Department of Surgical Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
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Das P, Delclos ME, Skibber JM, Rodriguez-Bigas MA, Feig BW, Chang GJ, Eng C, Bedi M, Krishnan S, Crane CH. Hyperfractionated accelerated radiotherapy for rectal cancer in patients with prior pelvic irradiation. Int J Radiat Oncol Biol Phys 2009; 77:60-5. [PMID: 19695792 DOI: 10.1016/j.ijrobp.2009.04.056] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Revised: 04/10/2009] [Accepted: 04/14/2009] [Indexed: 11/18/2022]
Abstract
PURPOSE To retrospectively determine rates of toxicity, freedom from local progression, and survival in rectal cancer patients treated with reirradiation. METHODS AND MATERIALS Between February 2001 and February 2005, 50 patients with a history of pelvic radiotherapy were treated with hyperfractionated accelerated radiotherapy for primary (n = 2 patients) or recurrent (n = 48 patients) rectal adenocarcinoma. Patients were treated with 150-cGy fractions twice daily, with a total dose of 39 Gy (n = 47 patients) if the retreatment interval was >or=1 year or 30 Gy (n = 3) if the retreatment interval was <1 year. Concurrent chemotherapy was administered to 48 (96%) patients. Eighteen (36%) patients underwent surgical resection following radiotherapy. RESULTS Two patients had grade 3 acute toxicity and 13 patients had grade 3 to 4 late toxicity. The 3-year rate of grade 3 to 4 late toxicity was 35%. The 3-year rate of freedom from local progression was 33%. The 3-year freedom from local progression rate was 47% in patients undergoing surgery and 21% in those not undergoing surgery (p = 0.057). The 3-year overall survival rate was 39%. The 3-year overall survival rate was 66% in patients undergoing surgery and 27% in those not undergoing surgery (p = 0.003). The 3-year overall survival rate was 53% in patients with a retreatment interval of >2 years and 21% in those with a retreatment interval of <or=2 years (p = 0.001). CONCLUSIONS Hyperfractionated, accelerated reirradiation was well tolerated, with low rates of acute toxicity and moderate rates of late toxicity. Reirradiation may help improve pelvic control in rectal cancer patients with a history of pelvic radiotherapy.
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Affiliation(s)
- Prajnan Das
- Department of Radiation Oncology, University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA.
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Hodges JC, Das P, Eng C, Reish AG, Beddar AS, Delclos ME, Krishnan S, Crane CH. Intensity-modulated radiation therapy for the treatment of squamous cell anal cancer with para-aortic nodal involvement. Int J Radiat Oncol Biol Phys 2009; 75:791-4. [PMID: 19231109 DOI: 10.1016/j.ijrobp.2008.11.021] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2008] [Revised: 11/03/2008] [Accepted: 11/14/2008] [Indexed: 11/15/2022]
Abstract
PURPOSE To determine the rates of toxicity, locoregional control, distant control, and survival in anal cancer patients with para-aortic nodal involvement, treated with intensity-modulated radiotherapy (IMRT) and concurrent chemotherapy at a single institution. METHODS AND MATERIALS Between 2001 and 2007, 6 patients with squamous cell anal cancer and para-aortic nodal involvement were treated with IMRT and concurrent infusional 5-fluorouracil and cisplatin. The primary tumor was treated with a median dose of 57.5 Gy (range, 54-60 Gy), involved para-aortic, pelvic, and inguinal lymph nodes were treated with a median dose of 55 Gy (range, 50.5-55 Gy), and noninvolved nodal regions were treated with a median dose of 45 Gy (range, 43.5-45 Gy). RESULTS After a median follow-up of 25 months, none of the patients had a recurrence at the primary tumor, pelvic/inguinal nodes, or para-aortic nodes, whereas 2 patients developed distant metastases to the liver. Four of the 6 patients are alive. The 3-year actuarial locoregional control, distant control, and overall survival rates were 100%, 56%, and 63%, respectively. Four of the 6 patients developed Grade 3 acute gastrointestinal toxicity during chemoradiation. CONCLUSIONS Intensity-modulated radiotherapy and concurrent chemotherapy could potentially serve as definitive therapy in anal cancer patients with para-aortic nodal involvement. Adjuvant chemotherapy may be indicated in these patients, as demonstrated by the distant failure rates. These patients need to be followed carefully because of the potential for treatment-related toxicities.
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Affiliation(s)
- Joseph C Hodges
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
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Park HC, Janjan NA, Mendoza TR, Lin EH, Vadhan-Raj S, Hundal M, Zhang Y, Delclos ME, Crane CH, Das P, Wang XS, Cleeland CS, Krishnan S. Temporal patterns of fatigue predict pathologic response in patients treated with preoperative chemoradiation therapy for rectal cancer. Int J Radiat Oncol Biol Phys 2009; 75:775-81. [PMID: 19231100 DOI: 10.1016/j.ijrobp.2008.11.027] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2008] [Revised: 11/18/2008] [Accepted: 11/18/2008] [Indexed: 11/18/2022]
Abstract
PURPOSE To investigate whether symptom burden before and during preoperative chemoradiation therapy (CRT) for rectal cancer predicts for pathologic tumor response. METHODS AND MATERIALS Fifty-four patients with T3/T4/N+ rectal cancers were treated on a Phase II trial using preoperative capecitabine and concomitant boost radiotherapy. Symptom burden was prospectively assessed before (baseline) and weekly during CRT by patient self-reported questionnaires, the MD Anderson Symptom Inventory (MDASI), and Brief Fatigue Inventory (BFI). Survival probabilities were estimated using the Kaplan-Meier method. Symptom scores according to tumor downstaging (TDS) were compared using Student's t tests. Logistic regression was used to determine whether symptom burden levels predicted for TDS. Lowess curves were plotted for symptom burden across time. RESULTS Among 51 patients evaluated for pathologic response, 26 patients (51%) had TDS. Fatigue, pain, and drowsiness were the most common symptoms. All symptoms increased progressively during treatment. Patients with TDS had lower MDASI fatigue scores at baseline and at completion (Week 5) of CRT (p = 0.03 for both) and lower levels of BFI "usual fatigue" at baseline. CONCLUSION Lower levels of fatigue at baseline and completion of CRT were significant predictors of pathologic tumor response gauged by TDS, suggesting that symptom burden may be a surrogate for tumor burden. The relationship between symptom burden and circulating cytokines merits evaluation to characterize the molecular basis of this phenomenon.
