1
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Ene CI, Abi Faraj C, Beckham TH, Weinberg JS, Andersen CR, Haider AS, Rao G, Ferguson SD, Alvarez-Brenkenridge CA, Kim BYS, Heimberger AB, McCutcheon IE, Prabhu SS, Wang CM, Ghia AJ, McGovern SL, Chung C, McAleer MF, Tom MC, Perni S, Swanson TA, Yeboa DN, Briere TM, Huse JT, Fuller GN, Lang FF, Li J, Suki D, Sawaya RE. Response of treatment-naive brain metastases to stereotactic radiosurgery. Nat Commun 2024; 15:3728. [PMID: 38697991 PMCID: PMC11066027 DOI: 10.1038/s41467-024-47998-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 04/15/2024] [Indexed: 05/05/2024] Open
Abstract
With improvements in survival for patients with metastatic cancer, long-term local control of brain metastases has become an increasingly important clinical priority. While consensus guidelines recommend surgery followed by stereotactic radiosurgery (SRS) for lesions >3 cm, smaller lesions (≤3 cm) treated with SRS alone elicit variable responses. To determine factors influencing this variable response to SRS, we analyzed outcomes of brain metastases ≤3 cm diameter in patients with no prior systemic therapy treated with frame-based single-fraction SRS. Following SRS, 259 out of 1733 (15%) treated lesions demonstrated MRI findings concerning for local treatment failure (LTF), of which 202 /1733 (12%) demonstrated LTF and 54/1733 (3%) had an adverse radiation effect. Multivariate analysis demonstrated tumor size (>1.5 cm) and melanoma histology were associated with higher LTF rates. Our results demonstrate that brain metastases ≤3 cm are not uniformly responsive to SRS and suggest that prospective studies to evaluate the effect of SRS alone or in combination with surgery on brain metastases ≤3 cm matched by tumor size and histology are warranted. These studies will help establish multi-disciplinary treatment guidelines that improve local control while minimizing radiation necrosis during treatment of brain metastasis ≤3 cm.
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Affiliation(s)
- Chibawanye I Ene
- Department of Neurosurgery, The University of Texas M D Anderson Cancer Center, Houston, TX, USA.
| | - Christina Abi Faraj
- Department of Neurosurgery, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Thomas H Beckham
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey S Weinberg
- Department of Neurosurgery, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Clark R Andersen
- Department of Biostatistics, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Ali S Haider
- Department of Neurosurgery, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Ganesh Rao
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Sherise D Ferguson
- Department of Neurosurgery, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | | | - Betty Y S Kim
- Department of Neurosurgery, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Amy B Heimberger
- Department of Neurological Surgery, Malnati Brain Tumor Institute of the Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Ian E McCutcheon
- Department of Neurosurgery, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Sujit S Prabhu
- Department of Neurosurgery, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Chenyang Michael Wang
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Amol J Ghia
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Susan L McGovern
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Caroline Chung
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Mary Frances McAleer
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Martin C Tom
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Subha Perni
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Todd A Swanson
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Debra N Yeboa
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Tina M Briere
- Department of Radiation Physics, Division of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Jason T Huse
- Department of Pathology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Gregory N Fuller
- Department of Pathology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Frederick F Lang
- Department of Neurosurgery, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Jing Li
- Department of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Dima Suki
- Department of Neurosurgery, The University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Raymond E Sawaya
- Faculty of Medicine and Medical Affairs, American University of Beirut, Beirut, Lebanon
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2
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Ludmir EB, Hoffman KE, Jhingran A, Kouzy R, Ip MCP, Sturdevant L, Ning MS, Minsky BD, McAleer MF, Chronowski GM, Arzu IY, Reed VK, Garg AK, Roberts T, Eastwick GA, Olson MR, Selek U, Gabel M, Koong AC, Kupferman ME, Kuban DA. Implementation and Efficacy of a Large-Scale Radiation Oncology Case-Based Peer-Review Quality Program across a Multinational Cancer Network. Pract Radiat Oncol 2024; 14:e173-e179. [PMID: 38176466 DOI: 10.1016/j.prro.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 12/05/2023] [Accepted: 12/14/2023] [Indexed: 01/06/2024]
Abstract
PURPOSE With expansion of academic cancer center networks across geographically-dispersed sites, ensuring high-quality delivery of care across all network affiliates is essential. We report on the characteristics and efficacy of a radiation oncology peer-review quality assurance (QA) system implemented across a large-scale multinational cancer network. METHODS AND MATERIALS Since 2014, weekly case-based peer-review QA meetings have been standard for network radiation oncologists with radiation oncology faculty at a major academic center. This radiotherapy (RT) QA program involves pre-treatment peer-review of cases by disease site, with disease-site subspecialized main campus faculty members. This virtual QA platform involves direct review of the proposed RT plan as well as supporting data, including relevant pathology and imaging studies for each patient. Network RT plans were scored as being concordant or nonconcordant based on national guidelines, institutional recommendations, and/or expert judgment when considering individual patient-specific factors for a given case. Data from January 1, 2014, through December 31, 2019, were aggregated for analysis. RESULTS Between 2014 and 2019, across 8 network centers, a total of 16,601 RT plans underwent peer-review. The network-based peer-review case volume increased over the study period, from 958 cases in 2014 to 4,487 in 2019. A combined global nonconcordance rate of 4.5% was noted, with the highest nonconcordance rates among head-and-neck cases (11.0%). For centers that joined the network during the study period, we observed a significant decrease in the nonconcordance rate over time (3.1% average annual decrease in nonconcordance, P = 0.01); among centers that joined the network prior to the study period, nonconcordance rates remained stable over time. CONCLUSIONS Through a standardized QA platform, network-based multinational peer-review of RT plans can be achieved. Improved concordance rates among newly added network affiliates over time are noted, suggesting a positive impact of network membership on the quality of delivered cancer care.
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Affiliation(s)
- Ethan B Ludmir
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Karen E Hoffman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Anuja Jhingran
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ramez Kouzy
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mee-Chung Puscilla Ip
- Quality Management Programs and Cancer Network, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Laurie Sturdevant
- Quality Management Programs and Cancer Network, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matthew S Ning
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Bruce D Minsky
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mary Frances McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Gregory M Chronowski
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Isidora Y Arzu
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Valerie Klairisa Reed
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amit K Garg
- Department of Radiation Oncology, Presbyterian MD Anderson Radiation Treatment Center, Rio Rancho, New Mexico
| | - Terence Roberts
- Department of Radiation Oncology, Banner MD Anderson Cancer Center, Gilbert, Arizona
| | - Gary A Eastwick
- Department of Radiation Oncology, MD Anderson Cancer Center at Cooper, Camden, New Jersey
| | - Michael R Olson
- Department of Radiation Oncology, Baptist Medical Center, Jacksonville, Florida
| | - Ugur Selek
- Department of Radiation Oncology, Radiation Treatment Center at American Hospital, Istanbul, Turkey
| | - Molly Gabel
- Department of Radiation Oncology, Summit Medical Group, New Brunswick, New Jersey
| | - Albert C Koong
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael E Kupferman
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Deborah A Kuban
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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3
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Bronk JK, McAleer MF, McGovern SL, Lassen-Ramshad Y, Safwat A, Daw NC, Rainusso N, Mahajan A, Grosshans DR, Paulino AC. Comprehensive radiotherapy for pediatric Ewing Sarcoma: Outcomes of a prospective proton study. Radiother Oncol 2024; 195:110270. [PMID: 38583721 DOI: 10.1016/j.radonc.2024.110270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 03/20/2024] [Accepted: 04/02/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND AND PURPOSE Patients with Ewing Sarcoma (EWS) are treated with multimodality therapy which includes radiation therapy (RT) as an option for local control. We report on the efficacy after proton radiation therapy (PRT) to the primary site for localized and metastatic EWS. MATERIALS AND METHODS Forty-two children with EWS (33 localized, 9 metastatic) treated between 2007 and 2020 were enrolled on 2 prospective registry protocols for pediatric patients undergoing PRT. PRT was delivered by passive scatter (74 %), pencil-beam scanning (12 %) or mixed technique (14 %). Treated sites included the spine (45 %), pelvis/sacrum (26 %), skull/cranium (14 %), extraosseous (10 %), and chest wall (5 %). Median radiation dose was 54 Gy-RBE (range 39.6-55.8 Gy-RBE). Patients with metastatic disease received consolidative RT to metastatic sites (4 at the time of PRT to the primary site, 5 after completion of chemotherapy). Median follow-up time was 47 months after PRT. RESULTS The 4-year local control (LC), progression-free survival (PFS), and overall survival (OS) rates were 83 %, 71 %, and 86 %, respectively. All local failures (n = 6) were in-field failures. Tumor size ≥ 8 cm predicted for inferior 4-year LC (69 % vs 95 %, p = 0.04). 4-year PFS and OS rates were not statistically different in patients with localized versus metastatic disease (72 % vs 67 %, p = 0.70; 89 % vs 78 %, p = 0.38, respectively). CONCLUSION In conclusion, LC for pediatric patients with EWS treated with PRT was comparable to that of historical patients who received photon-RT. Tumor size ≥ 8 cm predicted increased risk of local failure. Patients with metastatic disease, including non-pulmonary only metastases, received radiation therapy to all metastatic sites and had favorable survival outcomes.
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Affiliation(s)
- Julianna K Bronk
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States.
| | - Mary Frances McAleer
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Susan L McGovern
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | | | - Akmal Safwat
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Najat C Daw
- Department of Pediatrics, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Nino Rainusso
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine and Texas Children's Hospital Cancer and Hematology Centers, Houston, TX, United States
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - David R Grosshans
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Arnold C Paulino
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States.
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4
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Shanker MD, Cavazos AP, Li J, Beckham TH, Yeboa DN, Wang C, McAleer MF, Briere TM, Amini B, Tatsui CE, North RY, Alvarez-Breckenridge CA, Cezayirli PC, Rhines LD, Ghia AJ, Bishop AJ. Definitive single fraction spine stereotactic radiosurgery for metastatic sarcoma: Simultaneous integrated boost is associated with high tumor control and low vertebral fracture risk. Radiother Oncol 2024; 193:110119. [PMID: 38311030 DOI: 10.1016/j.radonc.2024.110119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 01/25/2024] [Accepted: 01/29/2024] [Indexed: 02/06/2024]
Abstract
INTRODUCTION Sarcoma spinal metastases (SSM) are particularly difficult to manage given their poor response rates to chemotherapy and inherent radioresistance. We evaluated outcomes in a cohort of patients with SSM uniformly treated using single-fraction simultaneous-integrated-boost (SIB) spine stereotactic radiosurgery (SSRS). MATERIALS AND METHODS A retrospective review was conducted at a single tertiary institution treated with SSRS for SSM between April 2007-April 2023. 16-24 Gy was delivered to the GTV and 16 Gy uniformly to the CTV. Kaplan-Meier analysis was conducted to assess time to progression of disease (PD) with proportionate hazards modelling used to determine hazard ratios (HR) and respective 95 % confidence intervals (CI). RESULTS 70 patients with 100 lesions underwent SSRS for SSM. Median follow-up was 19.3 months (IQR 7.7-27.8). Median age was 55 years (IQR42-63). Median GTV and CTVs were 14.5 cm3 (IQR 5-32) and 52.7 cm3 (IQR 29.5-87.5) respectively. Median GTV prescription dose and biologically equivalent dose (BED) [α/β = 10] was 24 Gy and 81.6 Gy respectively. 85 lesions received 24 Gy to the GTV. 27 % of patients had Bilsky 1b or greater disease. 16 of 100 lesions recurred representing a crude local failure rate of 16 % with a median time to failure of 10.4 months (IQR 5.7-18) in cases which failed locally. 1-year actuarial local control (LC) was 89 %. Median overall survival (OS) was 15.3 months (IQR 7.7-25) from SSRS. Every 1 Gy increase in GTV absolute minimum dose (DMin) across the range (5.8-25 Gy) was associated with a reduced risk of local failure (HR = 0.871 [95 % CI 0.782-0.97], p = 0.009). 9 % of patients developed vertebral compression fractures at a median of 13 months post SSRS (IQR 7-25). CONCLUSION This study represents one of the most homogenously treated and the largest cohorts of patients with SSM treated with single-fraction SSRS. Despite inherent radioresistance, SSRS confers durable and high rates of local control in SSM without unexpected long-term toxicity rates.
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Affiliation(s)
- Mihir D Shanker
- The University of Texas MD Anderson Cancer Centre, United States; The University of Queensland, Brisbane, Australia.
| | | | - Jing Li
- The University of Texas MD Anderson Cancer Centre, United States
| | - Thomas H Beckham
- The University of Texas MD Anderson Cancer Centre, United States
| | - Debra N Yeboa
- The University of Texas MD Anderson Cancer Centre, United States
| | - Chenyang Wang
- The University of Texas MD Anderson Cancer Centre, United States
| | | | | | - Behrang Amini
- The University of Texas MD Anderson Cancer Centre, United States
| | - Claudio E Tatsui
- The University of Texas MD Anderson Cancer Centre, United States
| | - Robert Y North
- The University of Texas MD Anderson Cancer Centre, United States
| | | | | | | | - Amol J Ghia
- The University of Texas MD Anderson Cancer Centre, United States
| | - Andrew J Bishop
- The University of Texas MD Anderson Cancer Centre, United States
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5
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Matsui JK, Allen PK, Perlow HK, Johnson JM, Paulino AC, McAleer MF, Fouladi M, Grosshans DR, Ghia AJ, Li J, Zaky W, Chintagumpala M, Palmer JD, McGovern SL. Prognostic Factors for Pediatric, Adolescent, and Young Adult Patients with Non-DIPG Grade 4 Gliomas: A Contemporary Pooled Institutional Experience. Int J Radiat Oncol Biol Phys 2023; 117:e532. [PMID: 37785650 DOI: 10.1016/j.ijrobp.2023.06.1815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) WHO grade 4 gliomas are rare tumors in the pediatric and AYA (adolescent and young adult) population. In this study, we evaluate prognostic factors, toxicities, and outcomes in the pediatric versus AYA population. MATERIALS/METHODS This retrospective pooled institutional study included patients < 30 years old with grade 4 gliomas. Overall survival (OS) and progression free survival (PFS) were characterized using Kaplan-Meier and Cox regression analysis. RESULTS Ninety-seven patients (n = 20 < 15y, n = 77 ≥ 15y) were identified with a median age 23.9y at diagnosis. Most had biopsy-proven glioblastoma (91%) and the remainder had diffuse midline glioma, H3K27M-altered (9%). All patients received surgery and adjuvant radiotherapy. Median PFS and OS were 20.9 months and 79.4 months, respectively. Gross total resection was associated with better PFS in multivariate analysis [HR 2.00 (1.01-3.62), p = 0.023]. Age ≥15y was also associated with improved OS [HR 0.36 (0.16-0.81), p = 0.014] while female gender [HR 2.12 (1.08-4.16), p = 0.03] and K27M altered histology [HR 2.79 (1.11-7.02), p = 0.029] were associated with worse OS. Only 7% of patients experienced grade 2 toxicity during radiation. Sixty-two percent of patients experienced tumor progression, 28% local and 34% distant. Analysis of salvage treatment found reirradiation was not associated with improved OS, but second surgery and systemic therapy significantly improved survival from the time of tumor progression. CONCLUSION Age is a significant prognostic factor in WHO grade 4 glioma, which may reflect age-related molecular alterations in the tumor. Diffuse midline glioma was associated with worse OS compared to hemispheric glioblastoma; this may be related to lack of effective targeted therapies. Surgery and systemic therapy were effective salvage options that significantly improved outcome. Better understanding of prognostic factors may guide future treatment within this understudied patient population, and prospective studies are warranted.
