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Kim IA, Winter KA, Sperduto PW, De Los Santos JF, Peereboom DM, Ogunleye T, Boulter D, Fritz JM, Cho KH, Shin KH, Zoberi I, Choi S, Palmer JD, Liem B, Kim YB, Anderson BM, Thakrar AW, Muanza TM, Kim MM, Choi DH, Mehta MP, White JR. Concurrent Lapatinib With Brain Radiation Therapy in Patients With HER2+ Breast Cancer With Brain Metastases: NRG Oncology-KROG/RTOG 1119 Phase 2 Randomized Trial. Int J Radiat Oncol Biol Phys 2024; 118:1391-1401. [PMID: 37506981 PMCID: PMC10811275 DOI: 10.1016/j.ijrobp.2023.07.019] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 06/03/2023] [Accepted: 07/14/2023] [Indexed: 07/30/2023]
Abstract
PURPOSE Lapatinib plus whole brain radiation therapy (WBRT) or stereotactic radiosurgery (SRS) was hypothesized to improve the 12-week intracranial complete response (CR) rate compared with either option of radiation therapy (RT) alone for patients with brain metastases (BM) from human epidermal growth factor receptor 2-positive (HER2+) breast cancer. METHODS AND MATERIALS This study included patients with HER2+ breast cancer with ≥1 measurable, unirradiated BM. Patients were randomized to WBRT (37.5 Gy/3 wk)/SRS (size-based dosing) ± concurrent lapatinib (1000 mg daily for 6 weeks). Secondary endpoints included objective response rate (ORR), lesion-specific response, central nervous system progression-free survival, and overall survival. RESULTS From July 2012 to September 2019, 143 patients were randomized, with 116 analyzable for the primary endpoint. RT + lapatinib did not improve 12-week CR (0% vs 6% for RT alone, 1-sided P = .97), or ORR at 12 weeks. At 4 weeks, RT + lapatinib showed higher ORR (55% vs 42%). Higher graded prognostic assessment and ≤10 lesions were associated with higher 12-week ORR. Grade 3 and 4 adverse event rates were 8% and 0% for RT and 28% and 6% for RT + lapatinib. CONCLUSIONS The addition of 6 weeks of concomitant lapatinib to WBRT/SRS did not improve the primary endpoint of 12-week CR rate or 12-week ORR. Adding lapatinib to WBRT/SRS showed improvement of 4-week ORR, suggesting a short-term benefit from concomitant therapy.
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Affiliation(s)
- In Ah Kim
- Department of Radiation Oncology, Seoul National University, Seoul, South Korea.
| | - Kathryn A Winter
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | - Paul W Sperduto
- Radiation Oncologist, Minneapolis Radiation Oncology, Minneapolis, Minnesota
| | | | - David M Peereboom
- Brain Tumor & Neuro-Oncology Cleveland Clinic Main Campus, Cleveland, Ohio
| | - Tomi Ogunleye
- Medical Physics Department, Northside Hospital Cancer Institute, Atlanta, Georgia
| | - Daniel Boulter
- Department of Radiology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Joel M Fritz
- Department of Radiology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Kwan Ho Cho
- Department of Radiation Oncology, Seoul National University, Seoul, South Korea
| | - Kyung Hwan Shin
- Department of Radiation Oncology, Seoul National University, Seoul, South Korea
| | - Imran Zoberi
- Department of Radiology Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Serah Choi
- Department of Radiation Oncology, University Hospitals Cleveland Medical Center and Case Comprehensive Cancer Center, Cleveland, Ohio
| | - Joshua D Palmer
- Department of Radiology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ben Liem
- Department of Internal Medicine, Division of Hematology/Oncology, New Mexico Minority Underserved NCORP, Albuquerque, New Mexico
| | - Yong Bae Kim
- Department of Radiation Oncology, Yonsei University Health System-Severance Hospital, Seoul, South Korea
| | - Bethany M Anderson
- Department of Human Oncology, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Anupama W Thakrar
- Department of Radiation Oncology, Stroger Hospital of Cook County Minority Underserved NCORP, Chicago, Illinois
| | - Thierry M Muanza
- Department of Radiation Oncology, Jewish General Hospital, Montreal, Quebec, Canada
| | - Michelle M Kim
- Department of Radiation Oncology, University of Michigan Comprehensive Cancer Center, Ann Arbor, Michigan
| | - Doo Ho Choi
- Department of Radiation Oncology, Samsung Medical Center, Seoul, South Korea
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Miami, Florida
| | - Julia R White
- Department of Radiation Oncology, University of Kansas, Kansas City, Kansas
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Breen WG, Aryal MP, Cao Y, Kim MM. Integrating multi-modal imaging in radiation treatments for glioblastoma. Neuro Oncol 2024; 26:S17-S25. [PMID: 38437666 PMCID: PMC10911793 DOI: 10.1093/neuonc/noad187] [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] [Indexed: 03/06/2024] Open
Abstract
Advances in diagnostic and treatment technology along with rapid developments in translational research may now allow the realization of precision radiotherapy. Integration of biologically informed multimodality imaging to address the spatial and temporal heterogeneity underlying treatment resistance in glioblastoma is now possible for patient care, with evidence of safety and potential benefit. Beyond their diagnostic utility, several candidate imaging biomarkers have emerged in recent early-phase clinical trials of biologically based radiotherapy, and their definitive assessment in multicenter prospective trials is already in development. In this review, the rationale for clinical implementation of candidate advanced magnetic resonance imaging and positron emission tomography imaging biomarkers to guide personalized radiotherapy, the current landscape, and future directions for integrating imaging biomarkers into radiotherapy for glioblastoma are summarized. Moving forward, response-adaptive radiotherapy using biologically informed imaging biomarkers to address emerging treatment resistance in rational combination with novel systemic therapies may ultimately permit improvements in glioblastoma outcomes and true individualization of patient care.
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Affiliation(s)
- William G Breen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Madhava P Aryal
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Yue Cao
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Michelle M Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
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3
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Dahl DM, Wu S, Lin SX, Hu M, Barney AA, Kim MM, Cornejo KM, Harisinghani MG, Feldman AS, Wu CL. Clinical significance of prostate cancer identified by transperineal standard template biopsy in men with nonsuspicious multiparametric magnetic resonance imaging. Urol Oncol 2024; 42:28.e21-28.e28. [PMID: 38182499 DOI: 10.1016/j.urolonc.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 10/31/2023] [Accepted: 11/06/2023] [Indexed: 01/07/2024]
Abstract
OBJECTIVE Multiparametric magnetic resonance imaging (mpMRI) of the prostate has excellent sensitivity in detecting clinically significant prostate cancer (csCaP). However, whether a negative mpMRI in patients with a clinical suspicion of CaP can omit a confirmatory biopsy remains less understood and without consensus. Transperineal (TP) standard template biopsy (SBx) provides an effective approach to CaP detection. Our aim is to provide a comprehensive understanding of the CaP characteristics detected through TP SBx that are systematically overlooked by mpMRI. METHODS We conducted a retrospective analysis of all men who underwent prebiopsy mpMRI and subsequent a 20-core TP SBx at our hospital from September 2019 to February 2021. Patients with suspicious mpMRI received a combined TP SBx and targeted biopsy (TBx) (suspicious group), while those without suspicious (negative) mpMRI and who proceeded to biopsy, received TP SBx only (nonsuspicious group). A negative mpMRI was defined as the absence of suspicious findings and/or the presence of low-risk areas with a PI-RADS score of ≤2. Subsequently, we compared and evaluated the clinical and biopsy characteristics between these 2 groups. RESULTS We identified 301 men in suspicious group and 215 men in nonsuspicious group. The overall CaP detection rate and csCaP detection rate by TP SBx were 74.1%, 38.9% for suspicious group and 43.3%, 14.9% for nonsuspicious group, respectively. csCaP NPV of mpMRI was 85.1% with a csCaP prevalence 28.9%. The greatest percentage of cancer involvement (GPC) in biopsy core from nonsuspicious group was significantly lower than those of suspicious group (40% vs. 50%, p = 0.005), In multivariate logistic analysis, only PSAD > 0.15 ng/ml/cc was identified as an independent and significant predictor of csCaP in nonsuspicious group. CONCLUSION Within our cohort, false-negative rates of mpMRI for csCaP are substantial, reaching 15%. Nonsuspicious cases may contain a large volume tumor since the high GPC of SBx. For cases with nonsuspicious imaging and higher PSAD, a confirmatory biopsy may be necessary due to the increased risk of missed csCaP by mpMRI.