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Affiliation(s)
- Hee Chul Park
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030-4009, USA
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Kim MM, Rana V, Janjan NA, Das P, Phan AT, Delclos ME, Mansfield PF, Ajani JA, Crane CH, Krishnan S. Clinical benefit of palliative radiation therapy in advanced gastric cancer. Acta Oncol 2008; 47:421-7. [PMID: 17899453 DOI: 10.1080/02841860701621233] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [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: 10/22/2022]
Abstract
BACKGROUND Local progression of advanced gastric cancer often manifests as bleeding, dysphagia/obstruction, or pain. We evaluated the magnitude and durability of palliation with radiotherapy (RT). MATERIAL AND METHODS From 1996 to 2004, 37 gastric cancer patients were treated with palliative RT (median dose 35 Gy in 14 fractions). Nearly two-thirds of all patients received concurrent chemoradiation therapy (CRT). Index pre-treatment symptoms were gastric bleeding, dysphagia/obstruction, and pain in 54%, 43%, and 19% of patients, respectively. RESULTS The rates of control for bleeding, dysphagia/obstruction, and pain were 70% (14/20), 81% (13/16), and 86% (6/7), respectively. These symptoms were controlled without additional interventions for a median of 70%, 81%, and 49% of the patient's remaining life, respectively. Patients receiving CRT had a trend towards better median overall survival than those receiving RT alone (6.7 vs. 2.4 months, p=0.08). Lower (<41 Gy) biologically effective dose (BED, assuming an alpha/beta ratio of 10 for early responding tissues) predicted for poorer local control (6-month local control 70% vs. 100%, p=0.05) while T4 tumors had a trend towards inferior local control (6-month LC 56% vs. 100%, p=0.06). DISCUSSION Palliative RT controls symptoms for most of the remaining life in the majority of gastric cancer patients. The role of a higher dose of RT (BED >or=41 Gy), especially in patients with T4 tumors, remains to be established. In order to accurately define the role for radiotherapy in palliation of these symptoms, prospective randomized studies need to be conducted.
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Affiliation(s)
- Michelle M Kim
- Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas 77030, USA
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Kim MM, Mansfield PF, Das P, Janjan NA, Badgwell BD, Phan AT, Delclos ME, Maru D, Ajani JA, Crane CH, Krishnan S. Chemoradiation therapy for potentially resectable gastric cancer: clinical outcomes among patients who do not undergo planned surgery. Int J Radiat Oncol Biol Phys 2008; 71:167-72. [PMID: 18406886 DOI: 10.1016/j.ijrobp.2007.09.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [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: 07/31/2007] [Revised: 09/21/2007] [Accepted: 09/21/2007] [Indexed: 12/24/2022]
Abstract
PURPOSE We retrospectively analyzed treatment outcomes among resectable gastric cancer patients treated preoperatively with chemoradiation therapy (CRT) but rendered ineligible for planned surgery because of clinical deterioration or development of overt metastatic disease. METHODS AND MATERIALS Between 1996 and 2004, 39 patients with potentially resectable gastric cancer received preoperative CRT but failed to undergo surgery. At baseline clinical staging, 33 (85%) patients had T3-T4 disease, and 27 (69%) patients had nodal involvement. Most patients received 45 Gy of radiotherapy with concurrent 5-fluorouracil-based chemotherapy. Twenty-one patients underwent induction chemotherapy before CRT. Actuarial times to local control (LC), distant control (DC), and overall survival (OS) were calculated by the Kaplan-Meier method. RESULTS The cause for surgical ineligibility was development of metastatic disease (28 patients, 72%; predominantly peritoneal, 18 patients), poor performance status (5 patients, 13%), patient/physician preference (4 patients, 10%), and treatment-related death (2 patients, 5%). With a median follow-up of 8 months (range, 1-95 months), actuarial 1-year LC, DC, and OS were 46%, 12%, and 36%, respectively. Median LC and OS were 11.0 and 10.1 months, respectively. CONCLUSIONS Patients with potentially resectable gastric cancer treated with preoperative CRT are found to be ineligible for surgery principally because of peritoneal progression. Patients who are unable to undergo planned surgery have outcomes comparable to that of patients with advanced gastric cancer treated with chemotherapy alone. CRT provides durable LC for the majority of the remaining life of these patients.
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Affiliation(s)
- Michelle M Kim
- Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA
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Abstract
Intraoperative radiation therapy (IORT) is a treatment option that directly irradiates a surgically exposed tumor or tumor bed while preventing radiation exposure of normal tissues. This article discusses the high-dose-rate intraoperative radiation therapy (HDR-IORT) technique by reviewing the roles of IORT team members, discussing needed equipment and supplies, describing quality assurance processes, explaining the HDR-IORT treatment delivery procedure, and reviewing the post-treatment phase.