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Affiliation(s)
- J K Matsui
- The Ohio State University College of Medicine, Columbus, OH; Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - P K Allen
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - H K Perlow
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - J M Johnson
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - A C Paulino
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - M F McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - M Fouladi
- Nationwide Children's Hospital, Columbus, OH
| | - D R Grosshans
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - A J Ghia
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - J Li
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - W Zaky
- Division of Pediatrics, MD Anderson Cancer Center, Houston, TX
| | | | - J D Palmer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - S L McGovern
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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6
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Grippin A, De B, Florez M, Tom MC, Beckham T, Wang C, Bishop AJ, Shanker MD, Li J, Amini B, Briere TM, Tatsui C, Rhines LD, McGovern SL, McAleer MF, Ghia AJ. Spine Stereotactic Radiosurgery for Primary and Metastatic Osteosarcoma. Int J Radiat Oncol Biol Phys 2023; 117:e299. [PMID: 37785092 DOI: 10.1016/j.ijrobp.2023.06.2312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Osteosarcoma is difficult to control due to its high propensity for metastasis and resistance to local and systemic therapies. High doses of radiation therapy (RT) may confer local control (LC) in some settings but for lesions involving the vertebral bodies, proximity to the spinal cord may limit the ability to deliver an adequate dose. In this analysis, we investigate the role of spine stereotactic radiosurgery (SSRS) to overcome this barrier and enable efficacious treatment of primary or metastatic osteosarcoma of the spine. MATERIALS/METHODS We retrospectively reviewed all patients treated with SSRS for osteosarcoma of the vertebrae between 2006 and 2022 at a single large tertiary cancer center. We utilized the Kaplan-Meier method to estimate overall survival (OS) and LC. RESULTS We identified 18 patients treated with SSRS for 25 lesions of spinal osteosarcoma. Median follow-up was 17.2 months. Two patients and three separate lesions were treated with SSRS for primary osteosarcoma of the vertebrae. The remaining 16 patients and 22 lesions received SSRS to the spine for metastatic disease. Lesions were treated to a dose of 24Gy in one fraction (n = 20) 27Gy in 3 fractions (n = 4) or 50Gy in 5 fractions (n = 1). Treatment sites included the cervical spine alone (n = 4), thoracic spine alone (n = 12), lumbar spine alone (n = 4), sacrum alone (n = 3), or both the thoracic and lumbar spine (n = 2). At latest follow up, local failure was observed in 9/25 (36%) treated lesions and median LC was 22.5 months (95% CI 6-43 months). Per-lesion LC at 1 year was 64% (95% CI 35-83%). Per-patient median OS was 14 months (95% CI 7-68 months) and OS estimates at 1 and 2 years were 60% (95% CI 32-80%) and 35% (11-60%), respectively. Among 15 patients who received 24 Gy in one fraction, at 1 year per-lesion LC was 72% (95% CI 41-88%) and per-patient OS was 60% (95% CI 28-81%). The most common acute treatment related toxicity was pain flare (12%). Four patients (16%) developed compression fractures in the treated vertebrae after radiation, with incidence between 57 and 578 days after radiation. Two of these fractures required intervention and two were incidental findings on imaging. No patients developed CTCAE Grade 3 or higher adverse events including neurological toxicities. CONCLUSION SSRS appears to be safe and effective in the treatment of metastatic or primary osteosarcoma involving spinal bone. Future work should include further investigation of this technique with pooled multi-institutional studies and randomized trials.
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Affiliation(s)
- A Grippin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - B De
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - M Florez
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - M C Tom
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - T Beckham
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - C Wang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - A J Bishop
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - M D Shanker
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - J Li
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - B Amini
- Department of Musculoskeletal Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - T M Briere
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - C Tatsui
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - L D Rhines
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - S L McGovern
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - M F McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - A J Ghia
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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7
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Marqueen KE, Strom EA, Ning MS, Smith BD, Tereffe W, Hoffman KE, Stauder MC, Perkins GH, Buchholz TA, Li J, McAleer MF, Reddy J, Woodward WA. Phase II Trial of Definitive Therapy for Osseous Oligometastases in Breast Cancer. Int J Radiat Oncol Biol Phys 2023; 117:e136. [PMID: 37784702 DOI: 10.1016/j.ijrobp.2023.06.941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Phase II data for consolidative local therapy for oligometastatic disease demonstrated improved outcomes for various malignancies. However, a randomized phase II study of oligometastatic breast cancer patients testing predominantly ablative dose radiotherapy (RT) did not demonstrate progression-free survival (PFS) benefit. We conducted a single-arm phase II trial evaluating local therapy as part of the multidisciplinary management of breast cancer patients with limited bone metastases. MATERIALS/METHODS Patients with synchronous (n = 15) and metachronous (n = 15) oligometastatic breast cancer involving ≤3 osseous sites were enrolled from July 2009 to April 2016 and treated to a total of 44 bone metastases. The trial closed early due to slow accrual. Following ≤9 months of systemic therapy, local therapy entailed surgery (n = 3) or RT delivered via conventional fractionation (≥60 Gy, n = 36) or stereotactic technique (27 Gy/3 fractions for spine mets, n = 6). When indicated, RT to the primary was delivered concurrently (n = 15). The primary endpoint was to determine PFS. Secondary endpoints were overall survival (OS), local control (LC) and toxicity. Outcomes were evaluated with Kaplan-Meier and univariate Cox proportional hazards analyses. RESULTS Of the 30 patients included in the trial, 23 (77%) had ER+ or PR+/HER2- disease, 4 (13%) had Her2+ disease, and 3 (10%) were triple negative. Median age was 53, and 20 patients (67%) presented with 1 distant metastasis. A total of 21 patients (70%) experienced disease progression at a median 20.5 months (IQR: 8.2-41.2), including 5 local failures among 44 treated bone metastases (11%). At a median follow-up of 76.7 mon (IQR: 45.4-108.8), the median PFS was 37.8 mon, with 2- and 5-year rates (95% CI) of 60% (45-80%) and 32% (19-55%), respectively. The 2- and 5-year OS rates were 93% (85-100%) and 64% (48-85%), respectively, and the 2- and 5-year LC rates were 91% (80-100%) and 71% (51-98%). For patients who achieved LC, median PFS was 47.7 months (IQR 12.2-73.0). Twenty-one patients (70%) received cytotoxic chemotherapy with or without endocrine therapy for newly diagnosed oligometastatic disease. Nine patients (30%) were still alive with no evidence of disease (NED) at a median 96.9 mon (range: 47.7-158.6). PFS was worse among triple negative patients (p = 0.03), with no difference based on synchronous vs non-synchronous presentation (p = 0.10), receipt of cytotoxic chemotherapy prior to definitive therapy (p = 0.08) or Her2+ status (p = 0.21). There were no Grade ≥3 adverse events. CONCLUSION Definitive, predominantly conventionally fractionated local therapy was associated with long-term NED status for 30% of patients with oligometastatic breast cancer involving osseous sites, with minimal treatment-associated toxicity. Developing randomized trials for breast cancer subsets may warrant consideration of standard fractionation regimen data and the need for strategies to identify patients who may benefit from definitive local therapy.
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Affiliation(s)
- K E Marqueen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - E A Strom
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - M S Ning
- MD Anderson Cancer Center, Houston, TX
| | - B D Smith
- Department of Breast Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - W Tereffe
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - K E Hoffman
- Department of Breast Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - M C Stauder
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - G H Perkins
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - J Li
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - M F McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - J Reddy
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - W A Woodward
- Department of Breast Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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Ioakeim-Ioannidou M, Yeap BY, Flood T, Marinelli J, Giantsoudi D, Philip N, Tarbell NJ, Yock TI, Grosshans DR, McAleer MF, McGovern SL, MacDonald SM. Multi-Institutional Phase I Feasibility Trial of Vertebral Body Sparing CSI for Pediatric Brain Tumors. Int J Radiat Oncol Biol Phys 2023; 117:e519-e520. [PMID: 37785619 DOI: 10.1016/j.ijrobp.2023.06.1787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Craniospinal irradiation (CSI) is an essential part of curative treatment for several pediatric brain tumors. Proton CSI allows for sparing of the organs anterior to the vertebral bodies (VBs), but this technique still includes the entire VB in the target for growing children. providing no advantage in marrow sparing or adverse effects on growth. Advances in proton therapy including Proton Beam Scanning (PBS) allow for delivery of proton CSI with substantial vertebral body sparing (VBS). We sought to determine the feasibility of VBS CSI using PBS based on the effects on tumor control and growth, and the occurrence of grade III/IV hematologic toxicity. MATERIALS/METHODS Clinical and treatment characteristics were recorded for 20 pediatric patients with medulloblastoma (n = 14) or germ cell tumor (GCT) (n = 6) who received proton VBS CSI without concurrent chemotherapy or with concurrent single-agent vincristine in a multi-institutional clinical trial. The following standard variables were extracted for each patient: age, histology, radiation dose, chemotherapy regimen, and growth hormone replacement status. Complete blood counts (CBC) with differential and data on height/weight were recorded at baseline pre-RT, weekly during RT, and after completion of cancer treatment. Hematologic toxicity was graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events version 4 (CTCAE v4). RESULTS Median age of 13 male and 7 female patients receiving proton VBS CSI was 10 years (range: 5.1 - 15.1). All GCT patients (n = 6, 30%) received pre-RT chemo. Median CSI dose was 23.4 Gy (range: 21.0 - 37.8), and total dose to tumor bed was 54 Gy in 18 patients (90%) while 2 patients with pure germinoma received a total dose of 36 and 37.5 Gy, respectively. 11 patients (55%) did not receive concurrent vincristine. At a median follow up of 26.4 months (range: 12.5 - 56.3) from the start of RT, no patients relapsed. 17 patients (85%) developed grade ≥3 hematologic toxicity including grade 3 lymphopenia (n = 16), leukopenia (n = 9), neutropenia (n = 8), anemia (n = 1), and grade 4 neutropenia (n = 1). The patient who developed grade 4 neutropenia had low white blood counts prior to RT. 14 patients (70%) received post-RT chemo. No patients required platelet transfusion during RT. Those findings are similar to historical controls. 4 patients started growth hormone replacement therapy after RT. No patients developed spine deformities after the completion of treatment. CONCLUSION Proton VBS CSI is a feasible and well tolerated treatment for children with brain tumors. Longer follow up is needed to assess for late effects on tumor control. It is too early to assess for height in this cohort but for the patients that had longer follow up, normal height was achieved.
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Affiliation(s)
- M Ioakeim-Ioannidou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - B Y Yeap
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - T Flood
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, Boston, MA
| | - J Marinelli
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, Boston, MA
| | - D Giantsoudi
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - N Philip
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - T I Yock
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - D R Grosshans
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - M F McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - S L McGovern
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - S M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Nasr LF, Li J, Swanson TA, Ghia AJ, Wang C, Yeboa DN, Grosshans DR, McAleer MF, Beckham T, McGovern SL. Early Outcomes from Proton Craniospinal Irradiation (pCSI) for Leptomeningeal Disease from Solid Tumors. Int J Radiat Oncol Biol Phys 2023; 117:e139-e140. [PMID: 37784708 DOI: 10.1016/j.ijrobp.2023.06.948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Prospective data suggest that proton craniospinal irradiation (pCSI) improves overall survival (OS) in patients with leptomeningeal disease (LMD) from solid tumors, compared to the historical standard of involved field radiation. To evaluate outcomes of this novel approach in a real-world setting, our institutional experience with treating adults with pCSI for LMD from solid malignancies was evaluated. MATERIALS/METHODS On an IRB-approved protocol, medical records of adults with LMD from solid tumors treated with pCSI were retrospectively reviewed for patient, disease and treatment characteristics and outcomes. CNS-PFS and OS were calculated from the last day of pCSI, and survival was modeled using Kaplan-Meier analysis. RESULTS From December 2021 to November 2022, 17 patients with median age 51y (range 22-71y) were treated with pCSI for LMD from solid tumors. Thirteen patients (76%) were female. Ten had ECOG PS of 0-1, and seven had PS 2-3. Nine patients (53%) had breast cancer, 3 (18%) had non-small cell lung cancer (NSCLC), 2 (12%) had melanoma, 1 (6%) had colorectal adenocarcinoma, 1 (6%) had endocervical adenocarcinoma, and 1 (6%) had two synchronous primaries (adenocarcinoma of the gastro-esophageal junction and neuroendocrine carcinoma of the lung). All patients had prior radiation; ten had prior radiation to the brain, one had prior radiation to the spine, and six had other sites previously radiated. Fourteen patients (82%) were treated to 30 Gy in 10 fractions and 3 (18%) were treated to 25 Gy in 10 fractions due to overlap with prior radiation fields. Median follow-up was 4 months (range, 1-13 months). Among 15 evaluable patients, median CNS-PFS and median OS were 3.6 months and 4.7 months, respectively. For patients with breast cancer or NSCLC, 62% were alive at 6 months; median OS has not been reached. Treatment was well tolerated with no grade 3-4 non-hematologic adverse events. CONCLUSION pCSI is a novel method for treatment of LMD from solid tumors that has been rapidly adopted. Based on our preliminary review, it is safe and well-tolerated; patient selection is critical. As these patients are often heavily pretreated, prior radiation fields must be considered in pCSI planning.
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Affiliation(s)
- L F Nasr
- Department of Lymphoma-Myeloma, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - J Li
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - T A Swanson
- University of Texas Medical Branch, Galveston, TX
| | - A J Ghia
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - C Wang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - D N Yeboa
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - D R Grosshans
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - M F McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - T Beckham
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - S L McGovern
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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Garg AK, Hernandez M, Schlembach PJ, McAleer MF, Brown PD, Gopal RS, Wiederhold L, Swanson TA, Shah SJ, Li J, Ferguson S, Philip N, De Gracia B, Bloom E, Chun SG. Frameless Fractionated Linear Accelerator-Based Stereotactic Radiotherapy for Brain Metastases: Results of a Single-Arm Phase II Multi-Institutional Clinical Trial. Int J Radiat Oncol Biol Phys 2023; 117:e94-e95. [PMID: 37786219 DOI: 10.1016/j.ijrobp.2023.06.857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Stereotactic radiotherapy (SRT) yields high rates of local control for brain metastases while minimizing neurocognitive side effects. While advanced SRT platforms are widely available in urban centers, rural/suburban patients face geographic and socioeconomic barriers to access SRS. For this reason, we conducted a multi-institutional Phase 2 clinical trial to test the safety and efficacy of 3-5 fraction frameless fractionated stereotactic radiotherapy (FFSRT) for brain metastases in an integrated academic satellite network MATERIALS/METHODS: This IRB-approved Phase 2 trial was conducted for patients ≥18-years-old with 1-4 brain metastases. Brain metastases involving the optic pathway or brainstem were excluded. Gross tumor volume (GTV) was delineated with a volumetric brain MRI and planning target volume (PTV) was GTV + 2 mm margin. Radiation dose was based on GTV size: < 3.0 cm, 27 Gy in 3 fractions, and 3.0-3.9 cm, 30 Gy in 5 fractions. Toxicity was evaluated using the Common Terminology Criteria for Adverse Events (CTCAE) version 4. RESULTS Of 76 evaluable patients, the median age was 67 years, 56.6% were female, 82.9% were white/Caucasian and 89.6% had an Eastern Cooperative Oncology Group performance status ≤ 2. Most brain metastases were from lung cancer (51.3%) and breast cancer (15.7%). With median follow-up of 10 months, local control was 93%, median survival was 1.8 years (95% confidence interval (CI): 1.5-2.4 years), 1-year OS was 73.8% (95% CI: 0.59-0.84), and 2-year OS was 31% (95% CI: 0.12-0.52). There were no CTCAE Grade ≥ 3 protocol-related adverse events. CONCLUSION Outcomes of this trial compare favorably with contemporary SRT trials for brain metastases. FFSRT may provide opportunities to expand SRS access for underserved populations across the MDACC enterprise and in future clinical trials for brain metastases.
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Affiliation(s)
- A K Garg
- Presbyterian Healthcare Services, Albuquerque, NM
| | - M Hernandez
- MD Anderson, Houston, TX; Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - P J Schlembach
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - M F McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - P D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - R S Gopal
- Radiation Care at Meridian Park, Tualitin, OR
| | | | - T A Swanson
- University of Texas Medical Branch, Galveston, TX
| | - S J Shah
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Sugar Land, TX
| | - J Li
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - S Ferguson
- Department of Neurosurgery, University of Texas MD Anderson Cancer Center, Houston, TX
| | - N Philip
- MD Anderson Cancer Center, HOUSTON, TX
| | - B De Gracia
- MD Anderson Cancer Center, Houston, TX, United States
| | - E Bloom
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - S G Chun
- University of Texas Southwestern Medical Center, Dallas, TX
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11
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Shanker MD, Cavazos A, Li J, Beckham T, Yeboa DN, Wang C, McAleer MF, Briere TM, Amini B, Tatsui C, North R, Alvarez-Breckenridge C, Cezayirli P, Rhines LD, Ghia AJ, Bishop AJ. Dosimetric Analysis of Local Failure Outcomes and Vertebral Compression Fracture Risk in Single-Fraction Spine Stereotactic Radiosurgery for Metastatic Sarcoma. Int J Radiat Oncol Biol Phys 2023; 117:e148-e149. [PMID: 37784729 DOI: 10.1016/j.ijrobp.2023.06.966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Sarcoma spinal metastases (SSM) are particularly difficult to manage given their poor response rates to chemotherapy and their inherent radioresistance. We sought to analyze dosimetric parameters impacting local failure and vertebral compression fracture outcomes in a homogenously treated cohort of patients with SSM treated with single-fraction spine stereotactic radiosurgery (SSRS). MATERIALS/METHODS A retrospective review was conducted on a cohort of patients with SSM treated with definitive SSRS at a single tertiary institution. 16-24 Gy was delivered to the GTV and 16 Gy uniformly to the CTV. Kaplan-Meier analysis was conducted to assess time to local failure (LF). The log-rank test was utilized to examine group differences. Patients were censored at time of last follow-up or death. Cox proportionate hazards modeling was used to determine hazard ratios (HR) and their respective 95% confidence intervals (CI). RESULTS A total of 66 patients with 96 lesions underwent SSRS for SSM. Median follow-up was 17 months (IQR 8-28). Median age was 55 years (IQR 41-63). The most common histological subtype was leiomyosarcoma (41%) followed by liposarcoma (9%). 81 lesions received 24 Gy to the GTV, 12 received 18 Gy and 3 received 16 Gy. Median GTV and CTV volume was 13.6cc (IQR 5-27) and 51.6cc (IQR 30-80) respectively. 27% of patients had Bilsky 1b or greater disease. 16 of 96 lesions demonstrated progression representing a crude local failure rate of 17% with median time to failure of 8 months (IQR 5-18). The 1-year actuarial progression free survival (PFS) was 89% with a median PFS of 13 months (IQR 16-63). Median overall survival (OS) was 15 months (IQR 8-28) from SSRS. 8% of patients developed vertebral compression fractures at a median of 13 months post SSRS (IQR 7-25). Every 1 Gy increase in GTV minimum dose (DMin) across the range (5.8-25cc) was associated with a reduced risk of local failure (HR = 0.875 [95% CI 0.787-0.974], p = 0.01). Stratifying thresholds for GTV DMin, a local control benefit was seen as low as 12 Gy and higher (HR = 0.329 [95% CI 0.11-0.97, p = 0.044) with a significantly greater magnitude benefit seen at 14 Gy (HR = 0.267 [95% CI 0.09-0.77, p = 0.014) and above 15 Gy (HR = 0.091 [95% CI 0.03-0.41], p = 0.0018). There were no other queried variables besides GTV Dmin associated with local control including: GTV: volume, mean, Dmax, D90, CTV: volume, Dmin, Dmean, Dmax, or D90. There was an increased risk of VCF with increasing CTV DMean (HR = 2.4 [95% CI 1.4-4.1], p = 0.002) and CTV D90 (HR = 2.2 [95% CI 1.2-4.0], p = 0.01); however, no association with GTV parameters. CONCLUSION This study represents one of the most homogenously treated and the largest cohorts of patients with sarcoma spinal metastases treated with single-fraction SSRS. Despite inherent radioresistance, SSRS confers durable and high rates of local control in SSM without unexpected long-term toxicity rates. Increasing GTV minimum dose is significantly associated with superior local control with no corresponding increased risk of VCF.