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Affiliation(s)
- Douglas M Dahl
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Shulin Wu
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Sharron X Lin
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Mengjie Hu
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Alfred A Barney
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Michelle M Kim
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Kristine M Cornejo
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Mukesh G Harisinghani
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Adam S Feldman
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Chin-Lee Wu
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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Redmond KJ, Hattangadi-Gluth J, Pollum EL, Trifiletti DM, Kim MM, Milano M. Navigating the Spinal Frontier: Recent Data on Stereotactic Body Radiation Therapy for Spine Metastases. Int J Radiat Oncol Biol Phys 2024; 118:313-317. [PMID: 38220248 DOI: 10.1016/j.ijrobp.2023.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 11/07/2023] [Accepted: 11/07/2023] [Indexed: 01/16/2024]
Affiliation(s)
- Kristin J Redmond
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | | | - Erqi Liu Pollum
- Department of Radiation Oncology, Stanford University Medical Center, Stanford, California
| | | | - Michelle M Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Michael Milano
- Department of Radiation Oncology, University of Rochester, Rochester, New York
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5
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Wu S, Feldman AS, Lin SX, Kim MM, Cornejo KM, Harisinghani MG, Wu CL, Dahl DM. Estimated Prostate Volume by Semiautomatic Segmentation of MRI Is More Accurately Correlated with Radical Prostatectomy Specimen Weight than the Volume Calculated by Ellipsoid Formula. Urol Int 2023; 108:35-41. [PMID: 37995664 DOI: 10.1159/000534742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 10/14/2023] [Indexed: 11/25/2023]
Abstract
INTRODUCTION Accurate in vivo prostate volume (PV) estimation is important for obtaining prostate-specific antigen density (PSAD) and further predicting clinically significant prostate cancer (csPCa). We aimed to evaluate the accuracy of multiparametric magnetic resonance imaging (mpMRI)-estimated PV compared to both volume and weight of radical prostatectomy (RP). METHODS We identified 310 PCa patients who underwent RP following combined targeted and systematic biopsy in our institution from September 2019 to February 2021. The MRI PV was determined using a semiautomated segmentation algorithm. RP PV was calculated using the prolate ellipsoid formula (length × width × height × π/6). Formula (prostate weight = [actual weight-3.8 g]/1.05 g/mL) was applied, and the resulting volume was used in further analysis. RESULTS The median PV from MRI, RP, and RP weight were 39 mL, 38 mL, and 44 mL, respectively. Spearman's rank correlation coefficients (ρ) were 0.841 (MRI PV vs. RP weight), 0.758 (RP PV vs. RP weight), and 0.707 (MRI PV vs. RP PV) (all p < 0.001). Decreased correlation between the MRI PV and RP PV was observed in the larger (more than 55 mL) prostate. The PSAD derived from MRI PV showed most efficient to detect csPCa in RP specimen (57.9% vs. 57.6% vs. 45.4%). CONCLUSION MRI PV is correlated better with RP weight than calculated RP PV, especially in larger prostate. The high csPCa detection rate in final pathology suggested that PSAD derived from MRI PV can be confidently used in clinical practice.
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Affiliation(s)
- Shulin Wu
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Adam S Feldman
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sharron X Lin
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michelle M Kim
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kristine M Cornejo
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mukesh G Harisinghani
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Chin-Lee Wu
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Douglas M Dahl
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Venneti S, Kawakibi AR, Ji S, Waszak SM, Sweha SR, Mota M, Pun M, Deogharkar A, Chung C, Tarapore RS, Ramage S, Chi A, Wen PY, Arrillaga-Romany I, Batchelor TT, Butowski NA, Sumrall A, Shonka N, Harrison RA, de Groot J, Mehta M, Hall MD, Daghistani D, Cloughesy TF, Ellingson BM, Beccaria K, Varlet P, Kim MM, Umemura Y, Garton H, Franson A, Schwartz J, Jain R, Kachman M, Baum H, Burant CF, Mottl SL, Cartaxo RT, John V, Messinger D, Qin T, Peterson E, Sajjakulnukit P, Ravi K, Waugh A, Walling D, Ding Y, Xia Z, Schwendeman A, Hawes D, Yang F, Judkins AR, Wahl D, Lyssiotis CA, de la Nava D, Alonso MM, Eze A, Spitzer J, Schmidt SV, Duchatel RJ, Dun MD, Cain JE, Jiang L, Stopka SA, Baquer G, Regan MS, Filbin MG, Agar NY, Zhao L, Kumar-Sinha C, Mody R, Chinnaiyan A, Kurokawa R, Pratt D, Yadav VN, Grill J, Kline C, Mueller S, Resnick A, Nazarian J, Allen JE, Odia Y, Gardner SL, Koschmann C. Clinical Efficacy of ONC201 in H3K27M-Mutant Diffuse Midline Gliomas Is Driven by Disruption of Integrated Metabolic and Epigenetic Pathways. Cancer Discov 2023; 13:2370-2393. [PMID: 37584601 PMCID: PMC10618742 DOI: 10.1158/2159-8290.cd-23-0131] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 05/30/2023] [Accepted: 08/10/2023] [Indexed: 08/17/2023]
Abstract
Patients with H3K27M-mutant diffuse midline glioma (DMG) have no proven effective therapies. ONC201 has recently demonstrated efficacy in these patients, but the mechanism behind this finding remains unknown. We assessed clinical outcomes, tumor sequencing, and tissue/cerebrospinal fluid (CSF) correlate samples from patients treated in two completed multisite clinical studies. Patients treated with ONC201 following initial radiation but prior to recurrence demonstrated a median overall survival of 21.7 months, whereas those treated after recurrence had a median overall survival of 9.3 months. Radiographic response was associated with increased expression of key tricarboxylic acid cycle-related genes in baseline tumor sequencing. ONC201 treatment increased 2-hydroxyglutarate levels in cultured H3K27M-DMG cells and patient CSF samples. This corresponded with increases in repressive H3K27me3 in vitro and in human tumors accompanied by epigenetic downregulation of cell cycle regulation and neuroglial differentiation genes. Overall, ONC201 demonstrates efficacy in H3K27M-DMG by disrupting integrated metabolic and epigenetic pathways and reversing pathognomonic H3K27me3 reduction. SIGNIFICANCE The clinical, radiographic, and molecular analyses included in this study demonstrate the efficacy of ONC201 in H3K27M-mutant DMG and support ONC201 as the first monotherapy to improve outcomes in H3K27M-mutant DMG beyond radiation. Mechanistically, ONC201 disrupts integrated metabolic and epigenetic pathways and reverses pathognomonic H3K27me3 reduction. This article is featured in Selected Articles from This Issue, p. 2293.
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Affiliation(s)
| | | | - Sunjong Ji
- University of Michigan, Ann Arbor, Michigan
| | - Sebastian M. Waszak
- University of California, San Francisco, San Francisco, California
- Centre for Molecular Medicine Norway (NCMM), Nordic EMBL Partnership, University of Oslo and Oslo University Hospital, Oslo, Norway
- Laboratory of Computational Neuro-Oncology, Swiss Institute for Experimental Cancer Research, School of Life Sciences, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Stefan R. Sweha
- University of Michigan, Ann Arbor, Michigan
- Cancer Biology and Genetics Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | | | - Chan Chung
- University of Michigan, Ann Arbor, Michigan
- Department of New Biology, Daegu Gyeongbuk Institute of Science and Technology (DGIST), Daegu, Republic of Korea
| | | | | | | | - Patrick Y. Wen
- Center for Neuro-Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts
| | | | | | | | | | | | | | - John de Groot
- University of California, San Francisco, San Francisco, California
| | | | | | | | | | | | - Kevin Beccaria
- Department of Neurosurgery, Necker Sick Children's University Hospital and Paris Descartes University, Paris, France
| | - Pascale Varlet
- Department of Neuropathology, Sainte-Anne Hospital and Paris Descartes University, Paris, France
| | | | | | | | | | | | | | | | - Heidi Baum
- University of Michigan, Ann Arbor, Michigan
| | | | - Sophie L. Mottl
- Centre for Molecular Medicine Norway (NCMM), Nordic EMBL Partnership, University of Oslo and Oslo University Hospital, Oslo, Norway
| | | | | | | | | | | | | | | | | | | | - Yujie Ding
- University of Michigan, Ann Arbor, Michigan
| | - Ziyun Xia
- University of Michigan, Ann Arbor, Michigan
| | | | - Debra Hawes
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Fusheng Yang
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Alexander R. Judkins
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California
| | | | | | - Daniel de la Nava
- Health Research Institute of Navarra (IdiSNA), Pamplona, Spain
- Solid Tumor Program, Cima Universidad de Navarra, Pamplona, Spain
- Department of Pediatrics, Clínica Universidad de Navarra, Pamplona, Spain
| | - Marta M. Alonso
- Health Research Institute of Navarra (IdiSNA), Pamplona, Spain
- Solid Tumor Program, Cima Universidad de Navarra, Pamplona, Spain
- Department of Pediatrics, Clínica Universidad de Navarra, Pamplona, Spain
| | - Augustine Eze
- Center for Genetic Medicine Research, Children's National Hospital, Washington, DC
| | - Jasper Spitzer
- Institute of Innate Immunity, AG Immunogenomics, University Hospital Bonn, Bonn, Germany