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Affiliation(s)
- Song Gao
- Department of Radiation Physics at the University of Texas, MD Anderson Cancer Center, Houston, TX, USA
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Yu TK, Bhosale PR, Crane CH, Iyer RB, Skibber JM, Rodriguez-Bigas MA, Feig BW, Chang GJ, Eng C, Wolff RA, Janjan NA, Delclos ME, Krishnan S, Das P. Patterns of locoregional recurrence after surgery and radiotherapy or chemoradiation for rectal cancer. Int J Radiat Oncol Biol Phys 2008; 71:1175-80. [PMID: 18207667 DOI: 10.1016/j.ijrobp.2007.11.018] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2007] [Revised: 10/25/2007] [Accepted: 11/09/2007] [Indexed: 12/14/2022]
Abstract
PURPOSE To identify patterns of locoregional recurrence in patients treated with surgery and preoperative or postoperative radiotherapy or chemoradiation for rectal cancer. METHODS AND MATERIALS Between November 1989 and October 2001, 554 patients with rectal cancer were treated with surgery and preoperative (85%) or postoperative (15%) radiotherapy, with 95% receiving concurrent chemotherapy. Among these patients, 46 had locoregional recurrence as the first site of failure. Computed tomography images showing the site of recurrence and radiotherapy simulation films were available for 36 of the 46 patients. Computed tomography images were used to identify the sites of recurrence and correlate the sites to radiotherapy fields in these 36 patients. RESULTS The estimated 5-year locoregional control rate was 91%. The 36 patients in the study had locoregional recurrences at 43 sites. There were 28 (65%) in-field, 7 (16%) marginal, and 8 (19%) out-of-field recurrences. Among the in-field recurrences, 15 (56%) occurred in the low pelvis, 6 (22%) in the presacral region, 4 (15%) in the mid-pelvis, and 2 (7%) in the high pelvis. Clinical T stage, pathologic T stage, and pathologic N stage were significantly associated with the risk of in-field locoregional recurrence. The median survival after locoregional recurrence was 24.6 months. CONCLUSIONS Patients treated with surgery and radiotherapy or chemoradiation for rectal cancer had a low risk of locoregional recurrence, with the majority of recurrences occurring within the radiation field. Because 78% of in-field recurrences occur in the low pelvic and presacral regions, consideration should be given to including the low pelvic and presacral regions in the radiotherapy boost field, especially in patients at high risk of recurrence.
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Affiliation(s)
- Tse-Kuan Yu
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA
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Reed VK, Krishnan S, Mansfield PF, Bhosale PR, Kim M, Das P, Janjan NA, Delclos ME, Lowy AM, Feig BW, Pisters PWT, Ajani JA, Crane CH. Incidence, natural history, and patterns of locoregional recurrence in gastric cancer patients treated with preoperative chemoradiotherapy. Int J Radiat Oncol Biol Phys 2007; 71:741-7. [PMID: 18164837 DOI: 10.1016/j.ijrobp.2007.10.030] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2007] [Revised: 10/15/2007] [Accepted: 10/16/2007] [Indexed: 01/02/2023]
Abstract
PURPOSE To retrospectively determine the incidence and patterns (in-field, marginal, or out-of-field) of locoregional gastric cancer recurrence in patients who received preoperative chemoradiotherapy and to determine the outcome in these patients. METHODS AND MATERIALS Between 1994 and 2004, 149 patients with gastric carcinoma were treated according to institutional protocols with preoperative chemoradiotherapy. Ultimately, 105 patients had an R0 resection. Of these 105 patients, 65 received preoperative chemotherapy followed by chemoradiotherapy and 40 received preoperative chemoradiotherapy. Most (96%) of these patients received 5-fluorouracil-based chemotherapy during radiotherapy, and the median radiation dose was 45 Gy. We retrospectively identified and classified the patterns of locoregional recurrence. RESULTS The 3-year actuarial incidence of locoregional recurrence was 13%, with locoregional disease recurring as any part of the failure pattern in 14 patients. Most (64%) of the evaluable locoregional recurrences were in-field. Of the 4 patients with a marginal recurrence, 2 had had inadequate coverage of the regional nodal volumes on their oblique fields. The pathologic complete response rate was 23%. A pathologic complete response was the only statistically significant predictor of locoregional control. CONCLUSION Patients with gastric cancer who received preoperative chemoradiotherapy had low rates of locoregional recurrence. This strategy merits prospective multi-institutional and randomized evaluation.
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Affiliation(s)
- Valerie K Reed
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Krishnan S, Rana V, Evans DB, Varadhachary G, Das P, Bhatia S, Delclos ME, Janjan NA, Wolff RA, Crane CH, Pisters PW. Role of adjuvant chemoradiation therapy in adenocarcinomas of the ampulla of vater. Int J Radiat Oncol Biol Phys 2007; 70:735-43. [PMID: 17980502 DOI: 10.1016/j.ijrobp.2007.07.2327] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2007] [Revised: 07/02/2007] [Accepted: 07/04/2007] [Indexed: 12/31/2022]
Abstract
PURPOSE The role of adjuvant chemoradiation therapy (CRT) in the treatment of ampullary cancers remains undefined. We retrospectively compared treatment outcomes in patients treated with pancreaticoduodenectomy alone versus those who received additional adjuvant CRT. METHODS AND MATERIALS Between May 1990 and January 2006, 54 of 96 patients with ampullary adenocarcinoma who underwent potentially curative pancreaticoduodenectomy also received adjuvant CRT. The median preoperative radiation dose was 45 Gy (range, 30-50.4 Gy) and median postoperative dose was 50.4 Gy (range, 45-55.8 Gy). Concurrent chemotherapy included primarily 5-fluorouracil (52%) and capecitabine (43%). Median follow-up was 31 months. Univariate and multivariate statistical methodologies were used to determine significant prognostic factors for local control (LC), distant control (DC), and overall survival (OS). RESULTS Actuarial 5-year LC, DC, and OS were 77%, 69%, and 64%, respectively. On univariate analysis, age, gender, race/ethnicity, tumor grade, use of adjuvant treatment, and sequencing of adjuvant therapy were not significantly associated with LC, DC, or OS. However, on univariate analysis, T3/T4 tumor stage was prognostic for poorer LC and OS (p = 0.02 and p < 0.001, respectively); node-positive disease was prognostic for poorer LC (p = 0.03). On multivariate analysis, T3/T4 tumor stage was independently prognostic for decreased OS (p = 0.002). Among these patients (n = 34), those who received adjuvant CRT had a trend toward improved OS (median, 35.2 vs. 16.5 months; p = 0.06). CONCLUSIONS Ampullary cancers have a distinctly better treatment outcome than pancreatic adenocarcinomas. Higher primary tumor stage (T3/T4), an independent adverse risk factor for poorer treatment outcomes, may warrant the addition of adjuvant CRT to pancreaticoduodenectomy.