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Affiliation(s)
- M D Shanker
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; The University of Queensland, St Lucia, Australia
| | - A Cavazos
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - J Li
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - T Beckham
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - D N Yeboa
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - C Wang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - M F McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - T M Briere
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - B Amini
- Department of Musculoskeletal Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - C Tatsui
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - R North
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - C Alvarez-Breckenridge
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - P Cezayirli
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - L D Rhines
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - A J Ghia
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - A J Bishop
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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12
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Yeboa DN, Woodhouse K, Prabhu S, Li J, Beckham T, Weinberg JS, Wang C, McCutcheon IE, Swanson TA, Kim BYS, McGovern SL, North R, McAleer MF, Alvarez-Breckenridge C, Jiang W, Ene C, Ejezie CL, Lang F, Rao G, Ferguson S. MD Anderson Phase III Randomized Preoperative Stereotactic Radiosurgery (SRS) vs. Postoperative SRS for Brain Metastases Trial. Int J Radiat Oncol Biol Phys 2023; 117:e160-e161. [PMID: 37784756 DOI: 10.1016/j.ijrobp.2023.06.990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Postoperative stereotactic radiation therapy/radiosurgery (SRT/SRS) is being evaluated in comparison to Preoperative SRT for brain metastases (mets) in a limited number of prospective clinical trials. Our objective is to address the significant knowledge gap concerning the logistics of preoperative SRT in comparison to postoperative SRT in a randomized controlled study. MATERIALS/METHODS Patients with brain mets with at least 1 surgically operable met were randomized (1:1) to Preop vs Postop SRT. In this abstract, we present non-primary endpoint data on the trial concept and logistics of treatment for this data safety monitoring board reviewed study. Patients enrolled had 1-2 lesions resected and <15 lesions treated at time of SRT to best reflect the standard population that receive SRT and surgery at our institution. RESULTS From 12/2018 to 12/2022, 99 patients with 1-2 operable brain mets were enrolled and randomized to Preop (n = 49) or Postop (n = 50) SRT. Males represented 56% of the cohort compared to females, and <25% were age 18-49 years, while 27%, 29, and 19% respectively were 50-59, 60-69, and > = 70. The most frequent histologies enrolled were lung (29%), renal cell (15%), melanoma (14%), and breast (11%) cancers. The majority of patients (83%) had 1-4 brain mets on their baseline MRI and 91% subsequently had a single lesion resected. Seventy-nine patients completed both SRT and surgery, while 9% received no therapy due to drop out before study therapy initiation. Among patients receiving both therapies in the combined cohort, 68% received a non-invasive stereotactic radiosurgery instrument to the randomized cavity lesion compared to 32% receiving LINAC based SRT. Treatment of the lesion or cavity with single fraction SRT was 51% in the Preop arm vs 31% in the Postop arm. Multi-fraction (3-5 SRT) was 67% in the Postop cohort in contrast to 47% in the Preop cohort. Time from randomization to RT was 5.6 days and 33.7 days in the Preop and Postop cohorts respectively, and for surgery was 10.2 days vs 12.9 days in the Postop vs Preop cohorts. The average time from RT to surgery was 7.3 days in the Preop arm and 23.5 days in the Postop arm (to allow for incisional healing time). CONCLUSION In one of the early initiated randomized prospective cohorts of Preop vs Postop SRT, we demonstrated logistical feasibility with an efficient clinical trial workflow for study treatment. Differences in Preop vs Postop logistics reflect clinical practice differences in time-to-treatment. Therapy with various modalities reflected real-world practice and possibly provider preferences in technique when addressing the nature of delineating cavities and changes in cavity volume with regard to fractionation. Independent of the primary outcomes, our data provides insights in the practical management of patients receiving these two modalities of therapy, and further data at the completion of trial will address relevant primary outcomes.
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Affiliation(s)
- D N Yeboa
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - S Prabhu
- Department of Neurosurgery, University of Texas MD Anderson Cancer Center, Houston, TX
| | - J Li
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - T Beckham
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - J S Weinberg
- Department of Neurosurgery, University of Texas MD Anderson Cancer Center, Houston, TX
| | - C Wang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - I E McCutcheon
- Department of Neurosurgery, University of Texas MD Anderson Cancer Center, Houston, TX
| | - T A Swanson
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - B Y S Kim
- Department of Neurosurgery, University of Texas MD Anderson Cancer Center, Houston, TX
| | - S L McGovern
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - R North
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - M F McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - W Jiang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - C Ene
- Department of Neurosurgery, University of Texas MD Anderson Cancer Center, Houston, TX
| | - C L Ejezie
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - F Lang
- Department of Neurosurgery, University of Texas MD Anderson Cancer Center, Houston, TX
| | - G Rao
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX
| | - S Ferguson
- Department of Neurosurgery, University of Texas MD Anderson Cancer Center, Houston, TX
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13
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Sherry AD, Maroongroge S, De B, Amini B, Conley AP, Bishop AJ, Wang C, Beckham T, Tom M, Briere T, Li J, Yeboa DN, McAleer MF, North R, Tatsui CE, Rhines LD, Ghia AJ. Management of chordoma and chondrosarcoma with definitive dose-escalated single-fraction spine stereotactic radiosurgery. J Neurooncol 2023; 164:377-386. [PMID: 37667065 DOI: 10.1007/s11060-023-04432-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 08/19/2023] [Indexed: 09/06/2023]
Abstract
PURPOSE The management of chordoma or chondrosarcoma involving the spine is often challenging due to adjacent critical structures and tumor radioresistance. Spine stereotactic radiosurgery (SSRS) has radiobiologic advantages compared with conventional radiotherapy, though there is limited evidence on SSRS in this population. We sought to characterize the long-term local control (LC) of patients treated with SSRS. METHODS We retrospectively reviewed patients with chordoma or chondrosarcoma treated with dose-escalated SSRS, defined as 24 Gy in 1 fraction to the gross tumor volume. Overall survival (OS) was calculated by Kaplan-Meier functions. Competing risk analysis using the cause-specific hazard function estimated LC time. RESULTS Fifteen patients, including 12 with chordoma and 3 with chondrosarcoma, with 22 lesions were included. SSRS intent was definitive, single-modality in 95% of cases (N = 21) and post-operative in 1 case (5%). After a median censored follow-up time of 5 years (IQR 4 to 8 years), median LC time was not reached (IQR 8 years to not reached), with LC rates of 100%, 100%, and 90% at 1 year, 2 years, and 5 years. The median OS was 8 years (IQR 3 years to not reached). Late grade 3 toxicity occurred after 23% of treatments (N = 5, fracture), all of which were managed successfully with stabilization. CONCLUSION Definitive dose-escalated SSRS to 24 Gy in 1 fraction appears to be a safe and effective treatment for achieving durable local control in chordoma or chondrosarcoma involving the spine, and may hold particular importance as a low-morbidity alternative to surgery in selected cases.
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Affiliation(s)
- Alexander D Sherry
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Sean Maroongroge
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Brian De
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Behrang Amini
- Department of Musculoskeletal Imaging, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anthony P Conley
- Department of Sarcoma Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew J Bishop
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Chenyang Wang
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Thomas Beckham
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Martin Tom
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Tina Briere
- Department of Radiation Physics, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jing Li
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Debra N Yeboa
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Mary Frances McAleer
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Robert North
- Department of Neurosurgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Claudio E Tatsui
- Department of Neurosurgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laurence D Rhines
- Department of Neurosurgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amol J Ghia
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA.
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14
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Chelariu-Raicu A, Piha-Paul SA, Chavez-MacGregor M, Johnson J, Sawaya R, McAleer MF, Nguyen A, Hartnett A, Tsimberidou AM, Meric-Bernstam F, Dumbrava EE. Multidisciplinary Care of a Large Brain Metastasis in a Patient with Hormone-Receptor-Positive Breast Cancer with Ataxia-Telangiectasia Mutation. J Immunother Precis Oncol 2023; 6:158-161. [PMID: 37637237 PMCID: PMC10448731 DOI: 10.36401/jipo-22-33] [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] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/23/2023] [Accepted: 05/09/2023] [Indexed: 08/29/2023]
Abstract
Poly (adenosine diphosphate-ribose) polymerase inhibitors (PARP)i are emerging as standard oncology treatments in various tumor types. The indications will expand as PARPi are being investigated in various breast cancer subtypes. Currently, except for BRCA1/2 mutation carriers with human epidermal growth factor receptor 2 (HER2)-negative breast cancer, there is inadequate identification of predictive biomarkers of response. We present a 57-year-old woman with metastatic breast cancer, hormone-receptor-positive, HER2 negative with a germline ataxia-telangiectasia mutation with a large brain metastasis with clinical benefit to talazoparib. This case report exemplifies the importance of the multidisciplinary management of patients with brain metastases and personalized biomarker selected treatment.
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Affiliation(s)
- Anca Chelariu-Raicu
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Obstetrics and Gynecology, Breast Center, Gynecologic Oncology Center, and CCC Munich, LMU University Hospital, Munich, Germany
| | - Sarina A. Piha-Paul
- Department of Investigational Cancer Therapeutics, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Mariana Chavez-MacGregor
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jason Johnson
- Department of Neuroradiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Raymond Sawaya
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mary Frances McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alissa Nguyen
- Department of Neuroradiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Audrey Hartnett
- Department of Investigational Cancer Therapeutics, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Apostolia M. Tsimberidou
- Department of Investigational Cancer Therapeutics, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Funda Meric-Bernstam
- Department of Investigational Cancer Therapeutics, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
- Department of Breast Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
- The Sheikh Khalifa Bin Zayed Al Nahyan Institute for Personalized Cancer Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ecaterina E. Dumbrava
- Department of Investigational Cancer Therapeutics, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
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15
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Altan M, Wang Y, Song J, Welsh J, Tang C, Guha-Thakurta N, Blumenschein GR, Carter BW, Wefel JS, Ghia AJ, Yeboa DN, McAleer MF, Chung C, Woodhouse KD, McGovern SL, Wang C, Kim BYS, Weinberg JS, Briere TM, Elamin YY, Lee X, Cascone T, Negrao MV, Skoulidis F, Ferrarotto R, Heymach JV, Li J. Nivolumab and ipilimumab with concurrent stereotactic radiosurgery for intracranial metastases from non-small cell lung cancer: analysis of the safety cohort for non-randomized, open-label, phase I/II trial. J Immunother Cancer 2023; 11:e006871. [PMID: 37402581 PMCID: PMC10335483 DOI: 10.1136/jitc-2023-006871] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Up to 20% of patients with non-small cell lung cancer (NSCLC) develop brain metastasis (BM), for which the current standard of care is radiation therapy with or without surgery. There are no prospective data on the safety of stereotactic radiosurgery (SRS) concurrent with immune checkpoint inhibitor therapy for BM. This is the safety cohort of the phase I/II investigator-initiated trial of SRS with nivolumab and ipilimumab for patients with BM from NSCLC. PATIENTS AND METHODS This single-institution study included patients with NSCLC with active BM amenable to SRS. Brain SRS and systemic therapy with nivolumab and ipilimumab were delivered concurrently (within 7 days). The endpoints were safety and 4-month intracranial progression-free survival (PFS). RESULTS Thirteen patients were enrolled in the safety cohort, 10 of whom were evaluable for dose-limiting toxicities (DLTs). Median follow-up was 23 months (range 9.7-24.3 months). The median interval between systemic therapy and radiation therapy was 3 days. Only one patient had a DLT; hence, predefined stopping criteria were not met. In addition to the patient with DLT, three patients had treatment-related grade ≥3 adverse events, including elevated liver function tests, fatigue, nausea, adrenal insufficiency, and myocarditis. One patient had a confirmed influenza infection 7 months after initiation of protocol treatment (outside the DLT assessment window), leading to pneumonia and subsequent death from hemophagocytic lymphohistiocytosis. The estimated 4-month intracranial PFS rate was 70.7%. CONCLUSION Concurrent brain SRS with nivolumab/ipilimumab was safe for patients with active NSCLC BM. Preliminary analyses of treatment efficacy were encouraging for intracranial treatment response.
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Affiliation(s)
- Mehmet Altan
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Yan Wang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Juhee Song
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - James Welsh
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Chad Tang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nandita Guha-Thakurta
- Department of Neuroradiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - George R Blumenschein
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Brett W Carter
- Department of Thoracic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jeffrey S Wefel
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Amol J Ghia
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Debra N Yeboa
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mary Frances McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Caroline Chung
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kristina D Woodhouse
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Susan L McGovern
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Chenyang Wang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Betty Y S Kim
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jeffrey S Weinberg
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tina M Briere
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Yasir Y Elamin
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Xiuning Lee
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tina Cascone
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Marcelo V Negrao
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ferdinandos Skoulidis
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Renata Ferrarotto
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - John V Heymach
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jing Li
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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16
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Matsui JK, Allen PK, Perlow HK, Johnson JM, Paulino AC, McAleer MF, Fouladi M, Grosshans DR, Ghia AJ, Li J, Zaky WT, Chintagumpala MM, Palmer JD, McGovern SL. Prognostic factors for pediatric, adolescent, and young adult patients with non-DIPG grade 4 gliomas: a contemporary pooled institutional experience. J Neurooncol 2023; 163:717-726. [PMID: 37440097 DOI: 10.1007/s11060-023-04386-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 06/28/2023] [Indexed: 07/14/2023]
Abstract
PURPOSE WHO grade 4 gliomas are rare in the pediatric and adolescent and young adult (AYA) population. We evaluated prognostic factors and outcomes in the pediatric versus AYA population. METHODS This retrospective pooled study included patients less than 30 years old (yo) with grade 4 gliomas treated with modern surgery and radiotherapy. Overall survival (OS) and progression-free survival (PFS) were characterized using Kaplan-Meier and Cox regression analysis. RESULTS Ninety-seven patients met criteria with median age 23.9 yo at diagnosis. Seventy-seven patients were ≥ 15 yo (79%) and 20 patients were < 15 yo (21%). Most had biopsy-proven glioblastoma (91%); the remainder had H3 K27M-altered diffuse midline glioma (DMG; 9%). All patients received surgery and radiotherapy. Median PFS and OS were 20.9 months and 79.4 months, respectively. Gross total resection (GTR) was associated with better PFS in multivariate analysis [HR 2.00 (1.01-3.62), p = 0.023]. Age ≥ 15 yo was associated with improved OS [HR 0.36 (0.16-0.81), p = 0.014] while female gender [HR 2.12 (1.08-4.16), p = 0.03] and DMG histology [HR 2.79 (1.11-7.02), p = 0.029] were associated with worse OS. Only 7% of patients experienced grade 2 toxicity. 62% of patients experienced tumor progression (28% local, 34% distant). Analysis of salvage treatment found that second surgery and systemic therapy significantly improved survival. CONCLUSION Age is a significant prognostic factor in WHO grade 4 glioma, which may reflect age-related molecular alterations in the tumor. DMG was associated with worse OS than glioblastoma. Reoperation and systemic therapy significantly increased survival after disease progression. Prospective studies in this population are warranted.