- Institute of Clinical Chemistry and Clinical Pharmacology, AG Immunmonitoring and Genomics, University Hospital Bonn, Bonn, Germany
| | - Susanne V. Schmidt
- Institute of Innate Immunity, AG Immunogenomics, University Hospital Bonn, Bonn, Germany
- Institute of Clinical Chemistry and Clinical Pharmacology, AG Immunmonitoring and Genomics, University Hospital Bonn, Bonn, Germany
| | - Ryan J. Duchatel
- Cancer Signalling Research Group, School of Biomedical Sciences and Pharmacy, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Precision Medicine Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
- Paediatric Program, Mark Hughes Foundation Centre for Brain Cancer Research, College of Health, Medicine, and Wellbeing, Callaghan, NSW, Australia
| | - Matthew D. Dun
- Cancer Signalling Research Group, School of Biomedical Sciences and Pharmacy, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Precision Medicine Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
- Paediatric Program, Mark Hughes Foundation Centre for Brain Cancer Research, College of Health, Medicine, and Wellbeing, Callaghan, NSW, Australia
| | - Jason E. Cain
- Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Molecular and Translational Sciences, Monash University, Clayton, VIC, Australia
| | - Li Jiang
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorder Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Sylwia A. Stopka
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gerard Baquer
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael S. Regan
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mariella G. Filbin
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorder Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Nathalie Y.R. Agar
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Cancer Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lili Zhao
- University of Michigan, Ann Arbor, Michigan
| | | | - Rajen Mody
- University of Michigan, Ann Arbor, Michigan
| | | | - Ryo Kurokawa
- University of Michigan, Ann Arbor, Michigan
- The University of Tokyo, Tokyo, Japan
| | - Drew Pratt
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
| | - Viveka N. Yadav
- Department of Pediatrics at Children's Mercy Research Institute, Kansas City, Missouri
| | - Jacques Grill
- Department of Pediatric and Adolescent Oncology and INSERM Unit 981, Gustave Roussy and University Paris-Saclay, Villejuif, France
| | - Cassie Kline
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Sabine Mueller
- University of California, San Francisco, San Francisco, California
- Department of Oncology, Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Adam Resnick
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Javad Nazarian
- Department of Pediatrics, Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
- Research Center for Genetic Medicine, Children's National Hospital, Washington, DC
- George Washington University School of Medicine and Health Sciences, Washington, DC
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Karschnia P, Smits M, Reifenberger G, Le Rhun E, Ellingson BM, Galldiks N, Kim MM, Huse JT, Schnell O, Harter PN, Mohme M, von Baumgarten L, Albert NL, Huang RY, Mehta MP, van den Bent M, Weller M, Vogelbaum MA, Chang SM, Berger MS, Tonn JC. A framework for standardised tissue sampling and processing during resection of diffuse intracranial glioma: joint recommendations from four RANO groups. Lancet Oncol 2023; 24:e438-e450. [PMID: 37922934 PMCID: PMC10849105 DOI: 10.1016/s1470-2045(23)00453-9] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 08/23/2023] [Accepted: 09/07/2023] [Indexed: 11/07/2023]
Abstract
Surgical resection represents the standard of care for people with newly diagnosed diffuse gliomas, and the neuropathological and molecular profile of the resected tissue guides clinical management and forms the basis for research. The Response Assessment in Neuro-Oncology (RANO) consortium is an international, multidisciplinary effort that aims to standardise research practice in neuro-oncology. These recommendations represent a multidisciplinary consensus from the four RANO groups: RANO resect, RANO recurrent glioblastoma, RANO radiotherapy, and RANO/PET for a standardised workflow to achieve a representative tumour evaluation in a disease characterised by intratumoural heterogeneity, including recommendations on which tumour regions should be surgically sampled, how to define those regions on the basis of preoperative imaging, and the optimal sample volume. Practical recommendations for tissue sampling are given for people with low-grade and high-grade gliomas, as well as for people with newly diagnosed and recurrent disease. Sampling of liquid biopsies is also addressed. A standardised workflow for subsequent handling of the resected tissue is proposed to avoid information loss due to decreasing tissue quality or insufficient clinical information. The recommendations offer a framework for prospective biobanking studies.
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Affiliation(s)
- Philipp Karschnia
- Department of Neurosurgery, Ludwig-Maximilians-University of Munich, Munich, Germany; German Cancer Consortium, Partner Site Munich, Munich, Germany
| | - Marion Smits
- Department of Neuroradiology and Nuclear Medicine, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Guido Reifenberger
- Institute of Neuropathology, Heinrich Heine University Medical Faculty and University Hospital Düsseldorf, Düsseldorf, Germany
| | - Emilie Le Rhun
- Department of Neurosurgery, University Hospital of Zurich and University of Zurich, Zurich, Switzerland; Department of Neurology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - Benjamin M Ellingson
- UCLA Brain Tumor Imaging Laboratory, Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Norbert Galldiks
- Department of Neurology, Faculty of Medicine, University of Cologne and University Hospital Cologne, Cologne, Germany; Research Center Juelich, Institute of Neuroscience and Medicine, Juelich, Germany
| | - Michelle M Kim
- Department of Radiation Oncology, University of Michigan Hospital, Ann Arbor, MI, USA
| | - Jason T Huse
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Oliver Schnell
- Department of Neurosurgery, University of Freiburg, Freiburg, Germany
| | - Patrick N Harter
- German Cancer Consortium, Partner Site Munich, Munich, Germany; Center for Neuropathology and Prion Research, Faculty of Medicine, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Malte Mohme
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Louisa von Baumgarten
- Department of Neurosurgery, Ludwig-Maximilians-University of Munich, Munich, Germany; German Cancer Consortium, Partner Site Munich, Munich, Germany
| | - Nathalie L Albert
- Department of Nuclear Medicine, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Raymond Y Huang
- Division of Neuroradiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Martin van den Bent
- Department of Neurology, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Michael Weller
- Department of Neurology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | | | - Susan M Chang
- Department of Neurosurgery and Division of Neuro-Oncology, University of California, San Francisco, CA, USA
| | - Mitchel S Berger
- Department of Neurosurgery and Division of Neuro-Oncology, University of California, San Francisco, CA, USA
| | - Joerg-Christian Tonn
- Department of Neurosurgery, Ludwig-Maximilians-University of Munich, Munich, Germany; German Cancer Consortium, Partner Site Munich, Munich, Germany.
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Scott AJ, Correa LO, Edwards DM, Sun Y, Ravikumar V, Andren AC, Zhang L, Srinivasan S, Jairath N, Verbal K, Muraszko K, Sagher O, Carty SA, Hervey-Jumper S, Orringer D, Kim MM, Junck L, Umemura Y, Leung D, Venneti S, Camelo-Piragua S, Lawrence TS, Ippolito JE, Al-Holou WN, Chinnaiyan P, Heth J, Rao A, Lyssiotis CA, Wahl DR. Metabolomic Profiles of Human Glioma Inform Patient Survival. Antioxid Redox Signal 2023; 39:942-956. [PMID: 36852494 PMCID: PMC10655010 DOI: 10.1089/ars.2022.0085] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 02/07/2023] [Accepted: 02/07/2023] [Indexed: 03/01/2023]
Abstract
Aims: Targeting tumor metabolism may improve the outcomes for patients with glioblastoma (GBM). To further preclinical efforts targeting metabolism in GBM, we tested the hypothesis that brain tumors can be stratified into distinct metabolic groups with different patient outcomes. Therefore, to determine if tumor metabolites relate to patient survival, we profiled the metabolomes of human gliomas and correlated metabolic information with clinical data. Results: We found that isocitrate dehydrogenase-wildtype (IDHwt) GBMs are metabolically distinguishable from IDH mutated (IDHmut) astrocytomas and oligodendrogliomas. Survival of patients with IDHmut gliomas was expectedly more favorable than those with IDHwt GBM, and metabolic signatures can stratify IDHwt GBMs subtypes with varying prognoses. Patients whose GBMs were enriched in amino acids had improved survival, while those whose tumors were enriched for nucleotides, redox molecules, and lipid metabolites fared more poorly. These findings were recapitulated in validation cohorts using both metabolomic and transcriptomic data. Innovation: Our results suggest the existence of metabolic subtypes of GBM with differing prognoses, and further support the concept that metabolism may drive the aggressiveness of human gliomas. Conclusions: Our data show that metabolic signatures of human gliomas can inform patient survival. These findings may be used clinically to tailor novel metabolically targeted agents for GBM patients with different metabolic phenotypes. Antioxid. Redox Signal. 39, 942-956.