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Affiliation(s)
- Sunil Krishnan
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030-4009, USA.
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Krishnan S, Rana V, Janjan NA, Varadhachary GR, Abbruzzese JL, Das P, Delclos ME, Gould MS, Evans DB, Wolff RA, Crane CH. Induction chemotherapy selects patients with locally advanced, unresectable pancreatic cancer for optimal benefit from consolidative chemoradiation therapy. Cancer 2007; 110:47-55. [PMID: 17538975 DOI: 10.1002/cncr.22735] [Citation(s) in RCA: 222] [Impact Index Per Article: 13.1] [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: 12/17/2022]
Abstract
BACKGROUND The current study was conducted to determine whether there were differences in outcome for patients with unresectable locally advanced pancreatic cancer (LAPC) who received treatment with chemoradiation therapy (CR) versus induction chemotherapy followed by CR (CCR). METHODS Between December 1993 and July 2005, 323 consecutive patients with LAPC were treated at the authors' institution with radiotherapy and concurrent gemcitabine or fluoropyrimidine chemotherapy. Two hundred forty-seven patients received CR as initial treatment, and 76 patients received a median of 2.5 months of gemcitabine-based induction chemotherapy prior to CR. Most patients received a radiation dose of 30 grays in 10 fractions (85%) concurrently with infusional 5-fluorouracil (41%), gemcitabine (39%), or capecitabine (20%). RESULTS The median follow-up was 5.5 months (range, 1-63 months). For all patients, the median overall survival (OS) and progression-free survival (PFS) were 9 months and 5 months, respectively, and the 2-year estimated OS and PFS rates were 9% and 5%, respectively. The median OS and PFS were 8.5 months and 4.2 months, respectively, in the CR group and 11.9 months and 6.4 months, respectively, in the CCR group (both P < .001). The median times to local and distant progression were 6.0 months and 5.6 months, respectively, in the CR group and 8.9 and 9.5 months, respectively, in the CCR group (P = .003 and P = .007, respectively). There was no significant difference in the patterns of failure with the use of induction chemotherapy. CONCLUSIONS The results from this analysis indicated that, by excluding patients with rapid distant progression, induction chemotherapy may select patients with LAPC for optimal benefit from consolidative CR. The authors believe that this strategy of enriching the population of patients who receive a locoregional treatment modality merits prospective randomized evaluation.
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Affiliation(s)
- Sunil Krishnan
- Department of Radiation Oncology, the University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030-4009, USA.
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Das P, Bhatia S, Eng C, Ajani JA, Skibber JM, Rodriguez-Bigas MA, Chang GJ, Bhosale P, Delclos ME, Krishnan S, Janjan NA, Crane CH. Predictors and patterns of recurrence after definitive chemoradiation for anal cancer. Int J Radiat Oncol Biol Phys 2007; 68:794-800. [PMID: 17379452 DOI: 10.1016/j.ijrobp.2006.12.052] [Citation(s) in RCA: 120] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2006] [Revised: 12/20/2006] [Accepted: 12/22/2006] [Indexed: 10/23/2022]
Abstract
PURPOSE To evaluate patterns of locoregional failure, and predictors of recurrence and survival in patients treated with chemoradiation for anal cancer. METHODS AND MATERIALS Between September 1992 and August 2004, 167 patients with nonmetastatic squamous cell anal carcinoma were treated with definitive chemoradiation. The median dose of radiotherapy was 5500 cGy. Concurrent chemotherapy was given with 5-fluorouracil and cisplatin in 117 patients, 5-fluorouracil and mitomycin C in 24 patients, and other regimens in 26 patients. RESULTS The estimated 3-year rates of locoregional control, distant control, disease-free survival, and overall survival were 81%, 88%, 67%, and 84%, respectively. Multivariate analysis showed that higher T stage and N stage independently predicted for a higher rate of locoregional failure; higher N stage and basaloid subtype independently predicted for a higher rate of distant metastasis; and higher N stage and positive human immunodeficiency virus status independently predicted for a lower rate of overall survival. Among the patients who had locoregional failure, 18 (75%) had failure involving the anus or rectum, 5 (21%) had other pelvic recurrences, and 1 (4%) had inguinal recurrence. The 5 pelvic recurrences all occurred in patients with the superior border of the radiotherapy field at the bottom of the sacroiliac joint. CONCLUSIONS Trials of more aggressive and innovative locoregional and systemic therapies are warranted in high-risk patients, based on their T and N stages. The majority of locoregional failures involve the anus and rectum, whereas inguinal recurrences occur rarely. Placing the superior border of the radiotherapy field at L5/S1 could potentially reduce pelvic recurrences.