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Affiliation(s)
- Jennifer K Matsui
- The Ohio State University College of Medicine, Columbus, OH, 43201, USA
- Department of Radiation Oncology, MD Anderson Cancer Center, 1515 Holcombe Blvd, Box 1152, Houston, TX, 77030, USA
| | - Pamela K Allen
- Department of Radiation Oncology, MD Anderson Cancer Center, 1515 Holcombe Blvd, Box 1152, Houston, TX, 77030, USA
| | - Haley K Perlow
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, 43201, USA
| | - Jason M Johnson
- Department of Neuroradiology, MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Arnold C Paulino
- Department of Radiation Oncology, MD Anderson Cancer Center, 1515 Holcombe Blvd, Box 1152, Houston, TX, 77030, USA
| | - Mary Frances McAleer
- Department of Radiation Oncology, MD Anderson Cancer Center, 1515 Holcombe Blvd, Box 1152, Houston, TX, 77030, USA
| | - Maryam Fouladi
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - David R Grosshans
- Department of Radiation Oncology, MD Anderson Cancer Center, 1515 Holcombe Blvd, Box 1152, Houston, TX, 77030, USA
| | - Amol J Ghia
- Department of Radiation Oncology, MD Anderson Cancer Center, 1515 Holcombe Blvd, Box 1152, Houston, TX, 77030, USA
| | - Jing Li
- Department of Radiation Oncology, MD Anderson Cancer Center, 1515 Holcombe Blvd, Box 1152, Houston, TX, 77030, USA
| | - Wafik T Zaky
- Department of Pediatrics, MD Anderson Cancer Center, Houston, TX, 77030, USA
| | | | - Joshua D Palmer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, 43201, USA
| | - Susan L McGovern
- Department of Radiation Oncology, MD Anderson Cancer Center, 1515 Holcombe Blvd, Box 1152, Houston, TX, 77030, USA.
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17
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Chevli N, Grosshans DR, McAleer MF, Foster JH, Harrison D, McGovern SL, Paulino AC. Renal function in abdominal neuroblastoma patients undergoing proton radiotherapy. Pediatr Blood Cancer 2023; 70:e29981. [PMID: 36129239 DOI: 10.1002/pbc.29981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 08/05/2022] [Accepted: 08/18/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND The purpose of this study is to analyze renal function outcomes in abdominal neuroblastoma patients undergoing proton therapy (PT). PROCEDURE From 2011 to 2019, two single-institution Institutional Review Board-approved protocols prospectively enrolled neuroblastoma patients for data collection. To assess renal function, serum creatinine (Cr), blood urea nitrogen (BUN), and creatinine clearance (CrCl) before proton therapy (pre-PT) were compared with the values at last follow-up. RESULTS A total of 30 children with abdominal neuroblastoma with median age 3.5 years (range, 0.9-9.1) at time of PT were included in this study. All patients underwent chemotherapy and resection of primary tumor prior to PT. Two patients required radical nephrectomy. Median follow-up after PT was 35 months. Mean dose to ipsilateral and contralateral kidney was 13.9 and 5.4 Gy, respectively. No patients developed hypertension or renal dysfunction during follow-up. There was no statistically significant change in serum BUN (p = .508), CrCl (p = .280), or eGFR (p = .246) between pre-PT and last follow-up. CONCLUSION At a median follow-up of almost 3 years, renal toxicity was uncommon after PT. Longer follow-up and larger patient cohort data are needed to further assess impact of PT on renal function in this population.
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Affiliation(s)
- Neil Chevli
- Department of Radiation Oncology, University of Texas Medical Branch, Galveston, TX, USA
| | - David R Grosshans
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mary Frances McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jennifer H Foster
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Douglas Harrison
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susan L McGovern
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Arnold C Paulino
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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18
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Bahouth SM, Yeboa DN, Ghia AJ, Tatsui CE, Alvarez-Breckenridge CA, Beckham TH, Bishop AJ, Li J, McAleer MF, North RY, Rhines LD, Swanson TA, Chenyang W, Amini B. Advances in the management of spinal metastases: what the radiologist needs to know. Br J Radiol 2023; 96:20220267. [PMID: 35946551 PMCID: PMC10997009 DOI: 10.1259/bjr.20220267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 07/21/2022] [Accepted: 07/25/2022] [Indexed: 11/05/2022] Open
Abstract
Spine is the most frequently involved site of osseous metastases. With improved disease-specific survival in patients with Stage IV cancer, durability of local disease control has become an important goal for treatment of spinal metastases. Herein, we review the multidisciplinary management of spine metastases, including conventional external beam radiation therapy, spine stereotactic radiosurgery, and minimally invasive and open surgical treatment options. We also present a simplified framework for management of spinal metastases used at The University of Texas MD Anderson Cancer Center, focusing on the important decision points where the radiologist can contribute.
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Affiliation(s)
- Sarah M Bahouth
- Musculoskeletal Imaging and Intervention Department, Brigham
and Women’s Hospital, Boston, United States
| | - Debra N Yeboa
- Department of Radiation Oncology, The University of Texas MD
Anderson Cancer Center, Houston, TX, United States
| | - Amol J Ghia
- Department of Radiation Oncology, The University of Texas MD
Anderson Cancer Center, Houston, TX, United States
| | - Claudio E Tatsui
- Department of Neurosurgery, The University of Texas MD
Anderson Cancer Center, Houston, TX, United States
| | | | - Thomas H Beckham
- Department of Radiation Oncology, The University of Texas MD
Anderson Cancer Center, Houston, TX, United States
| | - Andrew J Bishop
- Department of Radiation Oncology, The University of Texas MD
Anderson Cancer Center, Houston, TX, United States
| | - Jing Li
- Department of Radiation Oncology, The University of Texas MD
Anderson Cancer Center, Houston, TX, United States
| | - Mary Frances McAleer
- Department of Radiation Oncology, The University of Texas MD
Anderson Cancer Center, Houston, TX, United States
| | - Robert Y North
- Department of Neurosurgery, The University of Texas MD
Anderson Cancer Center, Houston, TX, United States
| | - Laurence D Rhines
- Department of Neurosurgery, The University of Texas MD
Anderson Cancer Center, Houston, TX, United States
| | - Todd A Swanson
- Department of Radiation Oncology, The University of Texas MD
Anderson Cancer Center, Houston, TX, United States
| | - Wang Chenyang
- Department of Radiation Oncology, The University of Texas MD
Anderson Cancer Center, Houston, TX, United States
| | - Behrang Amini
- Department of Musculoskeletal Imaging, The University of Texas
MD Anderson Cancer Center, Houston, TX, United
States
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19
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McGovern SL, Luo D, Johnson J, Nguyen K, Li J, McAleer MF, Yeboa D, Grosshans DR, Ghia AJ, Chung C, Bishop AJ, Song J, Thall PF, Brown PD, Mahajan A. A Prospective Study of Conventionally Fractionated Dose Constraints for Reirradiation of Primary Brain Tumors in Adults. Pract Radiat Oncol 2022; 13:231-238. [PMID: 36596356 DOI: 10.1016/j.prro.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 12/22/2022] [Accepted: 12/26/2022] [Indexed: 01/01/2023]
Abstract
PURPOSE Dose constraints for reirradiation of recurrent primary brain tumors are not well-established. This study was conducted to prospectively evaluate composite dose constraints for conventionally fractionated brain reirradiation. METHODS AND MATERIALS A single-institution, prospective study of adults with previously irradiated, recurrent brain tumors was performed. For 95% of patients, electronic dosimetry records from the first course of radiation (RT1) were obtained and deformed onto the simulation computed tomography for the second course of radiation (RT2). Conventionally fractionated treatment plans for RT2 were developed that met protocol-assigned dose constraints for RT2 alone and the composite dose of RT1 + RT2. Prospective composite dose constraints were based on histology, interval since RT1, and concurrent bevacizumab. Patients were followed with magnetic resonance imaging including spectroscopy and perfusion studies. Primary endpoint was the rate of symptomatic brain necrosis at 6 months after RT2. RESULTS Patients were enrolled from March 2017 to May 2018; 20 were evaluable. Eighteen had glioma, 1 had atypical choroid plexus papilloma, and 1 had hemangiopericytoma. Nineteen patients were treated with volumetric modulated arc therapy, and one was treated with protons. Median RT1 dose was 57 Gy (range, 50-60 Gy). Median RT1-RT2 interval was 49 months (range, 9-141 months). Median RT2 dose was 42.4 Gy (range, 36-60 Gy). Median planning target volume was 186 cc (range, 8-468 cc). Nineteen of 20 patients (95%) were free of grade 3+ central nervous system necrosis. One patient had grade 3+ necrosis 2 months after RT2; the patient recovered fully and lived another 18 months until dying of disease progression. Median overall survival from RT2 start for all patients was 13.3 months (95% credible interval, 6.3-20.7); for patients with glioblastoma, 11.5 months (95% credible interval, 6.1-20.1). CONCLUSIONS Brain reirradiation can be safely performed with conventionally fractionated regimens tailored to previous dose distributions. The prospective composite dose constraints described here are a starting point for future studies of conventionally fractionated reirradiation.
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Affiliation(s)
- Susan L McGovern
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - Dershan Luo
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason Johnson
- Department of Diagnostic Imaging, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kham Nguyen
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jing Li
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mary Frances McAleer
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Debra Yeboa
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David R Grosshans
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amol J Ghia
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Caroline Chung
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Andrew J Bishop
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Juhee Song
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Peter F Thall
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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20
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Hasanov M, Milton DR, Bea Davies A, Sirmans E, Saberian C, Posada EL, Opusunju S, Gershenwald JE, Torres-Cabala CA, Burton EM, Colen R, Huse JT, Glitza Oliva IC, Chung C, McAleer MF, McGovern SL, Yeboa DN, Kim BYS, Prabhu SS, McCutcheon IE, Weinberg J, Lang FF, Tawbi HA, Li J, Haydu LE, Davies MA, Ferguson SD. Changes In Outcomes And Factors Associated With Survival In Melanoma Patients With Brain Metastases. Neuro Oncol 2022:6889653. [PMID: 36510640 DOI: 10.1093/neuonc/noac251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUD Treatment options for patients with melanoma brain metastasis (MBM) have changed significantly in the last decade. Few studies have evaluated changes in outcomes and factors associated with survival in MBM patients over time. The aim of this study is to evaluate changes in clinical features and overall survival (OS) for MBM patients. METHODS Patients diagnosed with MBMs from 1/1/2009-12/31/2013 (Prior Era; PE) and 1/1/2014-12/31/2018 (Current Era; CE) at The University of Texas MD Anderson Cancer Center were included in this retrospective analysis. The primary outcome measure was OS. Log-rank test assessed differences between groups; multivariable analyses were performed with Cox proportional hazards models and recursive partitioning analysis (RPA). RESULTS 791 MBM patients (PE, n=332; CE, n=459) were included in analysis. Median OS from MBM diagnosis was 10.3 months (95% CI, 8.9 - 12.4) and improved in the CE versus PE (14.4 vs. 10.3 months, P < .001). Elevated serum LDH was the only factor associated with worse OS in both PE and CE patients. Factors associated with survival in CE MBM patients included patient age, primary tumor Breslow thickness, prior immunotherapy, leptomeningeal disease (LMD), symptomatic MBMs, and whole brain radiation therapy (WBRT). Several factors associated with OS in the PE were not significant in the CE. RPA demonstrated that elevated serum LDH and prior immunotherapy treatment are the most important determinants of survival in CE MBM patients. CONCLUSIONS OS and factors associated with OS have changed for MBM patients. This information can inform contemporary patient management and clinical investigations.
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Affiliation(s)
- Merve Hasanov
- Department of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Denái R Milton
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Alicia Bea Davies
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Elizabeth Sirmans
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Chantal Saberian
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Eliza L Posada
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sylvia Opusunju
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jeffrey E Gershenwald
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Elizabeth M Burton
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Rivka Colen
- Center for Artificial Intelligence Innovation in Medical Imaging, University of Pittsburg, Pittsburg, PA
| | - Jason T Huse
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Isabella C Glitza Oliva
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Caroline Chung
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mary Frances McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Susan L McGovern
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Debra N Yeboa
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Betty Y S Kim
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sujit S Prabhu
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ian E McCutcheon
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jeffrey Weinberg
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Frederick F Lang
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Hussein A Tawbi
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jing Li
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lauren E Haydu
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Michael A Davies
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sherise D Ferguson
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX
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21
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McAleer MF, Melchior P, Parkes J, Pater L, Rübe C, Saunders D, Paulino AC, Janssens GO, Kalapurakal J. Harmonica consensus, controversies, and future directions in radiotherapy for pediatric Wilms tumors. Pediatr Blood Cancer 2022; 70 Suppl 2:e30090. [PMID: 36482883 DOI: 10.1002/pbc.30090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 10/16/2022] [Accepted: 10/18/2022] [Indexed: 12/13/2022]
Abstract
Radiotherapy (RT) is essential for multimodality treatment of pediatric renal tumors, particularly in higher-risk and metastatic disease. Despite decades of use, particularly for Wilms tumor, there remain controversies regarding RT indications, timing, dose, and targets. To align global management, we address these issues in this international HARMONIsation and CollAboration (HARMONICA) project. There are multiple knowledge gaps and opportunities for future research including: (1) utilization of advanced RT technologies, including intensity-modulated RT, proton beam therapy, combined with image-guided RT to reduce target volumes; (2) impact of molecular biomarkers including loss of heterozygosity at 1p, 16q, and 1q gain on RT indications; (3) mitigation of reproductive toxicity following RT; (4) promotion of RT late effects research; and (5) support to overcome challenges in RT utilization in low- and middle-income countries where 90% of the world's children reside. Here, we outline current status and future directions for RT in pediatric renal tumors.
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Affiliation(s)
- Mary Frances McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Patrick Melchior
- Department of Radiation Oncology, Saarland University Hospital, Homburg, Germany
| | - Jeannette Parkes
- Department of Radiation Oncology, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa.,Low- and Middle-Income Countries Committee Co-Chair, Paediatric Radiation Oncology Society, Cape Town, South Africa
| | - Luke Pater
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Christian Rübe
- Department of Radiation Oncology, Saarland University Hospital, Homburg, Germany
| | | | - Arnold C Paulino
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Geert O Janssens
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - John Kalapurakal
- Department of Radiation Oncology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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22
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Bahouth SM, Yeboa DN, Ghia AJ, Tatsui CE, Alvarez-Breckenridge CA, Beckham TH, Bishio AJ, Li J, McAleer MF, North RY, Rhines LD, Swanson TA, Chenyang W, Amini B. Multidisciplinary management of spinal metastases: what the radiologist needs to know. Br J Radiol 2022; 95:20220266. [PMID: 35856792 PMCID: PMC9815745 DOI: 10.1259/bjr.20220266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 06/17/2022] [Accepted: 07/11/2022] [Indexed: 01/13/2023] Open
Abstract
The modern management of spinal metastases requires a multidisciplinary approach that includes radiation oncologists, surgeons, medical oncologists, and diagnostic and interventional radiologists. The diagnostic radiologist can play an important role in the multidisciplinary team and help guide assessment of disease and selection of appropriate therapy. The assessment of spine metastases is best performed on MRI, but imaging from other modalities is often needed. We provide a review of the clinical and imaging features that are needed by the multidisciplinary team caring for patients with spine metastases and stress the importance of the spine radiologist taking responsibility for synthesizing imaging features across multiple modalities to provide a report that advances patient care.
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Affiliation(s)
- Sarah M Bahouth
- Musculoskeletal Imaging and Intervention Department, Brigham and Women’s Hospital, Boston MA, USA
| | - Debra N Yeboa
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amol J Ghia
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Claudio E Tatsui
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Thomas H Beckham
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew J Bishio
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jing Li
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mary Frances McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Robert Y North
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laurence D Rhines
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Todd A Swanson
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wang Chenyang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Behrang Amini
- Department of Musculoskeletal Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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23
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McGovern S, Mackin D, Li J, Paulino A, Grosshans D, Weinberg J, Sandberg D, Chintagumpala M, Gill J, Zaky W, Briere T, McAleer MF. RONC-06. Stereotactic radiosurgery and stereotactic radiotherapy for pediatric brain metastases or recurrences. Neuro Oncol 2022. [PMCID: PMC9164904 DOI: 10.1093/neuonc/noac079.660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND/PURPOSE: Stereotactic radiosurgery (SRS) and stereotactic radiotherapy (SRT) deliver highly conformal, ablative doses of radiation over 1–5 treatments, while minimizing dose to surrounding normal tissues. To document toxicities and outcomes of these treatments in children, our updated institutional experience with SRS or SRT for intracranial targets in pediatric patients was reviewed. METHODS: On an IRB approved study, institutional databases were reviewed to identify pediatric patients with intracranial lesions treated with SRS or SRT from October 2009 to July 2021. Medical records were retrospectively reviewed for patient and treatment characteristics. Outcomes were analyzed for symptomatic radionecrosis and CNS progression. RESULTS: Thirty SRS or SRT treatment courses in 26 patients age 3.2 to 17.8y (median, 15.6y) at the time of SRS or SRT were identified. Twenty-two patients had one treatment and four had two treatments. Sixteen patients had brain metastases from extracranial primary disease; 10 had recurrence of a primary CNS tumor. Fifteen patients had prior fractionated radiation to the brain. Nineteen treatments used Gamma Knife (GK) with Leksell frame, three used GK ICON with mask, and eight used linear accelerator with volumetric modulated arc therapy with thermoplastic mask. All patients (10 treatments in nine patients) treated since July 2016 received mask-based radiation. Twelve of 26 (46%) patients were treated with anesthesia. With 9.6-month median follow up (range, 0.1-96.2m), five patients had progression of treated lesions, eight had distant CNS failure, and one had both local and distant failure, for a crude local failure rate of 6/26 (23%) and a crude distant failure rate of 9/26 (35%). There were no skull fractures or other complications from Leksell frame placement. One patient developed symptomatic radionecrosis requiring surgery. CONCLUSION: SRS and SRT can be safely performed in pediatric patients with intracranial lesions. Mask-based immobilization provides an alternative to frame-based treatments.