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Affiliation(s)
- Andrew J. Scott
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Luis O. Correa
- Department of Immunology Graduate Program, University of Michigan, Ann Arbor, Michigan, USA
| | - Donna M. Edwards
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Yilun Sun
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Visweswaran Ravikumar
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan, USA
| | - Anthony C. Andren
- Department of Molecular & Integrative Physiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Li Zhang
- Department of Molecular & Integrative Physiology, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Neil Jairath
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Kait Verbal
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Karin Muraszko
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Oren Sagher
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Shannon A. Carty
- Department of Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Shawn Hervey-Jumper
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Daniel Orringer
- Department of Neurosurgery, New York University Langone Health, New York, New York, USA
| | - Michelle M. Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Larry Junck
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Yoshie Umemura
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Denise Leung
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Sriram Venneti
- Department of Pathology, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Theodore S. Lawrence
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Joseph E. Ippolito
- Department of Biochemistry and Molecular Biophysics, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Wajd N. Al-Holou
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Prakash Chinnaiyan
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan, USA
- Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
| | - Jason Heth
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Arvind Rao
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan, USA
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan, USA
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Costas A. Lyssiotis
- Department of Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan, USA
- Department of Molecular & Integrative Physiology, University of Michigan, Ann Arbor, Michigan, USA
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Daniel R. Wahl
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan, USA
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Wang K, Shen C, Pacholke HD, Deal A, Pearlstein KA, Weiner AA, Xu V, Danquah F, Wahl DR, Jackson WC, Dess RT, Dragovic AF, Marks LB, Chera BS, Kim MM. Results of a Multi-institutional Randomized Phase 3 Trial of Parotid-Sparing Whole Brain Radiotherapy. Int J Radiat Oncol Biol Phys 2023; 117:S74-S75. [PMID: 37784566 DOI: 10.1016/j.ijrobp.2023.06.387] [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) Observational studies have reported that xerostomia is common after conventional whole brain radiotherapy (WBRT) and associated with parotid dose. In this multi-institutional, single-blind randomized controlled trial, we hypothesized that patient-reported xerostomia is reduced in patients randomized to parotid-sparing vs. standard WBRT fields. MATERIALS/METHODS Between 2018 and 2021, patients receiving conventional WBRT (30-35 Gy in 10-15 fractions) for any diagnosis were enrolled at 3 academic institutions. Patients were randomized between standard WBRT fields covering the C1 vertebra with no prospective parotid delineation (control) vs. parotid-sparing fields without C1 coverage (experimental). Patients completed the University of Michigan Xerostomia Questionnaire (Scored 0-100, higher is worse) at baseline, EndRT, 2 weeks, 1 month, 3 months, and 6 months. Patients were excluded from toxicity analyses if baseline xerostomia score was >50 or if they did not complete any post-baseline questionnaires. The primary endpoint was proportion of patients with ≥15 point absolute increase in xerostomia score from baseline to 1 month; 108 patients were needed for an 80% power to detect a 22% absolute difference (1-sided significance of 0.05). The secondary endpoint was the rate of marginal failures. RESULTS The study closed early after 56 patients were randomized. Median survival was 4.6 months. 46 patients (23 in each arm) were eligible for analysis. Mean parotid dose was 17 vs. 10 Gy in the standard vs. parotid-sparing arms, respectively. The table below shows mean xerostomia score and proportion of patients with ≥15 increase in xerostomia score at each time point. There was no difference in the proportion of patients experiencing ≥15 increase in xerostomia score at 1 month, though there was a trend toward lower xerostomia score at 1 month in patients randomized to parotid-sparing fields (p = 0.07, Table). Xerostomia rates were also significantly improved in the parotid-sparing arm at EndRT (p = 0.03), but no longer-term difference was observed with greater attrition at 3 and 6 months. On linear regression, there was a trend toward association between mean parotid dose and xerostomia score at 1 month (p = 0.06). There were no reported marginal failures in either arm. CONCLUSION Parotid-sparing without coverage of the C1 vertebra appears safe and may meaningfully reduce acute xerostomia in patients with limited life expectancy who are candidates for conventional WBRT, although the study was underpowered to detect a significant difference at 1 month.
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Affiliation(s)
- K Wang
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH
| | - C Shen
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, NC
| | | | - A Deal
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - K A Pearlstein
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, NC
| | - A A Weiner
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, NC
| | - V Xu
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - F Danquah
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, NC
| | - D R Wahl
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - W C Jackson
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - R T Dess
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - A F Dragovic
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - L B Marks
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, NC
| | - B S Chera
- Medical University of South Carolina, Charleston, SC
| | - M M Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
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10
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Wiersma RD, Kim MM, Koch CJ. Radiochemical Oxygen Depletion Depends on Chemical Environment and Dose-Rate: Implications for FLASH Effect. Int J Radiat Oncol Biol Phys 2023; 117:S36-S37. [PMID: 37784484 DOI: 10.1016/j.ijrobp.2023.06.304] [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) FLASH (dose rates > 40 Gy/s) radiotherapy (RT) protects normal tissues from radiation damage, compared with conventional RT (∼Gy/min). Radiation-chemical oxygen depletion (ROD) has been the leading and most-studied mechanism to explain FLASH. Previous studies have reported low ROD values of ∼0.35 µM/Gy, however, they do not accurately model (utilizing water or oxidized substrates such as albumin) the intracellular environment. It has been proposed that the intracellular environment may support higher ROD values due to its specific chemical makeup. As chemical reducing agents, which play a critical role in the cell, may promote ROD, we measured ROD for several well-known cellular reducing agents. MATERIALS/METHODS Precision polarographic oxygen sensors were used to measure ROD over a ∼100-0 µM oxygen concentration range in solutions containing various types of intracellular reducing agents, either alone or combined with glycerol (1M; to simulate the intracellular hydroxyl-radical-scavenging capacity). A Cs irradiator and a research proton beamline were used for radiation beam generation over a 10,000-fold (0.0085 to 100 Gy/s) dose rate range. Reagents were grouped generally into primary free-radical scavengers (glycerol & lysozyme) and reducing agents (cysteamine, cysteine, glutathione, dextrin-conjugated linoleic acid, NAD(P)H, ascorbate and uric acid). RESULTS Reducing agents at 1 mM significantly altered ROD values. ROD, at 0.1 Gy/s varied from greater than 1 µM/Gy for NADPH to less than 0.1 µM/Gy for uric acid. Even higher RODs were found at lower dose rates and/or higher reducing agent concentrations. Although most greatly increased ROD, ascorbate and uric acid decreased ROD and additionally imposed an oxygen dependence of ROD at low oxygen concentrations. Interestingly, all agents having high rates of ROD at low dose rates show a decrease at FLASH dose rates and this seems to be a proportional response (i.e., the greater the ROD at low dose rate, the greater the inhibition by FLASH). At FLASH dose rates our data for a simple mixture of glycerol and glutathione showed the same trend as recent studies that, in general, FLASH had ∼25% lower ROD rates than conventional demonstrating agreement between polarographic sensors and optical phosphorescence decay methods. CONCLUSION ROD was greatly augmented by some intracellular reducing agents but others effectively reversed this effect. Ascorbate had its greatest impact at low oxygen concentrations. ROD decreased with increasing dose rate and in all cases was less than 1 µM/Gy at 100 Gy/s, potentially posing a fundamental limit of max ROD for FLASH.
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Affiliation(s)
- R D Wiersma
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - M M Kim
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - C J Koch
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
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11
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Yoo Y, Gibson E, Zhao G, Sandu A, Re T, Das J, Hesheng W, Kim MM, Shen C, Lee YZ, Kondziolka D, Ibrahim M, Lian J, Jain R, Zhu T, Parmar H, Comaniciu D, Balter J, Cao Y. An Automated Brain Metastasis Detection and Segmentation System from MRI with a Large Multi-Institutional Dataset. Int J Radiat Oncol Biol Phys 2023; 117:S88-S89. [PMID: 37784596 DOI: 10.1016/j.ijrobp.2023.06.414] [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) Developments of automated systems for brain metastasis (BM) detection and segmentation from MRI for assisting early detection and stereotactic radiosurgery (SRS) have been reported but most based upon relatively small datasets from single institutes. This work aims to develop and evaluate a system using a large multi-institutional dataset, and to improve both identification of small/subtle BMs and segmentation accuracy of large BMs. MATERIALS/METHODS A 3D U-Net system was trained and evaluated to detect and segment intraparenchymal BMs with a size > 2mm using 1856 MRI volumes from 1791 patients treated with SRS from seven institutions (1539 volumes for training, 183 for validation, and 134 for testing). All patients had 3D post-Gd T1w MRI scans pre-SRS. Gross tumor volumes (GTVs) of BMs for SRS were curated by each institute first. Then, additional efforts were spent to create GTVs for the untreated and/or uncontoured BMs, including central reviews by two radiologists, to improve accuracy of ground truth. The training dataset was augmented with synthetic BMs of 3773 MRIs using a 3D generative pipeline. Our system consists of two U-Nets with one using small 3D patches dedicated for detecting small BMs and another using large 3D patches for segmenting large BMs, and a random-forest based fusion module for combining the two network outputs. The first U-Net was trained with 3D patches containing at least one BM < 0.1 cm3. For detection performance, we measured BM-level sensitivity and case-level false-positive (FP) rate. For segmentation performance, we measured BM-level Dice similarity coefficient (DSC) and 95-percentile Hausdorff distance (HD95). We also stratified performances based upon BM sizes. RESULTS For 739 BMs in the 134 testing cases, the overall lesion-level sensitivity was 0.870 with an average case-level FP of 1.34±1.92 (95% CI: 1.02-1.67). The sensitivity was >0.969 for the BMs >0.1 cm3, but dropped to 0.755 for the BMs < 0.1 cm3 (Table 1). The average DSC and HD95 for all detected BMs were 0.786 and 1.35mm. The worse performance for BMs > 20 cm3 was caused by a case with 83 cm3 GTV and artifacts in the MRI volume. CONCLUSION We achieved excellent detection sensitivity and segmentation accuracy for BMs > 0.1 cm3, and promising performance for small BMs (<0.1cm3) with a controlled FP rate using a large multi-institutional dataset. Clinical utility for assisting early detection and SRS planning will be investigated. Table 1: Per-lesion detection and segmentation performance stratified by individual BM size. N is the number of BMs in each category.