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Affiliation(s)
- Prajnan Das
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA.
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Krishnan S, Lin EH, Gunn GB, Chandra A, Beddar AS, Briere TM, Das P, Delclos ME, Janjan NA, Crane CH. Conformal Radiotherapy of the Dominant Liver Metastasis. Am J Clin Oncol 2006; 29:562-7. [PMID: 17148992 DOI: 10.1097/01.coc.0000236210.41199.91] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [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
OBJECTIVES To evaluate the safety and efficacy of conformal radiotherapy (RT) of the dominant liver metastasis as palliative treatment of patients with unresectable colorectal cancer liver metastases. METHODS We retrospectively reviewed the hospital and RT records of 17 patients with unresectable colorectal liver metastases who had been treated with palliative RT to the dominant liver metastasis at our institution. RESULTS The median size of the dominant liver metastasis was 10 cm (range, 3-19 cm). Twelve patients (71%) had evidence of extrahepatic disease. A median of 2 (range, 0-4) prior chemotherapy regimens had been administered. Median radiation dose was 42 Gy (range, 7.5-72 Gy). Concurrent chemotherapy included celecoxib in 1 (6%), capecitabine in 6 (35%), and both agents in 9 (53%) patients. Frequencies of acute diarrhea, nausea, vomiting, fatigue, hand-foot syndrome, and neutropenia were 29%, 47%, 6%, 29%, 7%, and 0%, respectively (all grade 2 or lower; no grade 3 toxicities). No late toxicities were noted. With a median follow-up time of 9.2 months, the median actuarial overall survival time from RT was 12.6 months (95% confidence interval [CI]: 3.3-40.9 months). The actuarial in-field local control rate was 62% at 6 months. The median actuarial time to in-field, out-of-field hepatic and distant progression were 6.8, 3.9, and 4.1 month, respectively (95% CIs, 3.9-15.8, 1.8-6.3, and 1.8-11.5 months, respectively). CONCLUSIONS Conformal RT to the dominant liver metastasis as palliative therapy for unresectable colorectal cancer liver metastases has an acceptable toxicity profile and may improve survival. This approach merits further exploration.
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Affiliation(s)
- Sunil Krishnan
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
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Krishnan S, Janjan NA, Skibber JM, Rodriguez-Bigas MA, Wolff RA, Das P, Delclos ME, Chang GJ, Hoff PM, Eng C, Brown TD, Crane CH, Feig BW, Morris J, Vadhan-Raj S, Hamilton SR, Lin EH. Phase II study of capecitabine (Xeloda®) and concomitant boost radiotherapy in patients with locally advanced rectal cancer. Int J Radiat Oncol Biol Phys 2006; 66:762-71. [PMID: 17011451 DOI: 10.1016/j.ijrobp.2006.05.063] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2006] [Revised: 05/25/2006] [Accepted: 05/30/2006] [Indexed: 12/27/2022]
Abstract
PURPOSE The aim of this study was to determine the efficacy of capecitabine (Xeloda), an oral fluoropyrimidine, as a radiosensitizer in the neoadjuvant treatment of locally advanced rectal cancer (LARC). METHODS AND MATERIALS We conducted a phase II study of capecitabine (825 mg/m2 orally, twice daily continuous) with radiotherapy (52.5 Gy/30 fractions to the primary tumor and perirectal nodes) in 54 patients with LARC (node-negative > or = T3 or any node-positive tumor) staged by endoscopic ultrasound (EUS). The primary endpoint was pathologic response rate; secondary endpoints included toxicity profiles and survival parameters. RESULTS Of the 54 patients (median age, 56.7 years; range, 21.3-78.7 years; male:female ratio, 1.7; Eastern Cooperative Oncology Group performance status 0-1: 100%), 51 patients (94%) had T3N0 or T3N1 disease by EUS. Surgery was not performed in 3 patients; 2 of these patients had metastatic disease, and the third patient refused after a complete clinical response. Of the 51 patients evaluable for pathologic response, 9 patients (18%) achieved complete response, and 12 patients (24%) had microscopic residual disease (< 10% viable cells). In addition, 26 patients of all 54 patients (51%) achieved T-downstaging, and 15 patients of 29 patients (52%) achieved N-downstaging. Grade 3/4 toxicities were radiation dermatitis (9%) and diarrhea (2%). Sphincter preservation rate for tumor < or = 5 cm from the anal verge was 67% (18/27). CONCLUSION This regimen of radiotherapy plus capecitabine is well tolerated and is more convenient than protracted venous infusion of 5-FU. The pathologic response rate is comparable to our previous experience using protracted venous infusion 5-FU for LARC.