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Affiliation(s)
| | | | - Jing Li
- MD Anderson Cancer Center , Houston, TX , USA
| | | | | | | | - David Sandberg
- Children’s Memorial Hermann Hospital , Houston, TX , USA
| | | | | | - Wafik Zaky
- MD Anderson Cancer Center , Houston, TX , USA
| | - Tina Briere
- MD Anderson Cancer Center , Houston, TX , USA
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24
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Briere TM, Agrusa JE, Martel MK, Jackson A, Olch AJ, Ronckers CM, Kremer LCM, Constine LS, McAleer MF. Acute and Late Pulmonary Effects After Radiation Therapy in Childhood Cancer Survivors: A PENTEC Comprehensive Review. Int J Radiat Oncol Biol Phys 2022:S0360-3016(22)00132-8. [PMID: 35525723 DOI: 10.1016/j.ijrobp.2022.01.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 12/07/2021] [Accepted: 01/29/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES The Pediatric Normal Tissue Effects in the Clinic (PENTEC) pulmonary task force reviewed dosimetric and clinical factors associated with radiation therapy (RT)-associated pulmonary toxicity in children. METHODS Comprehensive search of PubMed (1965-2020) was conducted to assess available evidence and predictive models of RT-induced lung injury in pediatric cancer patients (<21 years old). Lung dose for radiation pneumonitis (RP) was obtained from dose-volume histogram (DVH) data. RP grade was obtained from standard criteria. Clinical pulmonary outcomes were evaluated using pulmonary function tests (PFTs), clinical assessment, and questionnaires. RESULTS More than 2,400 abstracts were identified; 460 articles had detailed treatment and toxicity data; and 11 articles with both detailed DVH and toxicity data were formally reviewed. Pooled cohorts treated during 1999 to 2016 included 277 and 507 patients age 0.04 to 22.7 years who were evaluable for acute and late RP analysis, respectively. After partial lung RT, there were 0.4% acute and 2.8% late grade 2, 0.4% acute and 0.8% late grade 3, and no grade 4 to 5 RP. RP risk after partial thoracic RT with mean lung dose (MLD) <14 Gy and total lung V20Gy <30% is low. Clinical and self-reported pulmonary outcomes data included 8,628 patients treated during 1970 to 2013, age 0 to 21.9 years. At a median 2.9- to 21.9-year follow-up, patients were often asymptomatic; abnormal PFTs were common and severity correlated with lung dose. At ≥10-year follow-up, multi-institutional studies suggested associations between total or ipsilateral lung doses >10 Gy and pulmonary complications and deaths. After whole lung irradiation (WLI), pulmonary toxicity is higher; no dose response relationship was identified. Bleomycin and other chemotherapeutics at current dose regimens do not contribute substantially to adverse pulmonary outcomes after partial lung irradiation but increase risk with WLI. CONCLUSIONS After partial lung RT, acute pulmonary toxicity is uncommon; grade 2 to 3 RP incidences are <1%. Late toxicities, including subclinical/asymptomatic impaired pulmonary function, are more common (<4%). Incidence and severity appear to increase over time. Upon review of available literature, there appears to be low risk of pulmonary complications in children with MLD < 14 Gy and V20Gy <30% using standard fractionated RT to partial lung volumes. A lack of robust data limit guidance on lung dose/volume constraints, highlighting the need for additional work to define factors associated with RT-induced lung injury.
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Affiliation(s)
- Tina Marie Briere
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jennifer E Agrusa
- Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Mary K Martel
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Andrew Jackson
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Arthur J Olch
- Department of Radiation Oncology University of Southern California Keck School of Medicine and Children's Hospital Los Angeles, Los Angeles, California; Radiation Oncology Program, Children's Hospital Los Angeles, Los Angeles, California
| | - Cécile M Ronckers
- Department of Pediatrics, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; Institute of Biostatistics and Registry Research, Medical University Brandenburg Medical School-Theodor Fontane, Neuruppin, Germany
| | - Leontien C M Kremer
- Department of Pediatrics, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; Department of Pediatrics, UMC Amsterdam, Location AMC, Amsterdam, the Netherlands
| | - Louis S Constine
- Departments of Radiation Oncology and Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Mary Frances McAleer
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas.
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25
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Upadhyay R, Liao K, Grosshans DR, McGovern SL, Frances McAleer M, Zaky W, Chintagumpala MM, Mahajan A, Nana Yeboa D, Paulino AC. Quantifying the risk and dosimetric variables of symptomatic brainstem injury after proton beam radiation in pediatric brain tumors. Neuro Oncol 2022; 24:1571-1581. [PMID: 35157767 PMCID: PMC9435496 DOI: 10.1093/neuonc/noac044] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Brainstem toxicity after radiation therapy (RT) is a devastating complication and a particular concern with proton radiation (PBT). We investigated the incidence and clinical correlates of brainstem injury in pediatric brain tumors treated with PBT. METHODS All patients <21 years with brain tumors treated with PBT at our institution from 2007-2019, with a brainstem Dmean >30 Gy and/or Dmax >50.4 Gy were included. Symptomatic brainstem injury (SBI) was defined as any new or progressive cranial neuropathy, ataxia, and/or motor weakness with corresponding radiographic abnormality within brainstem. RESULTS A total of 595 patients were reviewed and 468 (medulloblastoma = 200, gliomas = 114, ependymoma = 87, ATRT = 43) met our inclusion criteria. Median age at RT was 6.3 years and median prescribed RT dose was 54Gy [RBE]. Fifteen patients (3.2%) developed SBI, at a median of 4 months after RT. Grades 2, 3, 4, and 5 brainstem injuries were seen in 7, 5, 1, and 2 patients respectively. Asymptomatic radiographic changes were seen in 51 patients (10.9%). SBI was significantly higher in patients with age ≤3 years, female gender, ATRT histology, patients receiving high-dose chemotherapy with stem cell rescue, and those not receiving craniospinal irradiation. Patients with SBI had a significantly higher V50-52. In 2014, our institution started using strict brainstem dose constraints (Dmax ≤57 Gy, Dmean ≤52.4 Gy, and V54≤10%). There was a trend towards decrease in SBI from 4.4% (2007-2013) to 1.5% (2014-2019) (P = .089) without affecting survival. CONCLUSION Our results suggest a low risk of SBI after PBT for pediatric brain tumors, comparable to photon therapy. A lower risk was seen after adopting strict brainstem dose constraints.
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Affiliation(s)
- Rituraj Upadhyay
- Department of Radiation Oncology, The James Cancer Centre Ohio State University, Columbus, Ohio, USA
| | - Kaiping Liao
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David R Grosshans
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Susan L McGovern
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mary Frances McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Wafik Zaky
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Debra Nana Yeboa
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Arnold C Paulino
- Corresponding Author: Arnold C. Paulino, MD, Department of Radiation Oncology, MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 0097, Houston, TX 77030, USA ()
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26
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Upadhyay R, Khose S, Pokhylevych H, Paulino AC, McAleer MF, Ghia A, Li J, Yeboa DN, Loghin M, Harrison R, O’Brien B, Kamiya-Matsuoka C, De Groot J, Puduvalli VK, Tatsui C, Alvarez-Breckenridge C, Prabhu S, Rhines L, Zaky W, Lin F, Weinberg JS, Fuller G, Sandberg DI, Johnson JM, McGovern SL. Patterns of failure after radiation therapy in primary spinal high-grade gliomas: A single institutional analysis. Neurooncol Adv 2022; 4:vdac129. [PMID: 36128585 PMCID: PMC9476222 DOI: 10.1093/noajnl/vdac129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background Primary spinal high-grade gliomas (S-HGG) are rare aggressive tumors; radiation therapy (RT) often plays a dominant role in management. We conducted a single-institution retrospective review to study the clinicopathological features and management of S-HGGs. Methods Patients with biopsy-proven S-HGG who received RT from 2001 to 2020 were analyzed for patient, tumor, and treatment characteristics. Kaplan–Meier estimates were used for survival analyses. Results Twenty-nine patients were identified with a median age of 25.9 years (range 1–74 y). Four patients had GTR while 25 underwent subtotal resection or biopsy. All patients were IDH wildtype and MGMT-promoter unmethylated, where available. H3K27M mutation was present in 5 out of 10 patients tested, while one patient harbored p53 mutation. Median RT dose was 50.4 Gy (range 39.6–54 Gy) and 65% received concurrent chemotherapy, most commonly temozolomide. Twenty-three (79%) of patients had documented recurrence. Overall, 16 patients relapsed locally, 10 relapsed in the brain and 8 developed leptomeningeal disease; only 8 had isolated local relapse. Median OS from diagnosis was 21.3 months and median PFS was 9.7 months. On univariate analysis, age, gender, GTR, grade, RT modality, RT dose and concurrent chemotherapy did not predict for survival. Patients with H3K27M mutation had a poorer PFS compared to those without mutation (10.1 m vs 45.1 m) but the difference did not reach statistical significance (P = .26). Conclusions The prognosis of patients with spinal HGGs remains poor with two-thirds of the patients developing distant recurrence despite chemoradiation. Survival outcomes were similar in patients ≤ 29 years compared to adults > 29 years. A better understanding of the molecular drivers of spinal HGGs is needed to develop more effective treatment options.
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Affiliation(s)
- Rituraj Upadhyay
- Department of Radiation Oncology, The James Cancer Centre, Ohio State University , Columbus, Ohio , USA
| | - Swapnil Khose
- Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center , Houston, Texas , USA
| | - Halyna Pokhylevych
- Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center , Houston, Texas , USA
| | - Arnold C Paulino
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center , Houston, Texas , USA
| | - Mary Frances McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center , Houston, Texas , USA
| | - Amol Ghia
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center , Houston, Texas , USA
| | - Jing Li
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center , Houston, Texas , USA
| | - Debra Nana Yeboa
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center , Houston, Texas , USA
| | - Monica Loghin
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center , Houston, Texas , USA
| | - Rebecca Harrison
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center , Houston, Texas , USA
| | - Barbara O’Brien
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center , Houston, Texas , USA
| | - Carlos Kamiya-Matsuoka
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center , Houston, Texas , USA
| | - John De Groot
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center , Houston, Texas , USA
| | - Vinay K Puduvalli
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center , Houston, Texas , USA
| | - Claudio Tatsui
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center , Houston, Texas , USA
| | | | - Sujit Prabhu
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center , Houston, Texas , USA
| | - Larry Rhines
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center , Houston, Texas , USA
| | - Wafik Zaky
- Division of Pediatrics, The University of Texas MD Anderson Cancer Center , Houston, Texas , USA
| | - Frank Lin
- Texas Children’s Cancer Center, Baylor College of Medicine , Houston, Texas , USA
| | - Jeffery S Weinberg
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center , Houston, Texas , USA
| | - Gregory Fuller
- Department of Neuro-pathology, The University of Texas MD Anderson Cancer Center , Houston, Texas , USA (G.F.)
| | - David I Sandberg
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center , Houston, Texas , USA
| | - Jason Michael Johnson
- Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center , Houston, Texas , USA
| | - Susan L McGovern
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center , Houston, Texas , USA
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27
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Weinberg J, Beckham T, McAleer MF, Johnson JM, Yuan Y, Lin H, Kudchadker R, Schwartz T, Knisely J, Dunbar E, McCracken D, Wefel J. RTID-01. PHASE III MULTICENTER RCT OF POST-SURGICAL STEREOTACTIC RADIOTHERAPY VERSUS SURGICALLY TARGETED RADIATION THERAPY FOR THE TREATMENT OF LARGE NEWLY DIAGNOSED BRAIN METASTASES – TRIAL IN PROGRESS. Neuro Oncol 2021. [DOI: 10.1093/neuonc/noab196.764] [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: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Resection (R) followed by single- or multi-fraction stereotactic radiosurgery (SRT) of brain metastases (BMs) lowers resection bed recurrence compared to R alone. Nevertheless, for larger BMs, 12-month recurrence rates after R+SRT can exceed 20–30%. Aiming to improve outcomes, a permanently implanted collagen tile brachytherapy device (GammaTile, GT Medical Technologies, Tempe, AZ) utilizing Cs-131 seeds embedded within a bioresorbable collagen tile was developed and is described as Surgically Targeted Radiation Therapy (STaRT) to distinguish it from external beam radiotherapy. STaRT allows rapid, intense localized radiation dose delivery directly to the tumor bed with predictable dosimetry immediately at the time of R, which may confer reduced risk for radiation necrosis compared to other therapies. It is hypothesized that R+ STaRT will increase surgical bed recurrence-free survival (SB-RFS), while reducing impact on functional and neurocognitive status compared to R+SRT.
METHODS
Multicenter, randomized, comparison trial of patients with resectable, previously untreated “index” BMs (≥ 2.5–5cm), and 0–3 other tumors, will be preoperatively randomized 1:1 to undergo R+SRT or R+STaRT to the index lesion; unresected tumors in both groups will receive SRT. Planned sample size is 180 from 14 sites. Enrollment opened 03/31/2021. First subject was enrolled 04/07/2021. Primary endpoint is SB-RFS. Secondary endpoints include overall survival, quality of life, neurocognition, functional status, imaging findings and adverse events. Follow-up will be through 24 months. This will be the first randomized trial comparing R+SRT versus R+STaRT delivered by Cs-131 sources in permanently implanted resorbable collagen tile carriers. Primary and secondary outcome measures captured will elucidate the potential risks and benefits of these two RT delivery methods in the setting of newly diagnosed BMs. We will present trial accrual progress, available data, experience and lessons learned.
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Affiliation(s)
| | - Thomas Beckham
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - Ying Yuan
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Heather Lin
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rajat Kudchadker
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - Erin Dunbar
- Piedmont Brain Tumor Center, Atlanta, GA, USA
| | | | - Jeffrey Wefel
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Upadhyay R, Khose S, Pokhylevych H, Paulino ADC, McAleer MF, Ghia A, Li J, Yeboa DN, Loghin M, Harrison R, O'Brien B, Kamiya-Matsuoka C, DeGroot J, Puduvalli V, Tatsui C, Prabhu S, Zaky W, Lin F, Weinberg J, Rhines L, Fuller G, Sandberg D, Johnson JM, McGovern S. RADT-09. ROLE OF RADIOTHERAPY IN MANAGEMENT OF PRIMARY SPINAL HIGH GRADE GLIOMA: A SINGLE INSTITUTION RETROSPECTIVE ANALYSIS. Neuro Oncol 2021. [DOI: 10.1093/neuonc/noab196.167] [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: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Primary spinal high-grade gliomas(S-HGG) are rare, aggressive tumors and radiation therapy(RT) plays a dominant role in the management given their infiltrative nature. We conducted a single-institution retrospective review to study the clinicopathological features and management of S-HGGs.
METHODS
Patients with biopsy-proven S-HGG who received RT from 2001-2020 were analyzed for patient, tumor, and treatment characteristics. Kaplan-Meier estimate and Cox proportional hazard regression method were used for survival analyses.
RESULTS
Twenty-nine patients were identified with a median age of 25.9 years (range 1-74y). Four patients had gross total resection(GTR) while 25 underwent subtotal resection or biopsy. Nineteen patients had WHO grade 4 tumor. IDH1 mutation and MGMT promoter methylation were analyzed in 14 and four patients respectively; all were IDH wildtype and MGMT-promoter unmethylated. H3K27M mutation was present in five out of 10 patients tested. Twenty-two patients received photon-based radiation and 7 received proton therapy. Median RT dose was 50.4 Gy (range 39.6-54Gy) with 79% receiving >45Gy. 65% patients received concurrent chemotherapy, most commonly temozolomide. Twenty-three (79%) patients had documented recurrence. Overall, 16 patients relapsed locally, 10 relapsed in the brain and 8 developed leptomeningeal disease; only 8(35%) had isolated local relapse. Median OS from diagnosis was 21.3 months and median PFS after RT was 9.7 months. On univariate analysis, age, sex, GTR, grade, RT modality, RT dose and concurrent chemotherapy did not predict for survival. Patients with H3K27M mutation had a poorer median PFS after RT compared to those without the mutation but the difference did not reach statistical significance (p = 0.26).