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Affiliation(s)
- Y Yoo
- Siemens Healthineers, Princeton, NJ
| | - E Gibson
- Siemens Healthineers, Princeton, NJ
| | - G Zhao
- Siemens Healthineers, Princeton, NJ
| | - A Sandu
- Siemens Healthineers, Princeton, NJ
| | - T Re
- Siemens Healthineers, Princeton, NJ
| | - J Das
- Siemens Healthineers, Princeton, NJ
| | | | - M M Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - C Shen
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, NC
| | - Y Z Lee
- University of North Carolina, Chapel Hill, NC
| | - D Kondziolka
- Department of Neurosurgery, NYU Langone Health, New York, NY
| | - M Ibrahim
- University of Michigan, Ann Arbor, MI
| | - J Lian
- University of North Carolina, Chapel Hill, NC
| | - R Jain
- New York University, New York, NY
| | - T Zhu
- Washington University, St. Louis, MO
| | - H Parmar
- Department of Radiology, University of Michigan, Ann Arbor, MI
| | | | - J Balter
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Y Cao
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
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Trifiletti DM, Milano MT, Redmond KJ, Pollom EL, Hattangadi-Gluth JA, Kim MM. Treatment Planning Expansions in Glioblastoma: How Less Can Be More. Int J Radiat Oncol Biol Phys 2023; 117:293-296. [PMID: 37652602 DOI: 10.1016/j.ijrobp.2023.03.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 03/23/2023] [Indexed: 09/02/2023]
Affiliation(s)
| | - Michael T Milano
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Erqi L Pollom
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Jona A Hattangadi-Gluth
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California
| | - Michelle M Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
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Jiang C, Hoover T, Kim MM, Han X, Plastaras JP, LaRiviere MJ. Outcomes of Proton Therapy for Patients with Infradiaphragmatic Lymphoma. Int J Radiat Oncol Biol Phys 2023; 117:e470. [PMID: 37785498 DOI: 10.1016/j.ijrobp.2023.06.1676] [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) While the role of proton radiation (PT) in treating supradiaphragmatic targets in lymphoma patients is becoming increasingly well-established, outcomes of PT for infradiaphragmatic locations have not been reported. We report on the radiation planning details, doses achieved to key organs at risk (OARs), and clinical outcomes for a cohort of lymphoma patients treated with PT to infradiaphragmatic locations. MATERIALS/METHODS This is a single institution retrospective study of patients with biopsy-proven lymphoma who received PT to an infradiaphragmatic target between 2011-2022. Patient, disease, and radiation details were collected. Comparison photon plans were generated for a subset of patients. Toxicity was reported using CTCAE version 5.0. Dosimetric and clinical factors associated with toxicity and oncologic outcomes were assessed via linear regression, Wilcoxon rank sum test, Fisher's exact test, and/or independent t-test while the paired t-test or Wilcoxon signed rank test was used for dosimetric analyses. RESULTS 38 patients comprising 40 PT courses were included. Median age was 63 years and median follow-up was 48 months. The most common diagnoses were DLBCL (58%) and Hodgkin lymphoma (18%). 28% of PT courses had direct overlap with a prior radiation field and 20% were palliative. Median dose was 30.6 GyE over 17 fractions to the retroperitoneum (30%), spine/paraspinal region (30%), pelvis (18%), inguinals (8%), spleen (3%), or other (8%). Top G1 toxicities were fatigue (65%), dermatitis (28%), and nausea (23%). 10% of PT courses led to a G2 toxicity and there were no G3+ toxicities. Higher number of fractions was associated with increased incidence of dermatitis (mean 16 vs. 19, p = 0.008), but no OAR parameters were associated with CTCAE toxicities. Among patients treated with curative intent, 44% experienced progression of disease (PD) at a median time of 3 months after PT; of these progressions, 60% were distant only, 20% were marginal only, 10% was marginal and distant, and 10% was in-field and distant. Higher number of systemic therapy lines received prior to PT was associated with increased likelihood of PD (mean 1.4 vs. 4.1, p = 0.01), and PD increased the risk of death (OR 15.3, 95% CI 2.5-95.2). 5/39 patients were diagnosed with a second malignancy after PT, two of which were hematologic. Among the 10 patients with photon comparison plans, PT provided a significant decrease in kidney doses (mean and V5), small bowel V5 Gy, large bowel V5 Gy, bowel bag V15 Gy, and mean liver (all p = 0.045 or less). However, average spinal cord/cauda Dmax was slightly higher with PT (24 vs. 25 Gy, p = 0.0156). CONCLUSION PT is a well-tolerated treatment for infradiaphragmatic lymphoma that leads to excellent outcomes with minimal high-grade toxicities. Compared to photon therapy, PT can significantly reduce doses to key abdominopelvic OARs.
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Affiliation(s)
- C Jiang
- University of Pennsylvania, Philadelphia, PA
| | - T Hoover
- Penn State School of Medicine, Hershey, PA
| | - M M Kim
- University of Pennsylvania, Philadelphia, PA
| | - X Han
- University of Pennsylvania, Philadelphia, PA
| | - J P Plastaras
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - M J LaRiviere
- Children's Hospital of Philadelphia, Philadelphia, PA
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Chuang HW, Wu S, Lin SX, Zhao T, Kim MM, Harisinghani M, Feldman AS, Dahl DM, Wu CL. Detection of extraprostatic extension by transperineal multiparametric magnetic resonance imaging-ultrasound fusion targeted combined with systemic template prostate biopsy. Diagn Pathol 2023; 18:101. [PMID: 37697349 PMCID: PMC10494402 DOI: 10.1186/s13000-023-01386-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 08/21/2023] [Indexed: 09/13/2023] Open
Abstract
BACKGROUND Extraprostatic extension (EPE) of prostate cancer (PCa) on transrectal (TR) needle core biopsy (Bx) is a rare histopathological finding that can help in clinical decision-making. The detection efficiency of the transperineal (TP) approach is yet to be explored. METHODS We retrospectively reviewed 2848 PCa cases using concomitant systemic template biopsy (SBx) and multiparametric magnetic resonance imaging (MRI)-ultrasound fusion-targeted biopsy (TBx) using the TR (n = 1917) or TP (n = 931) approach at our institution between January 2015 and July 2022. We assessed and compared clinical, MRI, and biopsy characteristics using different approaches (TP and TR) and methods (SBx and TBx). RESULTS In total, 40 EPE cases were identified (40/2848, 1.4%). TP showed a significantly higher EPE detection rate compared to TR in SBx (TR:0.7% vs. TP:1.6%; p = 0.028) and TBx (TR:0.5% vs. TP:1.2%; p = 0.033), as well as the combined methods (2.1% vs. 1.1%, p = 0.019). A significantly higher incidence of EPEs was found at non-base sites in TP than in TR (76.7% vs. 50%, p = 0.038). SBx showed a higher EPE detection rate than TBx; however, the difference was not statistically significant. TP showed higher prostate-specific antigen density (0.35 vs. 0.17, p = 0.005), higher frequency of GG4-5 in the cores with EPE (65.0% vs. 50.0%, p = 0.020), and more PCa-positive SBx cores (10 vs. 8, p = 0.023) compared to the TR. CONCLUSIONS TP may improve EPE detection compared with TR and should be applied to patients with adverse pre-biopsy features.