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Affiliation(s)
- Sunil Krishnan
- Department of Radiation Oncology, The University of Texas, M.D. Anderson Cancer Center, Houston, TX, USA
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Das P, Wolff RA, Abbruzzese JL, Varadhachary GR, Evans DB, Vauthey JN, Baschnagel A, Delclos ME, Krishnan S, Janjan NA, Crane CH. Concurrent capecitabine and upper abdominal radiation therapy is well tolerated. Radiat Oncol 2006; 1:41. [PMID: 17062148 PMCID: PMC1634749 DOI: 10.1186/1748-717x-1-41] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2006] [Accepted: 10/24/2006] [Indexed: 12/27/2022] Open
Abstract
We retrospectively evaluated acute toxicity in 88 patients that were treated with capecitabine and concurrent radiotherapy to the upper abdomen. These patients included 28 (32%) with pancreatic adenocarcinoma, 18 (20%) with cholangiocarcinoma, 11 (13%) with ampullary carcinoma, 11 (13%) with other primary tumors, 14 (16%) with liver metastases, and 6 (7%) with metastases at other sites. The median dose of radiotherapy was 45 Gy (range 30–72 Gy). The median dose of capecitabine was 850 mg/m2 twice daily, with 77% receiving 800–900 mg/m2 twice daily. The highest grade of acute toxicity was Common Terminology Criteria (CTC) grade 0 in 5 (6%), grade 1 in 60 (68%), grade 2 in 18 (20%), and grade 3 in 5 (6%) patients. No patient had CTC grade 4 toxicity. The most common grade 2 toxicities were nausea, hand-foot syndrome, fatigue, anorexia and diarrhea. The grade 3 toxicities included nausea, vomiting and fatigue. Three patients (3%) required hospitalization due to grade 3 acute toxicity. Capecitabine was interrupted, discontinued or given at an adjusted dose in 13 (15%) patients because of acute toxicity. Therefore, capecitabine and concurrent radiotherapy to the upper abdomen appears to be well tolerated. Capecitabine may serve as an alternative to bolus or infusional 5-FU during chemoradiation for upper gastrointestinal malignancies.
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Affiliation(s)
- Prajnan Das
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, USA
| | - Robert A Wolff
- Department of Gastrointestinal Medical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, USA
| | - James L Abbruzzese
- Department of Gastrointestinal Medical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, USA
| | - Gauri R Varadhachary
- Department of Gastrointestinal Medical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, USA
| | - Douglas B Evans
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, USA
| | - Jean Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, USA
| | - Andrew Baschnagel
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, USA
| | - Marc E Delclos
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, USA
| | - Sunil Krishnan
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, USA
| | - Nora A Janjan
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, USA
| | - Christopher H Crane
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, USA
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Das P, Lin EH, Bhatia S, Skibber JM, Rodriguez-Bigas MA, Feig BW, Chang GJ, Hoff PM, Eng C, Wolff RA, Delclos ME, Krishnan S, Janjan NA, Crane CH. Preoperative chemoradiotherapy with capecitabine versus protracted infusion 5-fluorouracil for rectal cancer: a matched-pair analysis. Int J Radiat Oncol Biol Phys 2006; 66:1378-83. [PMID: 17056196 DOI: 10.1016/j.ijrobp.2006.07.1374] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2006] [Revised: 07/25/2006] [Accepted: 07/25/2006] [Indexed: 12/27/2022]
Abstract
PURPOSE To retrospectively compare the acute toxicity, pathologic response, relapse rates, and survival in rectal cancer patients treated with preoperative radiotherapy (RT) and either concurrent capecitabine or concurrent protracted infusion 5-fluorouracil (5-FU). METHODS Between June 2001 and February 2004, 89 patients with nonmetastatic rectal adenocarcinoma were treated with preoperative RT and concurrent capecitabine, followed by mesorectal excision. These patients were individually matched by clinical T and N stage (as determined by endoscopic ultrasound and CT scans) with 89 control patients treated with preoperative RT and concurrent protracted infusion 5-FU between September 1997 and August 2002. RESULTS In each group, 5 patients (6%) had Grade 3-4 toxicity during chemoradiotherapy. The pathologic complete response rate was 21% with capecitabine and 12% with protracted infusion 5-FU (p = 0.19). Of the 89 patients in the capecitabine group and 89 in the 5-FU group, 46 (52%) and 55 (62%), respectively, had downstaging of the T stage after chemoradiotherapy (p = 0.20). The estimated 3-year local control (p = 0.15), distant control (p = 0.86), and overall survival (p = 0.12) rate was 94.4%, 86.3%, and 89.8% for patients treated with capecitabine and 98.6%, 86.6%, and 96.4% for patients treated with protracted infusion 5-FU, respectively. CONCLUSION Preoperative concurrent capecitabine and concurrent protracted infusion 5-FU were both well tolerated, with similar, low rates of Grade 3-4 acute toxicity. No significant differences were seen in the pathologic response, local and distant recurrence, or overall survival among patients treated with preoperative RT and concurrent capecitabine compared with those treated with RT and concurrent protracted infusion 5-FU.
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Affiliation(s)
- Prajnan Das
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
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Das P, Skibber JM, Rodriguez-Bigas MA, Feig BW, Chang GJ, Hoff PM, Eng C, Wolff RA, Janjan NA, Delclos ME, Krishnan S, Levy LB, Ellis LM, Crane CH. Clinical and pathologic predictors of locoregional recurrence, distant metastasis, and overall survival in patients treated with chemoradiation and mesorectal excision for rectal cancer. Am J Clin Oncol 2006; 29:219-24. [PMID: 16755173 DOI: 10.1097/01.coc.0000214930.78200.4a] [Citation(s) in RCA: 128] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To identify predictive factors for locoregional recurrence (LR), distant metastasis (DM), and overall survival (OS) in patients treated with chemoradiation and surgery for rectal cancer. METHODS Between 1989 and 2001, 470 patients with rectal cancer were treated with preoperative (89%) or postoperative (11%) chemoradiation and mesorectal excision. Median radiation dose was 45 Gy; 97% received concurrent infusional 5-fluorouracil, and 65% received adjuvant chemotherapy. Median follow-up interval was 5.7 years. RESULTS The 5-year rates of freedom from LR, freedom from DM, and OS were 90%, 79%, and 80%, respectively. On univariate analysis, significant predictors of LR were female sex, clinical T stage, pathologic T and N stages, and positive radial margin. Significant univariate predictors of DM were circumferential extent of tumor, tumor immobility, lymphovascular invasion, perineural involvement, and pathologic T and N stages. Significant univariate predictors of lower OS were age, circumferential extent of tumor, shorter distance from anal verge, tumor size, tumor immobility, anal canal involvement, lymphovascular invasion, perineural involvement, positive radial margin, and pathologic T and N stages. On Cox multivariate analysis, female sex and pathologic T and N stages independently predicted for LR; pathologic T and N stages independently predicted for DM; and age, circumferential extent of tumor, positive radial margin, and pathologic T and N stages independently predicted for lower OS. CONCLUSIONS Pathologic T and N stages significantly predicted for all 3 end points (LR, DM and OS) on multivariate analysis. Investigations of more aggressive adjuvant chemotherapy appear warranted for pathologic stage T3/T4 or N1/2 rectal cancer.