CONCLUSIONS
Although 86% of patients had gross disease at RT and received a lower median RT dose than typically used in cerebral high-grade gliomas, only 55% of patients failed locally. H3K27M mutation may portend worse survival; future studies to improve the therapeutic approach in these patients are warranted.
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Affiliation(s)
- Rituraj Upadhyay
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Swapnil Khose
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | | | - Amol Ghia
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jing Li
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Debra Nana Yeboa
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Monica Loghin
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rebecca Harrison
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Barbara O'Brien
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - John DeGroot
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vinay Puduvalli
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Claudio Tatsui
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sujit Prabhu
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wafik Zaky
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Frank Lin
- Texas Children's Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Jeffrey Weinberg
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laurence Rhines
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Greg Fuller
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David Sandberg
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Susan McGovern
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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29
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Buszek SM, Ludmir EB, Grosshans DR, McAleer MF, McGovern SL, Harrison DJ, Okcu MF, Chintagumpala MM, Mahajan A, Paulino AC. Disease Control and Patterns of Failure After Proton Beam Therapy for Rhabdomyosarcoma. Int J Radiat Oncol Biol Phys 2021; 109:718-725. [PMID: 33516439 DOI: 10.1016/j.ijrobp.2020.09.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 08/03/2020] [Accepted: 09/22/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Pediatric patients with rhabdomyosarcoma (RMS) are treated with multimodal therapy, often with radiation therapy (RT) as part of local therapy. We report on the efficacy and patterns of failure after proton beam therapy (PBT) for RMS. METHODS AND MATERIALS Between January 2006 and February 2017, patients with RMS were enrolled in a prospective institutional review board-approved registry protocol for pediatric patients undergoing PBT. Demographics, clinical characteristics, and treatment related outcomes were reviewed. RESULTS Ninety-four RMS patients were treated with a combination of chemotherapy (CT) and PBT. The majority of patients had head and neck (49%) and genitourinary (30%) primaries. Median tumor size was 4.1 cm (range, 1.0-16.5 cm); 33 patients (35%) had primary tumors >5 cm. Median cyclophosphamide equivalent dose was 14.4 g/m2 (range, 0-30.8 g/m2). Median time from CT initiation to RT initiation was 13 weeks (range, 1-58 weeks). With median follow-up of 4 years, 4-year overall survival (OS) was 71%, and 4-year progression-free survival (PFS) was 63%. Thirty patients (32%) experienced relapse (13% with local failure [LF]). Four-year local control (LC) was 85% overall; 4-year LC rates were 100% for low-risk, 85% for intermediate-risk, and 55% for high-risk patients (P = .02). Tumor size predicted LC (P = .007), with 7% versus 33% LF rate by tumor size (≤5 cm vs >5 cm). Delayed RT delivery (≥13 weeks from initiation of CT) predicted worse LC (P = .01). Increased tumor size predicted both inferior PFS (P = .02) and OS (P = .01). Delayed RT delivery predicted both inferior PFS (P = .04) and OS (P = .03). CONCLUSIONS PBT provides LC comparable to prior studies using photon RT. Inferior LC, PFS, and OS rates were observed for patients with larger tumors and those treated with delayed RT. This finding supports ongoing prospective efforts to dose-escalate treatment of tumors >5 cm; however, these data call into question the optimal timing of local therapy, particularly for patients treated with reduced-dose cyclophosphamide.
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Affiliation(s)
- Samantha M Buszek
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ethan B Ludmir
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David R Grosshans
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mary Frances McAleer
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Susan L McGovern
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Douglas J Harrison
- Division of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - M Fatih Okcu
- Department of Pediatrics, Texas Children's Cancer Center, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Murali M Chintagumpala
- Department of Pediatrics, Texas Children's Cancer Center, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Arnold C Paulino
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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30
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Paulino AC, Ludmir EB, Grosshans DR, Su JM, McGovern SL, Okcu MF, McAleer MF, Baxter PA, Mahajan A, Chintagumpala MM. Overall survival and secondary malignant neoplasms in children receiving passively scattered proton or photon craniospinal irradiation for medulloblastoma. Cancer 2021; 127:3865-3871. [PMID: 34254296 DOI: 10.1002/cncr.33783] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 05/10/2021] [Accepted: 06/18/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Both intensity-modulated radiotherapy (RT) and passively scattered proton therapy have a risk of secondary malignant neoplasm (SMN) in children. To determine the influence of RT modality on the incidence of SMN after craniospinal irradiation (CSI), the authors compared the incidence of SMN in children who had medulloblastoma treated with either photon CSI plus an intensity-modulated RT boost (group I) or passively scattered proton CSI plus a boost (group II). METHODS From 1996 to 2014, 115 children with medulloblastoma (group I, n = 63; group II, n = 52) received CSI followed by a boost to the tumor bed. Most patients had standard-risk disease (63.5%). The median follow-up was 12.8 years for group I and 8.7 years for group II. RESULTS The 5-year and 10-year overall survival (OS) rates were 88.8% and 85.1%, respectively, for standard-risk patients and 63.1% and 57.3%, respectively, for high-risk patients, with no OS difference by RT modality (P = .81). Six SMNs were identified (4 in group I, 2 in group II). The 5-year and 10-year SMN incidence rates were 1.0% and 6.9%, respectively (0.0% and 8.0%, respectively, in group I; 2.2% and 4.9%, respectively, in group II; P = .74). Two SMNs occurred in the clinical target volume in the brain, 2 occurred in the exit dose region from the photon spinal field, 1 occurred in the entrance path of a proton beam, and 1 occurred outside the radiation field. There were no reported cases of secondary leukemia. CONCLUSIONS This analysis demonstrates no difference in OS or SMN incidence between patients in groups I and II 10 years after RT. LAY SUMMARY One hundred fifteen children with medulloblastoma received radiotherapy (RT) with either photon craniospinal irradiation (CSI) and an intensity-modulated RT boost (group I; n = 63) or passively scattered proton CSI and a boost (group II;, n = 52). The majority of children had standard-risk disease (63.5%). The 5-year and 10-year overall survival rates were 88.8% and 85.1% for standard-risk patients, respectively, and 63.1% and 57.3% for high-risk patients, respectively, with no difference in overall survival by RT group (P = .81). The 5-year and 10-year second malignant neoplasm incidence rates were 1.0% and 6.9%, respectively, with no difference in second malignant neoplasm incidence according to RT group (P = .74).
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Affiliation(s)
- Arnold C Paulino
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Texas Children's Cancer Center at Baylor College of Medicine, Houston, Texas.,Department of Pediatrics, Division of Hematology/Oncology, Baylor College of Medicine, Houston, Texas
| | - Ethan B Ludmir
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David R Grosshans
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jack M Su
- Texas Children's Cancer Center at Baylor College of Medicine, Houston, Texas.,Department of Pediatrics, Division of Hematology/Oncology, Baylor College of Medicine, Houston, Texas
| | - Susan L McGovern
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - M Fatih Okcu
- Texas Children's Cancer Center at Baylor College of Medicine, Houston, Texas.,Department of Pediatrics, Division of Hematology/Oncology, Baylor College of Medicine, Houston, Texas
| | - Mary Frances McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Patricia A Baxter
- Texas Children's Cancer Center at Baylor College of Medicine, Houston, Texas.,Department of Pediatrics, Division of Hematology/Oncology, Baylor College of Medicine, Houston, Texas
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Murali M Chintagumpala
- Texas Children's Cancer Center at Baylor College of Medicine, Houston, Texas.,Department of Pediatrics, Division of Hematology/Oncology, Baylor College of Medicine, Houston, Texas
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31
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Spiotto MT, McGovern SL, Gunn GB, Grosshans D, McAleer MF, Frank SJ, Paulino AC. Proton Radiotherapy to Reduce Late Complications in Childhood Head and Neck Cancers. Int J Part Ther 2021; 8:155-167. [PMID: 34285943 PMCID: PMC8270100 DOI: 10.14338/ijpt-20-00069.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 12/07/2020] [Indexed: 11/21/2022] Open
Abstract
In most childhood head and neck cancers, radiotherapy is an essential component of treatment; however, it can be associated with problematic long-term complications. Proton beam therapy is accepted as a preferred radiation modality in pediatric cancers to minimize the late radiation side effects. Given that childhood cancers are a rare and heterogeneous disease, the support for proton therapy comes from risk modeling and a limited number of cohort series. Here, we discuss the role of proton radiotherapy in pediatric head and neck cancers with a focus on reducing radiation toxicities. First, we compare the efficacy and expected toxicities in proton and photon radiotherapy for childhood cancers. Second, we review the benefit of proton radiotherapy in reducing acute and late radiation toxicities, including risks for secondary cancers, craniofacial development, vision, and cognition. Finally, we review the cost effectiveness for proton radiotherapy in pediatric head and neck cancers. This review highlights the benefits of particle radiotherapy for pediatric head and neck cancers to improve the quality of life in cancer survivors, to reduce radiation morbidities, and to maximize efficient health care use.
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Affiliation(s)
- Michael T Spiotto
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susan L McGovern
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G Brandon Gunn
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David Grosshans
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mary Frances McAleer
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven J Frank
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Arnold C Paulino
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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32
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Weinberg J, McAleer MF, Johnson JM, Kudchadker R, Wefel JS, Yuan Y, Lin HY. A phase III multicenter randomized controlled trial of postsurgical stereotactic radiotherapy versus surgically targeted radiation therapy (STaRT) for the treatment of large (>2.5cm) newly diagnosed brain metastases: Trial in progress. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.tps2067] [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
TPS2067 Background: Resection (R) followed by single or multi-fraction stereotactic radiosurgery (SRT) of brain metastases lowers resection bed recurrence compared to R alone. Nevertheless, for larger (>2.5cm) brain metastasis, 12-month recurrence rates after R+SRT can exceed 20–30%. Aiming to improve outcomes, a permanently implanted collagen tile brachytherapy device (GammaTile or GT, GT Medical Technologies, Tempe, AZ) utilizing Cs-131 seeds embedded within a bioresorbable collagen tile was developed and is described as Surgically Targeted Radiation Therapy (STaRT) to distinguish it from external beam radiation therapy. It is hypothesized that immediate adjuvant radiotherapy (RT) and/or RT dose intensification could improve outcomes. The device is FDA-cleared for this indication and early commercial use is demonstrating favorable safety and efficacy outcomes. STaRT allows rapid dose delivery of radiation therapy directly to the tumor bed with predictable dosimetry immediately at the time of resection, and an intense but localized radiation treatment, which may confer a reduced risk for radiation necrosis compared to other therapies. The device is easily placed with minimal additional operative time and limited staff radiation exposure. It is hypothesized that R+ STaRT will increase the surgical bed recurrence-free survival, while reducing the impact on functional and neurocognitive status compared to R+SRT. Methods: Multicenter, randomized, comparison trial of patients with resectable, previously untreated “index” brain metastases measuring ≥2.5–5 cm, and 0–3 other tumors, will be preoperatively randomized 1:1 to undergo either R+ SRT or R+STaRT to the index lesion; unresected tumors in both groups will receive SRT. Planned sample size is 180 from 13 sites. Enrollment will open in Q1. Primary endpoint is surgical bed-recurrence free survival. Secondary endpoints include overall survival, quality of life (Functional Assessment of Cancer Therapy-Brain, Linear Analog Self-Assessment), neurocognition (Hopkins Verbal Learning Test, Trail Making Tests, Controlled Oral Word Association), functional status (Karnofsky Performance Scale, Barthel-ADL), and adverse events. Follow-up will be at 1,3,6,9, and 12 months, then every 6 months through 24 months. This will be the first randomized trial comparing R+SRT versus R+STaRT delivered by Cs-131 sources in permanently implanted resorbable collagen tile carriers. Primary and secondary outcome measures will be captured to elucidate the potential risks and benefits of these two differing post-operative RT delivery methods in the setting of newly diagnosed metastatic brain tumors. Clinical trial information: NCT04365374.
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Affiliation(s)
| | | | | | | | | | - Ying Yuan
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Heather Y. Lin
- The University of Texas MD Anderson Cancer Center, Houston, TX
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Ning MS, Das P, Rosenthal DI, Dabaja BS, Liao Z, Chang JY, Gomez DR, Klopp AH, Gunn GB, Allen PK, Nitsch PL, Natter RB, Briere TM, Herman JM, Wells R, Koong AC, McAleer MF. Early and Midtreatment Mortality in Palliative Radiotherapy: Emphasizing Patient Selection in High-Quality End-of-Life Care. J Natl Compr Canc Netw 2021; 19:805-813. [PMID: 33878727 DOI: 10.6004/jnccn.2020.7664] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 09/28/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Palliative radiotherapy (RT) is effective, but some patients die during treatment or too soon afterward to experience benefit. This study investigates end-of-life RT patterns to inform shared decision-making and facilitate treatment consistent with palliative goals. MATERIALS AND METHODS All patients who died ≤6 months after initiating palliative RT at an academic cancer center between 2015 and 2018 were identified. Associations with time-to-death, early mortality (≤30 days), and midtreatment mortality were analyzed. RESULTS In total, 1,620 patients died ≤6 months from palliative RT initiation, including 574 (34%) deaths at ≤30 days and 222 (14%) midtreatment. Median survival was 43 days from RT start (95% CI, 41-45) and varied by site (P<.001), ranging from 36 (head and neck) to 53 days (dermal/soft tissue). On multivariable analysis, earlier time-to-death was associated with osseous (hazard ratio [HR], 1.33; P<.001) and head and neck (HR, 1.45; P<.001) sites, multiple RT courses ≤6 months (HR, 1.65; P<.001), and multisite treatments (HR, 1.40; P=.008), whereas stereotactic technique (HR, 0.77; P<.001) and more recent treatment year (HR, 0.82; P<.001) were associated with longer survival. No difference in time to death was noted among patients prescribed conventional RT in 1 to 10 versus >10 fractions (median, 40 vs 47 days; P=.272), although the latter entailed longer courses. The 30-day mortality group included 335 (58%) inpatients, who were 27% more likely to die midtreatment (P=.031). On multivariable analysis, midtreatment mortality among these inpatients was associated with thoracic (odds ratio [OR], 2.95; P=.002) and central nervous system (CNS; OR, 2.44; P=.002) indications, >5-fraction courses (OR, 3.27; P<.001), and performance status of 3 to 4 (OR, 1.63; P=.050). Conversely, palliative/supportive care consultation was associated with decreased midtreatment mortality (OR, 0.60; P=.045). CONCLUSIONS Earlier referrals and hypofractionated courses (≤5-10 treatments) should be routinely considered for palliative RT indications, given the short life expectancies of patients at this stage in their disease course. Providers should exercise caution for emergent thoracic and CNS indications among inpatients with poor prognoses due to high midtreatment mortality.
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Affiliation(s)
| | | | | | | | | | | | - Daniel R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | | | - Paige L Nitsch
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Tina M Briere
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Joseph M Herman
- Department of Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, Lake Success, New York
| | - Rebecca Wells
- Department of Management, Policy, and Community Health, University of Texas Health Science Center School of Public Health, Houston, Texas; and
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34
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Thrower SL, Al Feghali KA, Luo D, Paddick I, Hou P, Briere T, Li J, McAleer MF, McGovern SL, Woodhouse KD, Yeboa DN, Brock KK, Chung C. The Effect of Slice Thickness on Contours of Brain Metastases for Stereotactic Radiosurgery. Adv Radiat Oncol 2021; 6:100708. [PMID: 34124413 PMCID: PMC8175282 DOI: 10.1016/j.adro.2021.100708] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 03/22/2021] [Accepted: 04/06/2021] [Indexed: 12/30/2022] Open
Abstract
Objectives Stereotactic radiosurgery is a common treatment for brain metastases and is typically planned on magnetic resonance imaging (MRI). However, the MR acquisition parameters used for patient selection and treatment planning for stereotactic radiosurgery can vary within and across institutions. In this work, we investigate the effect of MRI slice thickness on the detection and contoured volume of metastatic lesions in the brain. Methods and Materials A retrospective cohort of 28 images acquired with a slice thickness of 1 mm were resampled to simulate acquisitions at 2- and 3-mm slice thickness. A total of 102 metastases ranging from 0.0030 cc to 5.08 cc (75-percentile 0.36 cc) were contoured on the original images. All 3 sets of images were recontoured by experienced physicians. Results Of all the images detected and contoured on the 1 mm images, 3% of lesions were missed on the 2 mm images, and 13% were missed on the 3 mm images. One lesion that was identified on both the 2 mm and 3 mm images was determined to be a blood vessel on the 1 mm images. Additionally, the lesions were contoured 11% larger on the 2 mm and 43% larger on the 3 mm images. Conclusions Using images with a slice thickness >1 mm effects detection and segmentation of brain lesions, which can have an important effect on patient management and treatment outcomes.