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Affiliation(s)
- Hao-Wen Chuang
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Pathology and Laboratory Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, TW, Taiwan
- Institute of Oral Biology, School of Dentistry, National Yang Ming Chiao Tung University, Taipei, TW, Taiwan
| | - Shulin Wu
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sharron X Lin
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ting Zhao
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Michelle M Kim
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mukesh Harisinghani
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Adam S Feldman
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Douglas M Dahl
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Chin-Lee Wu
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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15
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Frendl DM, Chou WH, Chen YW, Chang DC, Kim MM. Early vs Delayed Transurethral Surgery in Acute Urinary Retention: Does Timing Make a Difference? J Urol 2023; 210:492-499. [PMID: 37249443 DOI: 10.1097/ju.0000000000003559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 05/15/2023] [Indexed: 05/31/2023]
Abstract
PURPOSE Our goal was to compare outcomes of early vs delayed transurethral surgery for benign prostatic hyperplasia after an episode of acute urinary retention compared to men without preoperative acute retention. MATERIALS AND METHODS We conducted a retrospective cohort analysis using data from the New York Statewide Planning and Research Cooperative System from 2002-2016. We identified men ≥40 years old who underwent primary ambulatory transurethral resection or photoselective vaporization of the prostate, assessing surgical failure as time to reoperation or recatheterization. We categorized presurgical acute urinary retention by number of episodes: none (reference), 1, or ≥2 precatheterizations, and time from first retention episode to surgery: none (reference), 0-6 months, and >6 months. We used Fine-Gray competing-risk models to predict surgical failure at 10 years, with presurgical acute retention as the primary predictor, adjusted for age, race, insurance, Charlson Comorbidity Index score, preoperative urinary infection, and procedure type, with death as the competing risk. RESULTS Among 17,474 patients undergoing transurethral surgery, 10% had preoperative acute retention with a median time to surgery of 2.4 months (IQR: 1-18). Among men with preoperative retention, 37% had ≥6 months of delay to surgery. The 10-year cumulative treatment failure rate was 17.2% among catheter naïve men vs 34.0% with ≥2 precatheterizations and 32.9% with ≥6 months delay to surgery. Delays from catheterization to surgery were associated with higher rates of treatment failure (<6 months SHR 1.49, P < .001; ≥6 months SHR 2.11, P < .001) vs catheter naïve men. CONCLUSIONS Preoperative acute urinary retention and delay to surgery once catheterized are associated with poorer long-term postoperative outcomes after surgery for benign prostatic hyperplasia.
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Affiliation(s)
- Daniel M Frendl
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Urology, Mayo Clinic, Phoenix, Arizona
| | - Wesley H Chou
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ya-Wen Chen
- Codman Center, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - David C Chang
- Codman Center, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michelle M Kim
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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16
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Umemura Y, Orringer D, Junck L, Varela ML, West MEJ, Faisal SM, Comba A, Heth J, Sagher O, Leung D, Mammoser A, Hervey-Jumper S, Zamler D, Yadav VN, Dunn P, Al-Holou W, Hollon T, Kim MM, Wahl DR, Camelo-Piragua S, Lieberman AP, Venneti S, McKeever P, Lawrence T, Kurokawa R, Sagher K, Altshuler D, Zhao L, Muraszko K, Castro MG, Lowenstein PR. Combined cytotoxic and immune-stimulatory gene therapy for primary adult high-grade glioma: a phase 1, first-in-human trial. Lancet Oncol 2023; 24:1042-1052. [PMID: 37657463 DOI: 10.1016/s1470-2045(23)00347-9] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/07/2023] [Accepted: 07/14/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND High-grade gliomas have a poor prognosis and do not respond well to treatment. Effective cancer immune responses depend on functional immune cells, which are typically absent from the brain. This study aimed to evaluate the safety and activity of two adenoviral vectors expressing HSV1-TK (Ad-hCMV-TK) and Flt3L (Ad-hCMV-Flt3L) in patients with high-grade glioma. METHODS In this dose-finding, first-in-human trial, treatment-naive adults aged 18-75 years with newly identified high-grade glioma that was evaluated per immunotherapy response assessment in neuro-oncology criteria, and a Karnofsky Performance Status score of 70 or more, underwent maximal safe resection followed by injections of adenoviral vectors expressing HSV1-TK and Flt3L into the tumour bed. The study was conducted at the University of Michigan Medical School, Michigan Medicine (Ann Arbor, MI, USA). The study included six escalating doses of viral particles with starting doses of 1×1010 Ad-hCMV-TK viral particles and 1×109 Ad-hCMV-Flt3L viral particles (cohort A), and then 1×1011 Ad-hCMV-TK viral particles and 1×109 Ad-hCMV-Flt3L viral particles (cohort B), 1×1010 Ad-hCMV-TK viral particles and 1×1010 Ad-hCMV-Flt3L viral particles (cohort C), 1×1011 Ad-hCMV-TK viral particles and 1×1010 Ad-hCMV-Flt3L viral particles (cohort D), 1×1010 Ad-hCMV-TK viral particles and 1×1011 Ad-hCMV-Flt3L viral particles (cohort E), and 1×1011 Ad-hCMV-TK viral particles and 1×1011 Ad-hCMV-Flt3L viral particles (cohort F) following a 3+3 design. Two 1 mL tuberculin syringes were used to deliver freehand a mix of Ad-hCMV-TK and Ad-hCMV-Flt3L vectors into the walls of the resection cavity with a total injection of 2 mL distributed as 0·1 mL per site across 20 locations. Subsequently, patients received two 14-day courses of valacyclovir (2 g orally, three times per day) at 1-3 days and 10-12 weeks after vector administration and standad upfront chemoradiotherapy. The primary endpoint was the maximum tolerated dose of Ad-hCMV-Flt3L and Ad-hCMV-TK. Overall survival was a secondary endpoint. Recruitment is complete and the trial is finished. The trial is registered with ClinicalTrials.gov, NCT01811992. FINDINGS Between April 8, 2014, and March 13, 2019, 21 patients were assessed for eligibility and 18 patients with high-grade glioma were enrolled and included in the analysis (three patients in each of the six dose cohorts); eight patients were female and ten were male. Neuropathological examination identified 14 (78%) patients with glioblastoma, three (17%) with gliosarcoma, and one (6%) with anaplastic ependymoma. The treatment was well-tolerated, and no dose-limiting toxicity was observed. The maximum tolerated dose was not reached. The most common serious grade 3-4 adverse events across all treatment groups were wound infection (four events in two patients) and thromboembolic events (five events in four patients). One death due to an adverse event (respiratory failure) occurred but was not related to study treatment. No treatment-related deaths occurred during the study. Median overall survival was 21·3 months (95% CI 11·1-26·1). INTERPRETATION The combination of two adenoviral vectors demonstrated safety and feasibility in patients with high-grade glioma and warrants further investigation in a phase 1b/2 clinical trial. FUNDING Funded in part by Phase One Foundation, Los Angeles, CA, The Board of Governors at Cedars-Sinai Medical Center, Los Angeles, CA, and The Rogel Cancer Center at The University of Michigan.
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Affiliation(s)
- Yoshie Umemura
- Department of Neurology, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Daniel Orringer
- Department of Neurosurgery, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Larry Junck
- Department of Neurology, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Maria L Varela
- Department of Neurosurgery, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA; Department of Cell and Developmental Biology, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA; The Rogel Cancer Center, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Molly E J West
- Department of Neurosurgery, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA; Department of Cell and Developmental Biology, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA; The Rogel Cancer Center, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Syed M Faisal
- Department of Neurosurgery, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA; Department of Cell and Developmental Biology, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA; The Rogel Cancer Center, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Andrea Comba
- Department of Neurosurgery, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA; Department of Cell and Developmental Biology, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA; The Rogel Cancer Center, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Jason Heth
- Department of Neurosurgery, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Oren Sagher
- Department of Neurosurgery, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Denise Leung
- Department of Neurology, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Aaron Mammoser
- Department of Neurology, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Shawn Hervey-Jumper
- Department of Neurosurgery, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Daniel Zamler
- Department of Neurosurgery, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Viveka N Yadav
- Department of Neurosurgery, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Patrick Dunn
- Department of Neurosurgery, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Wajd Al-Holou
- Department of Neurosurgery, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Todd Hollon
- Department of Neurosurgery, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Michelle M Kim
- Department of Radiation Oncology, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Daniel R Wahl
- Department of Radiation Oncology, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Sandra Camelo-Piragua
- Department of Pathology, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Andrew P Lieberman
- Department of Pathology, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Sriram Venneti
- Department of Pathology, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Paul McKeever
- Department of Pathology, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Theodore Lawrence
- Department of Radiation Oncology, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Ryo Kurokawa
- Department of Radiology, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Karen Sagher
- Department of Neurosurgery, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - David Altshuler
- Department of Neurosurgery, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Lili Zhao
- Department of Biostatistics, The University of Michigan School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Karin Muraszko
- Department of Neurosurgery, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Maria G Castro
- Department of Neurosurgery, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA; Department of Cell and Developmental Biology, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA; The Rogel Cancer Center, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Pedro R Lowenstein
- Department of Neurosurgery, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA; Department of Cell and Developmental Biology, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA; The Rogel Cancer Center, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA; Department of Biomedical Engineering, University of Michigan School of Engineering, University of Michigan, Ann Arbor, MI, USA.