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Affiliation(s)
- Prajnan Das
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA.
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Crane CH, Ellis LM, Abbruzzese JL, Amos C, Xiong HQ, Ho L, Evans DB, Tamm EP, Ng C, Pisters PWT, Charnsangavej C, Delclos ME, O'Reilly M, Lee JE, Wolff RA. Phase I trial evaluating the safety of bevacizumab with concurrent radiotherapy and capecitabine in locally advanced pancreatic cancer. J Clin Oncol 2006; 24:1145-51. [PMID: 16505434 DOI: 10.1200/jco.2005.03.6780] [Citation(s) in RCA: 181] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
PURPOSE To study the safety of bevacizumab with capecitabine-based chemoradiotherapy. PATIENTS AND METHODS Patients with inoperable pancreatic adenocarcinoma received bevacizumab 2 weeks before radiotherapy (50.4 Gy treating the primary tumor and gross adenopathy), every 2 weeks during radiotherapy (12 patients each at 2.5, 5.0, 7.5, and 10 mg/kg), and after radiotherapy until disease progression. Capecitabine was administered on days 14 through 52 (650 mg/m2 orally twice daily for the first six patients; 825 mg/m2 for the remaining patients). RESULTS Significant acute gastrointestinal (43% grade 2; 4% grade 3), hand and foot syndrome (21% grade 2), and transient hematologic (8% grade 3 or greater) events were uncommon with protocol mandated dose reductions of capecitabine grade 2 toxicity (43% of patients). Among the first 30 patients treated, three patients had tumor-associated bleeding duodenal ulcers, and one had a contained duodenal perforation. No additional bleeding events occurred among the final 18 patients after patients with duodenal involvement by tumor were excluded. Nine (20%) of 46 assessable patients had confirmed partial responses until distant progression for a median of 6.2 months. Four patients have undergone pancreaticoduodenectomy without perioperative complication. The median survival was 11.6 months (95% CI, 9.6 to 13.6), from the start of protocol therapy. CONCLUSION Concurrent bevacizumab did not significantly increase the acute toxicity of a relatively well-tolerated chemoradiotherapy regimen. However, ulceration and bleeding in the radiation field possibly related to bevacizumab occurred when tumor involved the duodenal mucosa. The encouraging efficacy end points suggest that the further study of bevacizumab with chemoradiotherapy is warranted.
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Affiliation(s)
- Christopher H Crane
- Department of Radiation Oncology, Unit 97, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA.
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Beddar AS, Krishnan S, Briere TM, Wang X, Delclos ME, Ballo MT, Das P, Gould S, Horton JL, Crane CH. The optimization of dose delivery for intraoperative high-dose-rate radiation therapy using curved HAM applicators. Radiother Oncol 2006; 78:207-12. [PMID: 16376445 DOI: 10.1016/j.radonc.2005.11.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2005] [Revised: 11/29/2005] [Accepted: 11/29/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND PURPOSE To determine the effect of the curvature of Harrison-Anderson-Mick applicators on the dose distribution in high-dose-rate intraoperative radiation therapy (HDR-IORT). MATERIAL AND METHODS Treatment planning was performed with flat applicators using (192)Ir as the radioactive source, and dwell times were optimized using dose-point optimization techniques. These optimized dwell times were then used for the curved applicators, and the dose distributions that would actually be delivered to patients were determined. RESULTS The dose directly below the central catheter was strongly dependent on the curvature of the applicator. Steep parabolic curves caused underdoses of as much as 19% at a point 1cm from the convex side of the applicator. The rate of dose reduction with increasing distance from the applicator surface was also a function of the curvature of the applicator. CONCLUSIONS The curvature of the applicator profoundly affects dosimetry and can be exploited to optimize coverage of the target during HDR-IORT procedures. To ensure accurate dose delivery, these dose perturbations must be accounted for in the planning process. We recommend maintaining a dosimetry atlas of various applicator sizes and curvatures in addition to one for flat applicators.