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Affiliation(s)
- Sara L Thrower
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Karine A Al Feghali
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Dershan Luo
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ian Paddick
- Queen Square Radiosurgery Centre, National Hospital for Neurology and Neurosurgery, London, England
| | - Ping Hou
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Tina Briere
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jing Li
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mary Frances McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Susan L McGovern
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kristina Demas Woodhouse
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Debra Nana Yeboa
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kristy K Brock
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Caroline Chung
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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35
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Hanania AN, Paulino AC, Ludmir EB, Shah VS, Su JM, McGovern SL, Baxter PA, McAleer MF, Grosshans DR, Okcu MF, Chintagumpala MM. Early radiotherapy preserves vision in sporadic optic pathway glioma. Cancer 2021; 127:2358-2367. [PMID: 33739455 DOI: 10.1002/cncr.33497] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 01/02/2021] [Accepted: 01/26/2021] [Indexed: 01/15/2023]
Abstract
BACKGROUND Sporadic optic pathway/hypothalamic gliomas represent a unique entity within pediatric low-grade glioma. Despite favorable survival, location makes treatment difficult and local progression debilitating. This study is a longitudinal assessment of visual acuity (VA) among children treated within the last 2 decades. METHODS Clinical characteristics were abstracted for patients treated from 2000 to 2018 at Texas Children's Cancer Center in Houston. Ophthalmologic data taken at 3- to 6-month intervals were examined with age-appropriate VA metrics converted to the LogMAR (logarithm of the minimum angle of resolution) scale. Kaplan-Meier blindness-free survival (BFS) curves, calculated as time-to-bilateral functional blindness (LogMAR ≥0.8 in both eyes), were calculated for patients receiving early radiation therapy (RT; upfront or as first-line salvage treatment) or chemotherapy (CT) and evaluated using the log-rank test. RESULTS Thirty-eight patients with a median follow-up of 8.5 years (range, 2-17 years) were identified. Median age at diagnosis was 3 years (interquartile range, <1-6 years). Early RT was administered in 11 patients (29%). Twenty-seven patients (71%) were treated primarily with CT, initiated at a median age of 3.5 years (range, <1-11 years). Eight patients in the CT group did eventually require RT secondary to VA loss and following multiple lines of CT. Median age at RT for all patients was 11 years (range, 3-17 years). BFS rates were 81% at 5 years and 60% at 8 years for CT and 100% at 5 and 8 years for early RT (P = .017). CONCLUSIONS In a contemporary cohort, early RT, defined as initial or first-line salvage therapy, was found to have superior BFS for appropriately selected patients with sporadic optic pathway/hypothalamic gliomas. LAY SUMMARY Children with low-grade brain tumors of the optic pathway generally have excellent long-term survival; however, given the location of these tumors, there can commonly be threatened vision if the tumor grows. Although radiation is generally deferred in children on the basis of legitimate concerns regarding the effects on the developing brain, it may represent a vision-preserving therapy for well-selected older patients.
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Affiliation(s)
- Alexander N Hanania
- Department of Radiation Oncology, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, Texas.,Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Arnold C Paulino
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ethan B Ludmir
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Veeral S Shah
- Department of Pediatric Ophthalmology, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Jack M Su
- Texas Children's Cancer Center, Baylor College of Medicine, Houston, Texas
| | - Susan L McGovern
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Patricia A Baxter
- Texas Children's Cancer Center, Baylor College of Medicine, Houston, Texas
| | - Mary Frances McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David R Grosshans
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - M Fatih Okcu
- Texas Children's Cancer Center, Baylor College of Medicine, Houston, Texas
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Mohan R, Liu AY, Brown PD, Mahajan A, Dinh J, Chung C, McAvoy S, McAleer MF, Lin SH, Li J, Ghia AJ, Zhu C, Sulman EP, de Groot JF, Heimberger AB, McGovern SL, Grassberger C, Shih H, Ellsworth S, Grosshans DR. Proton therapy reduces the likelihood of high-grade radiation-induced lymphopenia in glioblastoma patients: phase II randomized study of protons vs photons. Neuro Oncol 2021; 23:284-294. [PMID: 32750703 PMCID: PMC7906048 DOI: 10.1093/neuonc/noaa182] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [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: 12/16/2022] Open
Abstract
BACKGROUND We investigated differences in radiation-induced grade 3+ lymphopenia (G3+L), defined as an absolute lymphocyte count (ALC) nadir of <500 cells/µL, after proton therapy (PT) or X-ray (photon) therapy (XRT) for patients with glioblastoma (GBM). METHODS Patients enrolled in a randomized phase II trial received PT (n = 28) or XRT (n = 56) concomitantly with temozolomide. ALC was measured before, weekly during, and within 1 month after radiotherapy. Whole-brain mean dose (WBMD) and brain dose-volume indices were extracted from planned dose distributions. Univariate and multivariate logistic regression analyses were used to identify independent predictive variables. The resulting model was evaluated using receiver operating characteristic (ROC) curve analysis. RESULTS Rates of G3+L were lower in men (7/47 [15%]) versus women (19/37 [51%]) (P < 0.001), and for PT (4/28 [14%]) versus XRT (22/56 [39%]) (P = 0.024). G3+L was significantly associated with baseline ALC, WBMD, and brain volumes receiving 5‒40 Gy(relative biological effectiveness [RBE]) or higher (ie, V5 through V40). Stepwise multivariate logistic regression analysis identified being female (odds ratio [OR] 6.2, 95% confidence interval [CI]: 1.95‒22.4, P = 0.003), baseline ALC (OR 0.18, 95% CI: 0.05‒0.51, P = 0.003), and whole-brain V20 (OR 1.07, 95% CI: 1.03‒1.13, P = 0.002) as the strongest predictors. ROC analysis yielded an area under the curve of 0.86 (95% CI: 0.79-0.94) for the final G3+L prediction model. CONCLUSIONS Sex, baseline ALC, and whole-brain V20 were the strongest predictors of G3+L for patients with GBM treated with radiation and temozolomide. PT reduced brain volumes receiving low and intermediate doses and, consequently, reduced G3+L.
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Affiliation(s)
- Radhe Mohan
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amy Y Liu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic Hospital, Rochester, Minnesota
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic Hospital, Rochester, Minnesota
| | - Jeffrey Dinh
- Millennium Physicians Radiation Oncology, The Woodlands, Texas
| | - Caroline Chung
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sarah McAvoy
- Department of Radiation Oncology, University of Maryland, Baltimore, Maryland
| | - Mary Frances McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Steven H Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jing Li
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amol J Ghia
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Cong Zhu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, The University of Texas Health Science Center, Houston, Texas
| | - Erik P Sulman
- Department of Radiation Oncology, NYU Grossman School of Medicine, New York, New York
| | - John F de Groot
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amy B Heimberger
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Susan L McGovern
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Clemens Grassberger
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Helen Shih
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Susannah Ellsworth
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, Indiana
| | - David R Grosshans
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Liu SM, Brooks ED, Rubin ML, Grosshans DR, Frank SJ, McAleer MF, McGovern SL, Paulino AC, Woodhouse KD. Referral Patterns and Treatment Delays in Medulloblastoma: A Large Academic Proton Center Experience. Int J Part Ther 2020; 7:1-10. [PMID: 33604411 PMCID: PMC7886269 DOI: 10.14338/ijpt-20-00038.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 08/13/2020] [Indexed: 12/04/2022] Open
Abstract
Purpose Patient travel time can cause treatment delays when providers and families decide to seek proton therapy. We examined whether travel distance or referral pattern (domestic versus international) affects time to radiation therapy and subsequent disease outcomes in patients with medulloblastoma at a large academic proton center. Patients and Methods Children with medulloblastoma treated at MD Anderson (MDA) with a protocol of proton beam therapy (PBT) between January 4, 2007, and June 25, 2014, were included in the analysis. The Wilcoxon rank-sum test was used to study the association between time to start of radiation and distance. Classification- and regression-tree analyses were used to explore binary thresholds for continuous covariates (ie, distance). Failure-free survival was defined as the time interval between end of radiation and failure or death. Results 96 patients were included in the analysis: 17 were international (18%); 19 (20%) were from Houston, Texas; 21 were from other cities inside Texas (21%); and 39 (41%) were from other US states. The median time from surgery to start of radiation was not significantly different for international patients (median = 1.45 months) compared with US patients (median = 1.15 months; P = .13). However, time from surgery to start of radiation was significantly longer for patients residing > 1716 km (> 1066 miles) from MDA (median = 1.31 months) than for patients residing ≤ 1716 km (≤ 1066 miles) from MDA (median = 1.05 months; P = .01). This 1- to 2-week delay (median = 7.8 days) did not affect failure-free survival (hazard ratio = 1.34; P = .43). Conclusion We found that short delays in proton access can exist for patients traveling long distances to proton centers. However, in this study, treatment delays did not affect outcomes. This highlights the appropriateness of PBT in the face of travel coordination. Investment by proton centers in a rigorous intake process is justified to offer timely access to curative PBT.
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Affiliation(s)
- Sean M Liu
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eric D Brooks
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Proton Therapy Center, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - M Laura Rubin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - David R Grosshans
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Proton Therapy Center, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Proton Therapy Center, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mary Frances McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Proton Therapy Center, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susan L McGovern
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Proton Therapy Center, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Arnold C Paulino
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Proton Therapy Center, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kristina D Woodhouse
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Proton Therapy Center, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Sadighi Z, Pokhylevych H, Gule-Monroe M, Chen M, Fuller G, Gruschkus S, Sandberg D, McGovern S, McAleer MF, Zaky W, Khatua S, Johnson J. IMG-15. PEDIATRIC GLIOBLASTOMAS CONTRAST ENHANCEMENT PATTERN IS PREDICTIVE OF SURVIVAL. Neuro Oncol 2020. [PMCID: PMC7715233 DOI: 10.1093/neuonc/noaa222.350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Pediatric GBMs are rare, accounting for 3% of all pediatric CNS tumors. Despite advances in treatment, the outcomes for pediatric glioblastomas (GBM) have not significantly improved. Research suggests a link between enhancement patterns and survival in adult patients with glial tumors. We sought to study this relationship in a cohort of pediatric GBMs. METHODS A radiology database was searched for cases < 22 years, pathology proven brain glioblastoma, and pre-surgical MR imaging available for review. Based on pre-treatment, T1-contrast enhanced MR images, size, and contrast enhancement patterns were characterized as focal, diffuse, or ring-like. The extent of resection was assessed by comparing pre- and post-surgery T2 hyperintensity and contrast enhancement. RESULTS 64 eligible patients (age 2-21y, 14.6 + 5.4) were identified. The majority of lesions demonstrated enhancement on gadolinium-enhanced T1 imaging. (n=58/64; 90%). The lesions were categorized into six (9.4%) cases with focal enhancement, 37 (57.8%) cases with diffuse enhancement, and 15 (23.4%) with ring-like enhancement. Patients who received GTR/subtotal resection (STR) and had focal-enhanced GBMs had a significantly longer progression-free survival (PFS) – 14.1 months (p = 0.0308), comparing to diffuse and ring-like enhancing glioblastomas which had respectively 13.9 and 5.5 months of PFS. DISCUSSION Our data suggests that the contrast enhancement pattern is a significant prognostic factor for survival in pediatric GBM. Patients with GTR/STR who had focal-enhancing GBMs had a significantly longer progression-free survival (p=0.03) comparing to other enhancement patterns.
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Affiliation(s)
- Zsila Sadighi
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - Melissa Chen
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Greg Fuller
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - David Sandberg
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susan McGovern
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Wafik Zaky
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Soumen Khatua
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jason Johnson
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Woodhouse K, Alvarez VA, Boyce D, Li J, Yeboa D, Grosshans D, Briere T, Tatsui C, Rhines L, Behrang A, McGovern S, Paulino A, McAleer MF, Ghia A. RONC-17. STEREOTACTIC RADIOSURGERY FOR SPINE METASTASES IN PEDIATRIC MALIGNANCIES. Neuro Oncol 2020. [PMCID: PMC7715826 DOI: 10.1093/neuonc/noaa222.786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Spine stereotactic radiosurgery (SSRS) is a non-invasive technique that delivers ablative radiotherapy for optimal control of bony disease. While SSRS is known to provide excellent local control (LC) and minimal toxicity in adults, the role of SSRS in pediatrics is less clear.
PURPOSE
To evaluate SSRS in pediatric patients with spinal metastases.
METHODS
A retrospective review of patients (<18 yrs) treated with SSRS at MDACC was performed after IRB approval. Descriptive statistics were utilized for analysis.
RESULTS
From 2011–2019, 12 metastatic osseous sites (3 cervical, 4 thoracic, 5 lumbar-sacral) in 9 patients were treated. Median follow-up was 9 months (range 2–41). Six males (67%) and 3 females (33%) all KPS ≥70, received radiation to ≤3 contiguous vertebral bodies. Median age was 16 yrs (range 8–18). No patients required sedation. Histologies included 7 osteosarcomas, one rhabdomyosarcoma and one Ewing’s sarcoma. Metastatic epidural spinal cord compression scores ranged from 0 (6), 1b (3) and 3 (3). No sites had surgery prior to SSRS and one site received prior conventional radiation. SSRS doses included 24 Gy in 1 fraction (7), 24–27 Gy in 3 fractions (4) and 50 Gy in 5 fractions (1). Six-month LC was 83% with one local failure following 27 Gy. OS at 6 and 12 mo were 55% and 23%. There was no grade ≥3 acute toxicity, no radiation myelopathy or vertebral compression fractures.
CONCLUSION
In this initial report, SSRS represents a promising modality that is well tolerated and provides excellent LC. However, further follow-up is warranted in the pediatric setting.
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Affiliation(s)
| | - Victor Albornoz Alvarez
- MD Anderson Cancer Center, University of Texas, Houston, TX, USA
- Baylor College of Medicine, Houston, TX, USA
| | - David Boyce
- MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Jing Li
- MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Debra Yeboa
- MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - David Grosshans
- MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Tina Briere
- MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Claudio Tatsui
- MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Laurence Rhines
- MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Amini Behrang
- MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Susan McGovern
- MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Arnold Paulino
- MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | | | - Amol Ghia
- MD Anderson Cancer Center, University of Texas, Houston, TX, USA
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McGovern S, Johnson J, Kralik S, Grosshans D, McAleer MF, Zaky W, Baxter P, Lin F, Chintagumpala M, Paulino A. RONC-09. PSEUDOPROGRESSION AFTER PROTON THERAPY OF PEDIATRIC SPINAL PILOCYTIC ASTROCYTOMA AND MYXOPAPILLARY EPENDYMOMA. Neuro Oncol 2020. [PMCID: PMC7715742 DOI: 10.1093/neuonc/noaa222.781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Pseudoprogression after proton therapy of CNS tumors is a challenging clinical situation. The rate of pseudoprogression after proton therapy of pediatric spinal tumors is unknown. METHODS Records of pediatric patients with spinal pilocytic astrocytoma (sPA; n = 9) or myxopapillary ependymoma (MPE; n = 6) with gross disease treated with proton therapy with at least 6 months of follow up from completion of proton therapy were retrospectively reviewed for demographics, treatment characteristics, and occurrence of pseudoprogression. Pseudoprogression was defined as a post-radiation increase in tumor size with subsequent decrease in size without additional tumor-directed therapy. RESULTS The median age at radiation for sPA patients was 10.1y (range, 7.0 – 16.2y) and 12.7y (range, 7.9 – 14.4y) for MPE patients. The median prescribed dose was 45 GyRBE (range, 39.6 – 50.4 GyRBE) for sPA patients and 50.4 GyRBE (range, 45 – 54 GyRBE) for MPE patients. One sPA patient received concurrent vincristine. Median follow up after proton therapy was 44 months (range, 9 – 99 months). Six of nine sPA patients (67%) had pseudoprogression occurring at a median of 81 days (range, 34 – 136 days) after proton therapy; no MPE patients developed pseudoprogression (0%; p < 0.03). Two sPA patients with pseudoprogression were symptomatic and improved with medical therapy. CONCLUSION Preliminary analysis suggests that pseudoprogression occurs frequently within 6 months after proton therapy for sPA and infrequently after proton therapy for MPE.
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Affiliation(s)
| | | | | | | | | | - Wafik Zaky
- MD Anderson Cancer Center, Houston, TX, USA
| | | | - Frank Lin
- Texas Children’s Hospital, Houston, TX, USA
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Augustyn A, Patel R, Ludmir E, Haydu L, Guha-Thakurta N, Bishop A, Chung C, Ghia A, McAleer MF, McGovern S, Wang C, Woodhouse K, Yeboa D, Ferguson S, Kim B, Glitza I, Li J. RADT-13. EARLY CONCURRENT IMMUNOTHERAPY WITH STEREOTACTIC RADIOSURGERY IS ASSOCIATED WITH PROLONGED SURVIVAL AND DECREASED DISTANT BRAIN FAILURE IN PATIENTS WITH NEWLY DIAGNOSED MELANOMA BRAIN METASTASES (MBM). Neuro Oncol 2020. [DOI: 10.1093/neuonc/noaa215.766] [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: 11/13/2022] Open
Abstract
Abstract
INTRODUCTION
We evaluated outcomes of patients with newly diagnosed MBM treated with concurrent immune checkpoint inhibition (ICI) and stereotactic radiosurgery (SRS) (concurrentTx), defined as treatment delivery within 30 days of each other.