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17
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Kim MM, Mehta MP, Smart DK, Steeg PS, Hong JA, Espey MG, Prasanna PG, Crandon L, Hodgdon C, Kozak N, Armstrong TS, Morikawa A, Willmarth N, Tanner K, Boire A, Gephart MH, Margolin KA, Hattangadi-Gluth J, Tawbi H, Trifiletti DM, Chung C, Basu-Roy U, Burns R, Oliva ICG, Aizer AA, Anders CK, Davis J, Ahluwalia MS, Chiang V, Li J, Kotecha R, Formenti SC, Ellingson BM, Gondi V, Sperduto PW, Barnholtz-Sloan JS, Rodon J, Lee EQ, Khasraw M, Yeboa DN, Brastianos PK, Galanis E, Coleman CN, Ahmed MM. National Cancer Institute Collaborative Workshop on Shaping the Landscape of Brain Metastases Research: challenges and recommended priorities. Lancet Oncol 2023; 24:e344-e354. [PMID: 37541280 PMCID: PMC10681121 DOI: 10.1016/s1470-2045(23)00297-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/13/2023] [Accepted: 06/21/2023] [Indexed: 08/06/2023]
Abstract
Brain metastases are an increasing global public health concern, even as survival rates improve for patients with metastatic disease. Both metastases and the sequelae of their treatment are key determinants of the inter-related priorities of patient survival, function, and quality of life, mandating a multidimensional approach to clinical care and research. At a virtual National Cancer Institute Workshop in September, 2022, key stakeholders convened to define research priorities to address the crucial areas of unmet need for patients with brain metastases to achieve meaningful advances in patient outcomes. This Policy Review outlines existing knowledge gaps, collaborative opportunities, and specific recommendations regarding consensus priorities and future directions in brain metastases research. Achieving major advances in research will require enhanced coordination between the ongoing efforts of individual organisations and consortia. Importantly, the continual and active engagement of patients and patient advocates will be necessary to ensure that the directionality of all efforts reflects what is most meaningful in the context of patient care.
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Affiliation(s)
- Michelle M Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA.
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - DeeDee K Smart
- Radiation Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Patricia S Steeg
- Women's Malignancies Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Julie A Hong
- Radiation Research Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Rockville, MD, USA
| | - Michael G Espey
- Radiation Research Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Rockville, MD, USA
| | - Pataje G Prasanna
- Radiation Research Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Rockville, MD, USA
| | | | | | | | - Terri S Armstrong
- Neuro-Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Aki Morikawa
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Kirk Tanner
- National Brain Tumor Society, Newton, MA, USA
| | - Adrienne Boire
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | - Jona Hattangadi-Gluth
- Department of Radiation Oncology, University of California San Diego Health, La Jolla, CA, USA
| | - Hussein Tawbi
- Department of Melanoma Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Caroline Chung
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Robyn Burns
- Melanoma Research Foundation, Washington, DC, USA
| | - Isabella C Glitza Oliva
- Department of Melanoma Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ayal A Aizer
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA, USA
| | - Carey K Anders
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | | | - Manmeet S Ahluwalia
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Veronica Chiang
- Department of Neurosurgery and Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Jing Li
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Silvia C Formenti
- Department of Radiation Oncology, Weill Cornell Medicine, New York, NY, USA
| | - Benjamin M Ellingson
- UCLA Brain Tumor Imaging Laboratory, Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Vinai Gondi
- Department of Radiation Oncology, Northwestern Medicine Cancer Center Warrenville and Proton Center, Warrenville, IL, USA
| | - Paul W Sperduto
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Jill S Barnholtz-Sloan
- Informatics and Data Science Program, Center for Biomedical Informatics and Information Technology, Trans-Divisional Research Program, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | - Jordi Rodon
- Department of Investigational Cancer Therapeutics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eudocia Q Lee
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Mustafa Khasraw
- Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA
| | - Debra Nana Yeboa
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Priscilla K Brastianos
- Division of Hematology/Oncology and Division of Neuro-Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Evanthia Galanis
- Department of Oncology, Mayo Clinic Comprehensive Cancer Center, Mayo Clinic, Rochester, MN, USA
| | - C Norman Coleman
- Radiation Research Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Rockville, MD, USA
| | - Mansoor M Ahmed
- Radiation Research Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Rockville, MD, USA.
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18
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Wu S, Feldman AS, Kim MM, Lin SX, Cornejo KM, Harisinghani MG, Dahl DM, Wu CL. Gleason Grade Group Concordance between Systematic Template Combining Magnetic Resonance Imaging Fusion Targeted Biopsy and Radical Prostatectomy Specimens: A Comparison of Transperineal and Transrectal Approaches. Urology 2023:S0090-4295(23)00150-4. [PMID: 36828261 DOI: 10.1016/j.urology.2023.02.001] [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: 12/01/2022] [Revised: 01/19/2023] [Accepted: 02/01/2023] [Indexed: 02/24/2023]
Abstract
OBJECTIVE To evaluate the Gleason grade (GG) discrepancy between biopsy (Bx) techniques (transperineal [TP] /transrectal [TR] approaches or multiparametric magnetic resonance imaging [mpMRI] targeted biopsy [TBx] / standard template biopsies [SBx]) and radical prostatectomy (RP) specimens. PATIENTS AND METHODS We identified 310 prostate cancer (PCa) patients who underwent RP following either TP TBx combining SBx (20-core) (n = 105) or TR TBx combining SBx (12-core) (n = 205) from September 2019 to February 2021. The Bx GG was based on the core with the highest GG and clinically significant PCa (csPCa) was defined as grade group 2 or greater prostate adenocarcinoma. RESULTS TP combined TBx and SBx (CBx) showed a better GG concordance (63.8% vs 57.1%) than the TR approach, but did not reach a statistical significance. TBx demonstrated a significantly higher csPCa detection than SBx in all patients including both approaches (70.2% vs 63.9%, P < .001). TR TBx showed a significantly higher concordance than TR SBx (52.2% vs 41.5%, P = .0.002) while TP TBx did not differ from TP SBx. TP CBx showed the highest Kappa coefficient (κ =0.48) followed by TR CBx (κ = 0.39). Thirty-eight of 69 (55.1%) cases with a GG1 diagnosis in CBx were upgraded to csPCa in RP. TR approach showed a trend of 2.8-fold risk to upgrade to RP csPCa than TP approach (P = .0.065). CONCLUSION The combination of SBx and TBx led to a better pathological concordance and lower upgrading rate for both TP and TR approaches to RP. With more SBx cores, TP CBx showed a better performance than TR CBx.
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Affiliation(s)
- Shulin Wu
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Adam S Feldman
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Michelle M Kim
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Sharron X Lin
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Kristine M Cornejo
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Mukesh G Harisinghani
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Douglas M Dahl
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| | - Chin-Lee Wu
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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19
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Tsien CI, Pugh SL, Dicker AP, Raizer JJ, Matuszak MM, Lallana EC, Huang J, Algan O, Deb N, Portelance L, Villano JL, Hamm JT, Oh KS, Ali AN, Kim MM, Lindhorst SM, Mehta MP. NRG Oncology/RTOG1205: A Randomized Phase II Trial of Concurrent Bevacizumab and Reirradiation Versus Bevacizumab Alone as Treatment for Recurrent Glioblastoma. J Clin Oncol 2023; 41:1285-1295. [PMID: 36260832 PMCID: PMC9940937 DOI: 10.1200/jco.22.00164] [Citation(s) in RCA: 41] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 06/07/2022] [Accepted: 08/16/2022] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To assess whether reirradiation (re-RT) and concurrent bevacizumab (BEV) improve overall survival (OS) and/or progression-free survival (PFS), compared with BEV alone in recurrent glioblastoma (GBM). The primary objective was OS, and secondary objectives included PFS, response rate, and treatment adverse events (AEs) including delayed CNS toxicities. METHODS NRG Oncology/RTOG1205 is a prospective, phase II, randomized trial of re-RT and BEV versus BEV alone. Stratification factors included age, resection, and Karnofsky performance status (KPS). Patients with recurrent GBM with imaging evidence of tumor progression ≥ 6 months from completion of prior chemo-RT were eligible. Patients were randomly assigned 1:1 to re-RT, 35 Gy in 10 fractions, with concurrent BEV IV 10 mg/kg once in every 2 weeks or BEV alone until progression. RESULTS From December 2012 to April 2016, 182 patients were randomly assigned, of whom 170 were eligible. Patient characteristics were well balanced between arms. The median follow-up for censored patients was 12.8 months. There was no improvement in OS for BEV + RT, hazard ratio, 0.98; 80% CI, 0.79 to 1.23; P = .46; the median survival time was 10.1 versus 9.7 months for BEV + RT versus BEV alone. The median PFS for BEV + RT was 7.1 versus 3.8 months for BEV, hazard ratio, 0.73; 95% CI, 0.53 to 1.0; P = .05. The 6-month PFS rate improved from 29.1% (95% CI, 19.1 to 39.1) for BEV to 54.3% (95% CI, 43.5 to 65.1) for BEV + RT, P = .001. Treatment was well tolerated. There were a 5% rate of acute grade 3+ treatment-related AEs and no delayed high-grade AEs. Most patients died of recurrent GBM. CONCLUSION To our knowledge, NRG Oncology/RTOG1205 is the first prospective, randomized multi-institutional study to evaluate the safety and efficacy of re-RT in recurrent GBM using modern RT techniques. Overall, re-RT was shown to be safe and well tolerated. BEV + RT demonstrated a clinically meaningful improvement in PFS, specifically the 6-month PFS rate but no difference in OS.