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Affiliation(s)
- A Sam Beddar
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
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Krishnan S, Rana V, Janjan NA, Abbruzzese JL, Gould MS, Das P, Delclos ME, Palla S, Guha S, Varadhachary G, Evans DB, Wolff RA, Crane CH. Prognostic factors in patients with unresectable locally advanced pancreatic adenocarcinoma treated with chemoradiation. Cancer 2006; 107:2589-96. [PMID: 17083124 DOI: 10.1002/cncr.22328] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [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: 11/05/2022]
Abstract
BACKGROUND Although patients with locally advanced pancreatic cancer (LAPC) have an extremely poor prognosis, they are a heterogeneous group. Prognostic factors are inadequately defined for disease-free survival and overall survival in patients with LAPC who are receiving chemoradiation, so more definitive prognostic factors would be very useful for designing clinical trials. METHODS Between December 1993 and July 2005, 247 patients with nonmetastatic LAPC were treated at M. D. Anderson Cancer Center (Houston, Tex) with concurrent chemoradiation (CRT). Median radiation dose was 30 Gy (range, 15-52.2 Gy). Radiosensitizers included 5-fluorouracil (54%), gemcitabine (33%), and capecitabine (13%). Actuarial univariate and multivariate statistical methods were used to determine significant prognostic factors for disease-free survival and overall survival. RESULTS Median follow-up was 4.3 months (range, 1-63 months). Median disease-free survival and overall survival were 4.2 months and 8.5 months, respectively. On univariate analysis, prognostic factors for improved disease-free survival were a Karnofsky performance scale (KPS) status of >80 (P < .01) and a hemoglobin (Hgb)level at presentation of >/=12 (P = .03). On multivariate analysis, KPS was the only independent prognostic factor for disease-free survival. Median disease-free survival was 4.9 months among patients with a KPS score of >80 and was 3.9 months among those with a KPS score of </=80. On univariate analysis, prognostic factors for improved overall survival were an Hgb level of >/=12 (P = .02), KPS>80 (P < .001), and <5% weight loss (P = .03). On multivariate analysis, Hgb and KPS were independent prognostic factors for overall survival. CONCLUSIONS In the current study, KPS score was an independent prognostic factor for disease-free and overall survival among patients treated with chemoradiation for LAPC. The pretreatment Hgb level was an additional independent prognostic factor for overall survival.
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Affiliation(s)
- Sunil Krishnan
- Department of Radiation Oncology, The University of Texas, M. D. Anderson Cancer Center, Houston, Texas, USA.
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Beddar AS, Briere TM, Krishnan S, Delclos ME, Crane CH, Rodriguez-Bigas MA, Skibber JM, Gillin MT. SU-FF-T-242: Evaluation of Implantable MOSFET Dosimeters for Conventional and Intraoperative Radiation Therapy. Med Phys 2005. [DOI: 10.1118/1.1997970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Bonnen M, Crane C, Vauthey JN, Skibber J, Delclos ME, Rodriguez-Bigas M, Hoff PM, Lin E, Eng C, Wong A, Janjan NA, Feig BW. Long-term results using local excision after preoperative chemoradiation among selected T3 rectal cancer patients. Int J Radiat Oncol Biol Phys 2004; 60:1098-105. [PMID: 15519780 DOI: 10.1016/j.ijrobp.2004.04.062] [Citation(s) in RCA: 134] [Impact Index Per Article: 6.7] [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: 11/04/2003] [Revised: 04/16/2004] [Accepted: 04/20/2004] [Indexed: 01/23/2023]
Abstract
PURPOSE To assess the pelvic failure among patients with T3 rectal cancer treated with local excision after preoperative chemoradiation. METHODS AND MATERIALS Between January 1990 and June 2002, 431 patients with clinically staged T3 rectal cancer were treated with preoperative chemoradiation followed by surgical resection. Full-thickness local excision [Kraske (n = 3) or a transanal excision (n = 23)] was performed in 26 patients because of patient refusal of abdominoperineal resection (APR) (n = 13), medical comorbidity (n = 4), physician preference after a complete clinical response (n = 6), and other reasons (n = 3). All patients were treated with continuous-infusion 5-fluorouracil (5-FU) (300 mg/m(2) Monday to Friday) and concomitant pelvic radiation (45 Gy in 25 fractions with a 3-field belly board technique). Ten local-excision patients received a concomitant boost during the last week of therapy (1.5-Gy second daily fractions) for a total dose of 52.5 Gy. Similar preoperative treatment was followed by total mesorectal excision in 405 patients. Among the local-excision patients, the median tumor size was 3.5 cm (range, 0.5-7 cm). Well-differentiated or moderately-differentiated histology was present in all but 3 cases, and endoscopic ultrasound staging examination was performed in 25 of 26 patients. Based on CT findings, 1 patient was node positive. The median circumference involved by tumor was 33%, (20%-75%). The median distance from the anal verge was 3 cm (range, 1-8 cm). RESULTS The mean follow-up was 46 months (range, 5-109 months) in the local-excision group. In the local-excision group, 19 of 26 patients had only residual scarring noted on digital rectal examination and rigid proctoscopy before surgery. Fourteen patients (54%) had a complete histologic response to chemoradiation, 9 patients (35%) had microscopic residual disease, and 3 patients (12%) had gross residual disease. Two intrapelvic recurrences occurred at 76 and 20 months among the 26 patients treated with local excision (6% 5-year actuarial pelvic recurrence rate). This rate compared with an 8% 5-year actuarial pelvic recurrence rate among T3 patients treated with mesorectal excision and a 6% pelvic recurrence rate in the subgroup of mesorectal-excision patients with a complete clinical response to preoperative chemoradiation. One additional local-excision patient recurred in an inguinal lymph node after local excision and subsequently died of metastatic disease. A total of 2 local-excision patients died of metastatic rectal cancer. Actuarial overall survival at 5 years was 86% in the local-excision group compared with 81% among mesorectal-excision patients (p = NS), and 85% in patients with a complete clinical response to chemoradiation followed by mesorectal excision by APR or LAR (p = NS). CONCLUSIONS In an experience stimulated by patient refusal of APR, highly selected patients who responded well to conventional external-beam radiotherapy (CXRT) were selected to undergo local excision. Most of these patients had pathologic complete response. Local control and survival rates are comparable to those achieved with chemoradiation followed by mesorectal excision. This strategy should be prospectively studied in a group of patients with low rectal cancer who have no clinical evidence of tumor after chemoradiation.
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Affiliation(s)
- Mark Bonnen
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
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