METHODS
Screening of 2,617 melanoma patients who received ICI (anti-CTLA4/anti-PD1/both) between 2011-2019 identified 151 pts who received concurrentTx for MBM. Among these, 51 had newly-diagnosed MBM and received no prior ICI or SRS, and were included in the current study. Overall survival (OS) and distant brain failure (DBF) were estimated using the Kaplan-Meier method. Incidence of radiation necrosis (RN) was captured.
RESULTS
Median follow up from treatment initiation (either ICI or SRS, whichever occurred first) was 37 months. Median OS was 30 months. Median interval between ICI/SRS was 12 days (range: 1-29). Twenty-two patients received ICI first and 29 received SRS first, without differences in OS (p=0.22), DBF (p=0.91), or development of RN (p=0.86). However, the interval between ICI and SRS was significant. Patients who received concurrentTx 1-11 days apart (n=25, “early”) experienced a significant improvement in OS and DBF compared to 12-29 days apart (n=26, “delayed”) (p=0.01, HR 2.8; 95%CI 1.3-6.2 for OS and p=0.02, HR 2.5; 95%CI 1.2-5.6 for DBF). OS and DBF at 36 months were 67% vs. 26% and 60% vs. 27%, respectively, for the early vs. delayed groups. Time to concurrentTx as a continuous variable was significantly associated with DBF (p=0.02), but not OS (p=0.06). Although not significant, more patients developed RN in the early (26.0%) versus delayed (3.8%) group (p=0.07). No additional patient or treatment differences were identified.
CONCLUSIONS
Early concurrentTx was associated with prolonged OS and improved DBF in newly diagnosed MBM patients who did not receive prior CNS-directed therapy. This finding suggests therapeutic synergism related to combined early treatment and should be validated in a prospective clinical trial.
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Affiliation(s)
| | - Roshal Patel
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ethan Ludmir
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lauren Haydu
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Andrew Bishop
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Caroline Chung
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amol Ghia
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Susan McGovern
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Chenyang Wang
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Debra Yeboa
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Betty Kim
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Isabella Glitza
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jing Li
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
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42
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Lin TA, Ludmir EB, Liao KP, McAleer MF, Bishop AJ, Grosshans D, McGovern S, Woodhouse KD, Paulino AC, Yeboa DN. Relationship between treatment center case volume and survival for localized Ewing sarcoma: The role of radiotherapy timing. Pediatr Blood Cancer 2020; 67:e28685. [PMID: 32881378 DOI: 10.1002/pbc.28685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 08/18/2020] [Accepted: 08/20/2020] [Indexed: 11/06/2022]
Abstract
In the treatment of localized Ewing sarcoma (EWS), delays in local therapy are known to adversely impact overall survival (OS). However, the role of treatment center volume in EWS outcomes, and the interaction between center volume and local therapy timing with definitive radiotherapy, remains unknown. Using the National Cancer Database, we demonstrate that treatment at the lowest EWS volume centers is associated with reduced OS, explained partly by higher rates of delayed local therapy. Treatment at the highest volume centers results in improved OS, but appears independent of radiotherapy timing. Future efforts to improve care for EWS patients across treatment centers are imperative.
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Affiliation(s)
- Timothy A Lin
- The University of Texas MD Anderson Cancer Center, Houston, Texas.,The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ethan B Ludmir
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kai-Ping Liao
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Andrew J Bishop
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David Grosshans
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Susan McGovern
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Arnold C Paulino
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Debra Nana Yeboa
- The University of Texas MD Anderson Cancer Center, Houston, Texas
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Maroongroge S, Smith B, Bloom ES, Ning MS, Wang C, Das P, Koong AC, McAleer MF, Woodhouse KD. Telemedicine for Radiation Oncology in a Post-COVID World. Int J Radiat Oncol Biol Phys 2020; 108:407-410. [PMID: 32890522 PMCID: PMC7462809 DOI: 10.1016/j.ijrobp.2020.06.040] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 06/21/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Sean Maroongroge
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - Benjamin Smith
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elizabeth S Bloom
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matthew S Ning
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Chenyang Wang
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Prajnan Das
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Albert C Koong
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mary Frances McAleer
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kristina D Woodhouse
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
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Ning MS, McAleer MF, Jeter MD, Minsky BD, Ghafar RA, Robinson IJ, Nitsch PL, Zaebst DJ, Todd SE, Nguyen J, Lin SH, Liao Z, Lee P, Gunn GB, Klopp AH, Dabaja BS, Nguyen QN, Chronowski GM, Bloom ES, Koong AC, Das P. Mitigating the impact of COVID-19 on oncology: Clinical and operational lessons from a prospective radiation oncology cohort tested for COVID-19. Radiother Oncol 2020; 148:252-257. [PMID: 32474129 PMCID: PMC7256609 DOI: 10.1016/j.radonc.2020.05.037] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/20/2020] [Accepted: 05/23/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND PURPOSE The COVID-19 pandemic warrants operational initiatives to minimize transmission, particularly among cancer patients who are thought to be at high-risk. Within our department, a multidisciplinary tracer team prospectively monitored all patients under investigation, tracking their test status, treatment delays, clinical outcomes, employee exposures, and quarantines. MATERIALS AND METHODS Prospective cohort tested for SARS-COV-2 infection over 35 consecutive days of the early pandemic (03/19/2020-04/22/2020). RESULTS A total of 121 Radiation Oncology patients underwent RT-PCR testing during this timeframe. Of the 7 (6%) confirmed-positive cases, 6 patients were admitted (4 warranting intensive care), and 2 died from acute respiratory distress syndrome. Radiotherapy was deferred or interrupted for 40 patients awaiting testing. As the median turnaround time for RT-PCR testing decreased from 1.5 (IQR: 1-4) to ≤1-day (P < 0.001), the median treatment delay also decreased from 3.5 (IQR: 1.75-5) to 1 business day (IQR: 1-2) [P < 0.001]. Each patient was an exposure risk to a median of 5 employees (IQR: 3-6.5) through prolonged close contact. During this timeframe, 39 care-team members were quarantined for a median of 3 days (IQR: 2-11), with a peak of 17 employees simultaneously quarantined. Following implementation of a "dual PPE policy," newly quarantined employees decreased from 2.9 to 0.5 per day. CONCLUSION The severe adverse events noted among these confirmed-positive cases support the notion that cancer patients are vulnerable to COVID-19. Active tracking, rapid diagnosis, and aggressive source control can mitigate the adverse effects on treatment delays, workforce incapacitation, and ideally outcomes.
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Affiliation(s)
- Matthew S Ning
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA.
| | - Mary Frances McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Melenda D Jeter
- Department of Radiation 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
| | - Robert A Ghafar
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Ivy J Robinson
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Paige L Nitsch
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Denise J Zaebst
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Sarah E Todd
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Jennifer Nguyen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Steven H Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Percy Lee
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - G Brandon Gunn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Ann H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Bouthaina S Dabaja
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Quynh-Nhu Nguyen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Gregory M Chronowski
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Elizabeth S Bloom
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Albert C Koong
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
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45
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Noticewala SS, Ludmir EB, Li J, McAleer MF. In Reply to Rathod et al. Adv Radiat Oncol 2020; 5:748. [PMID: 32775787 PMCID: PMC7397937 DOI: 10.1016/j.adro.2020.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 06/18/2020] [Indexed: 11/09/2022] Open
Affiliation(s)
- Sonal S. Noticewala
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ethan B. Ludmir
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jing Li
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mary Frances McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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46
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McGinnis GJ, Ning MS, Nitsch PL, O'Reilly MS, McAleer MF, Koong AC, Chang JY. Rapid Detection of Asymptomatic Coronavirus Disease 2019 by Computed Tomography Image Guidance for Stereotactic Ablative Radiotherapy. J Thorac Oncol 2020; 15:1085-1087. [PMID: 32311499 PMCID: PMC7162784 DOI: 10.1016/j.jtho.2020.04.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 04/13/2020] [Accepted: 04/14/2020] [Indexed: 11/22/2022]
Affiliation(s)
- Gwendolyn J McGinnis
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matthew S Ning
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Paige L Nitsch
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael S O'Reilly
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mary Frances McAleer
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Albert C Koong
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Joe Y Chang
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas.
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47
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Noticewala SS, Ludmir EB, Bishop AJ, Chung C, Ghia AJ, Grosshans D, McGovern S, Paulino ADLC, Wang C, Woodhouse KD, Yeboa DN, Prabhu SS, Weathers SP, Das P, Koong AC, McAleer MF, Li J. Radiation for Glioblastoma in the Era of Coronavirus Disease 2019 (COVID-19): Patient Selection and Hypofractionation to Maximize Benefit and Minimize Risk. Adv Radiat Oncol 2020; 5:743-745. [PMID: 32775785 PMCID: PMC7251361 DOI: 10.1016/j.adro.2020.04.040] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 04/16/2020] [Accepted: 04/16/2020] [Indexed: 11/16/2022] Open
Abstract
We describe the institutional guidelines of a major tertiary cancer center with regard to using hypofractionated radiation regimens to treat glioblastoma as a measure to minimize exposure to coronavirus disease 2019 (COVID-19) while not sacrificing clinical outcomes. Our guidelines review level one evidence of various hypofractionated regimens, and recommend a multidisciplinary approach while balancing the risk of morbidity and mortality among individuals at high risk for severe illness from COVID-19 infection. We also briefly outline strategies our department is taking in mitigating risk among our cancer patients undergoing radiation.
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Affiliation(s)
- Sonal S Noticewala
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ethan B Ludmir
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Andrew J Bishop
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Caroline Chung
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amol J Ghia
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David Grosshans
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Susan McGovern
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Chenyang Wang
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kristina D Woodhouse
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Debra N Yeboa
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sujit S Prabhu
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shiao-Pei Weathers
- Department of Neurooncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Prajnan Das
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Albert C Koong
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mary Frances McAleer
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jing Li
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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48
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Noticewala SS, Koong AC, Bloom ES, Choi S, Chronowski G, Ghafar RA, Guadagnolo BA, Gunn GB, Klopp A, Lee P, Li J, Liao Z, Ludmir EB, McAleer MF, Nguyen QN, Ning MS, Robinson IJ, Rosenthal DI, Shah SJ, Woodward WA, Zaebst DJ, Dabaja BS, Das P. Radiation Oncology Strategies to Flatten the Curve During the Coronavirus Disease 2019 (COVID-19) Pandemic: Experience From a Large Tertiary Cancer Center. Adv Radiat Oncol 2020; 5:567-572. [PMID: 32775771 PMCID: PMC7240274 DOI: 10.1016/j.adro.2020.04.038] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 04/10/2020] [Accepted: 04/13/2020] [Indexed: 01/27/2023] Open
Abstract
During the coronavirus disease 2019 pandemic, minimizing exposure risk for patients with cancer and health care personnel was of utmost importance. Here, we present steps taken to date to flatten the curve at the radiation oncology division of a tertiary cancer center with the goal of mitigating risk of exposure among patients and staff, and optimizing resource utilization. Response to the coronavirus disease 2019 pandemic in this large tertiary referral center included volume reduction, personal protective equipment recommendations, flexible clinic visit interaction types dictated by need and risk reduction, and numerous social distancing strategies. We hope these outlined considerations can assist the wider radiation oncology community as we collectively face this ongoing challenge.
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Affiliation(s)
- Sonal S Noticewala
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Albert C Koong
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elizabeth S Bloom
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Seungtaek Choi
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Gregory Chronowski
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Robert A Ghafar
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - B Ashleigh Guadagnolo
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - G Brandon Gunn
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ann Klopp
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Percy Lee
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jing Li
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Zhongxing Liao
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ethan B Ludmir
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mary Frances McAleer
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Quynh-Nhu Nguyen
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matthew S Ning
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ivy J Robinson
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David I Rosenthal
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shalin J Shah
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Wendy A Woodward
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Denise J Zaebst
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Bouthaina S Dabaja
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Prajnan Das
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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49
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Li J, Wang Y, Tang C, Welsh JW, Guha- Thakurta N, Carter BW, Wefel JS, Ghia AJ, Yeboa D, McAleer MF, Chung C, Woodhouse KD, Elamin Y, Le X, Cascone T, Negrao MV, Skoulidis F, Ferrarotto R, Heymach J, Altan M. Concurrent nivolumab and ipilimumab with brain stereotactic radiosurgery for brain metastases from non-small cell lung cancer: A phase I trial. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.2531] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
2531 Background: Nivolumab (nivo) and ipilimumab (ipi) were found in the recent phase III CheckMate 227 trial to have an overall survival benefit over chemotherapy for advanced non-small cell lung cancer (NSCLC). However, patients (pts) with untreated brain metastasis (mets) were excluded from that trial. Because 30% of NSCLC pts develop brain mets, we tested nivo/ipi with concurrent stereotactic radiosurgery (SRS) for NSCLC pts with active brain mets. Methods: We report the safety data from the phase I portion of an ongoing phase I/II single-institution trial in which one treatment group was given SRS with nivo (3 mg/kg) every 2 weeks (wks) plus ipi (1 mg/kg) every 6 wks x 4 cycles, followed by maintenance nivo (480 mg) every 4 wks until disease progression, unacceptable toxicity, or withdrawal of consent. Brain SRS was delivered within 7 days of initiation of nivo/ipi. The primary endpoints were safety and 4-month (mo) intracranial progression-free survival (PFS). Dose-limiting toxicity (DLT) was defined as > 15% intracranial toxicity (>G3 hypophysitis / neurologic toxicity) or > 30% extracranial toxicity (>G3 non-dermatologic non-lab toxicity or >G4 dermatologic / lab toxicity), refractory to medical management, assessed at 8 wks after treatment initiation. Target accrual for phase I was 10 evaluable pts, with enrollment suspended after every 5 pts for DLT assessment. Results: Since June 15, 2018, 13 pts were enrolled and 10 were evaluable for DLT. The median follow-up time was 6.8 mo (range 1.2‒18). As of January 6, 2020, only 1 pt had DLT-defined toxicity and thus the predefined stopping criteria were not met. This pt had G3 seizure right after SRS that resolved within a week, and then had increased but asymptomatic CNS edema 4 wks later. Aside from DLTs, 3 pts (25%) developed treatment-related G3 (elevated liver function tests, fatigue, nausea, adrenal insufficiency, and myocarditis) or G4 events (pneumonitis/acute respiratory distress syndrome in 1 pt with confirmed influenza at 7 mos after treatment initiation). This pt subsequently died of hemophagocytic lymphohistiocytosis (considered possibly related to the study drugs). Median intracranial PFS time was 9.7 mo, and the 4-mo intracranial PFS rate was 75%. Extracranial objective response rate was 33% in the 12 evaluable pts with a median response duration of 9.1 mo. Conclusions: Concurrent SRS withnivo/ipi was safe for pts with active NSCLC brain mets. Preliminary analyses of efficacy were encouraging for durable intracranial and extracranial response. Clinical trial information: NCT02696993 .
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Affiliation(s)
- Jing Li
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Yan Wang
- UT M.D.Anderson Cancer Center, Houston, TX
| | - Chad Tang
- University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | - Brett W. Carter
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Amol J. Ghia
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Debra Yeboa
- University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | | | - Xiuning Le
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Tina Cascone
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | - John Heymach
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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50
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Patel RR, Verma V, Miller AB, Lin TA, Jethanandani A, Espinoza AF, Mainwaring W, Augustyn A, Fuller CD, Sulman EP, Yeboa DN, Chung CC, McAleer MF, Li J, Yoshor D, de Groot JF, Mandel JJ, Ludmir EB. Exclusion of patients with brain metastases from cancer clinical trials. Neuro Oncol 2020; 22:577-579. [PMID: 31900480 PMCID: PMC7158639 DOI: 10.1093/neuonc/noz246] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Roshal R Patel
- The University of Texas MD Anderson Cancer Center, Houston, Texas
- Albany Medical College, Albany, New York
| | - Vivek Verma
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Austin B Miller
- The University of Texas MD Anderson Cancer Center, Houston, Texas
- The University of Texas Health Science Center McGovern Medical School, Houston, Texas
| | - Timothy A Lin
- The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Amit Jethanandani
- The University of Tennessee Health Science Center College of Medicine, Memphis, Tennessee
| | | | | | | | - C David Fuller
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Erik P Sulman
- New York University Langone School of Medicine, New York, New York
| | - Debra N Yeboa
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Caroline C Chung
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Jing Li
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - John F de Groot
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Ethan B Ludmir
- The University of Texas MD Anderson Cancer Center, Houston, Texas
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