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Affiliation(s)
| | - Stephanie L. Pugh
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA
| | | | | | | | | | - Jiayi Huang
- Washington University School of Medicine in St Louis-Siteman Cancer Center, St. Louis, MO
| | - Ozer Algan
- University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Nimisha Deb
- St Luke's University Hospital & Health Network accruals Thomas Jefferson University Hospital, Bethlehem, PA
| | - Lorraine Portelance
- University of Miami Miller School of Medicine-Sylvester Comprehensive Cancer Center, Miami, FL
| | | | - John T. Hamm
- Norton Hospital Pavilion and Medical Campus, Louisville, KY
| | - Kevin S. Oh
- Dana-Farber/Harvard Cancer Center, Boston, MA
| | - Arif N. Ali
- The Hope Center accruals Emory University/Winship Cancer Institute, Dalton, GA
| | - Michelle M. Kim
- University of Michigan Comprehensive Cancer Center, Ann Arbor, MI
| | - Scott M. Lindhorst
- Medical University of South Carolina Minority Underserved NCORP, Charleston, SC
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Fleege NMG, Pierce-Gjeldum D, Swartz LK, Verbal K, Merajver S, Friese CR, Kiyota A, Heth J, Leung D, Smith SR, Gabel N, Kim MM, Morikawa A. IMPACT the Brain: A Team-Based Approach to Management of Metastatic Breast Cancer With CNS Metastases. JCO Oncol Pract 2023; 19:e67-e77. [PMID: 36223556 PMCID: PMC9870235 DOI: 10.1200/op.22.00291] [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: 11/07/2022] Open
Abstract
PURPOSE CNS metastases are associated with decreased survival and quality of life for patients with metastatic breast cancer (MBC). Team-based care can optimize outcomes. IMPACT the Brain is a care coordination program that aims to improve access to team-based care for patients with MBC and CNS metastases. MATERIALS AND METHODS Patients with MBC and CNS metastases were eligible for enrollment in this care coordination program. A team of specialists supported a dedicated program coordinator who provided navigation, education, specialty referral, and clinical trial screening. A unique intake form developed for the program created personalized, coordinated, and expedited specialty referrals. Patient-reported outcomes and caregiver burden assessments were collected on a voluntary basis throughout enrollment. Data were analyzed using descriptive statistics. RESULTS Sixty patients were referred, and 53 were enrolled (88%). The median time to program enrollment was 1 day (range, 0-11) and to first visit was 5 days (range, 0-25). On the basis of the program intake form, 47 referrals were made across six specialties, most commonly physical medicine and rehabilitation (n = 10), radiation oncology (n = 10), and neuropsychology (n = 10). Nineteen patients (36%) consented to enroll in clinical trials. CONCLUSION A tailored team-based care coordination program for patients with MBC and CNS metastases is feasible. Use of a unique intake screening form by a dedicated program coordinator resulted in faster time to first patient visit, enabled access to subspecialist care, and supported enrollment in clinical trials. Future research should focus on intervention development using PRO data collected in this care coordination program.
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Affiliation(s)
- Nicole M. Grogan Fleege
- University of Michigan Health System, Ann Arbor, MI,Nicole M. Grogan Fleege, MD, 1500 E. Medical Center Dr, Ann Arbor, MI 48109 Twitter: @NicoleFleege; e-mail:
| | | | | | - Kait Verbal
- University of Michigan Health System, Ann Arbor, MI
| | | | | | - Ayano Kiyota
- University of Michigan Health System, Ann Arbor, MI
| | - Jason Heth
- University of Michigan Health System, Ann Arbor, MI
| | - Denise Leung
- University of Michigan Health System, Ann Arbor, MI
| | | | | | | | - Aki Morikawa
- University of Michigan Health System, Ann Arbor, MI
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Trifiletti DM, Redmond KJ, Kim MM, Soltys SG, Milano MT, Hattangadi-Gluth JA. Novel Applications of Stereotactic Radiosurgery Beyond Oncology: Prospective Trials in Functional Radiosurgery. Int J Radiat Oncol Biol Phys 2023; 115:4-6. [PMID: 36526398 DOI: 10.1016/j.ijrobp.2022.06.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 06/12/2022] [Indexed: 12/23/2022]
Affiliation(s)
| | - Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Michelle M Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Michael T Milano
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - Jona A Hattangadi-Gluth
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California
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22
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Wang NC, Noll DC, Srinivasan A, Gagnon-Bartsch J, Kim MM, Rao A. Simulated MRI Artifacts: Testing Machine Learning Failure Modes. BME Front 2022; 2022:9807590. [PMID: 37850164 PMCID: PMC10521705 DOI: 10.34133/2022/9807590] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 09/08/2022] [Indexed: 10/19/2023] Open
Abstract
Objective. Seven types of MRI artifacts, including acquisition and preprocessing errors, were simulated to test a machine learning brain tumor segmentation model for potential failure modes. Introduction. Real-world medical deployments of machine learning algorithms are less common than the number of medical research papers using machine learning. Part of the gap between the performance of models in research and deployment comes from a lack of hard test cases in the data used to train a model. Methods. These failure modes were simulated for a pretrained brain tumor segmentation model that utilizes standard MRI and used to evaluate the performance of the model under duress. These simulated MRI artifacts consisted of motion, susceptibility induced signal loss, aliasing, field inhomogeneity, sequence mislabeling, sequence misalignment, and skull stripping failures. Results. The artifact with the largest effect was the simplest, sequence mislabeling, though motion, field inhomogeneity, and sequence misalignment also caused significant performance decreases. The model was most susceptible to artifacts affecting the FLAIR (fluid attenuation inversion recovery) sequence. Conclusion. Overall, these simulated artifacts could be used to test other brain MRI models, but this approach could be used across medical imaging applications.
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Affiliation(s)
- Nicholas C. Wang
- Department of Computational Medicine and Bioinformatics, University of Michigan, USA
| | - Douglas C. Noll
- Department of Biomedical Engineering, University of Michigan, USA
- Department of Radiology, University of Michigan, USA
| | - Ashok Srinivasan
- Department of Radiology, Division of Neuroradiology, University of Michigan, USA
- Rogel Cancer Center, University of Michigan, USA
- Frankel Cardiovascular Center, University of Michigan, USA
| | | | - Michelle M. Kim
- Department of Radiation Oncology, University of Michigan, USA
| | - Arvind Rao
- Department of Computational Medicine and Bioinformatics, University of Michigan, USA
- Department of Radiation Oncology, University of Michigan, USA
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Kim MM, Goldman RD. Ear-piercing complications in children and adolescents. Can Fam Physician 2022; 68:661-663. [PMID: 36100383 PMCID: PMC9470180 DOI: 10.46747/cfp.6809661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
QUESTION Ear piercing is one of the most common forms of body modification seen in children and adolescents presenting to my office. Parents of my younger pediatric patients inquire about potential post-piercing complications and risk factors associated with earlobe infections. What guidance should I give them? Also, are there any specific post-piercing complications to consider for older pediatric patients seeking second piercings in the upper cartilage area? ANSWER Piercing the earlobe or auricular cartilage continues to be a popular procedure among children and adolescents. Despite its widespread practice, improper aseptic piercing technique, insufficient training, and trauma to the soft tissue during high-pressure piercing (eg, use of spring-loaded ear-piercing instruments) can increase one's susceptibility to infections, bleeding, and microfractures. Other post-piercing complications include embedded earrings, keloids, hypertrophic scarring, and cutaneous hypersensitivity. Early recognition and treatment of infections and perichondritis secondary to transcartilaginous piercings can prevent the progression of severe ear deformities requiring reconstructive surgical interventions.
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Gondi V, Bauman G, Bradfield L, Burri SH, Cabrera AR, Cunningham DA, Eaton BR, Hattangadi-Gluth JA, Kim MM, Kotecha R, Kraemer L, Li J, Nagpal S, Rusthoven CG, Suh JH, Tomé WA, Wang TJC, Zimmer AS, Ziu M, Brown PD. Radiation Therapy for Brain Metastases: An ASTRO Clinical Practice Guideline. Pract Radiat Oncol 2022; 12:265-282. [PMID: 35534352 DOI: 10.1016/j.prro.2022.02.003] [Citation(s) in RCA: 77] [Impact Index Per Article: 38.5] [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: 02/02/2022] [Accepted: 02/07/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE This guideline provides updated evidence-based recommendations addressing recent developments in the management of patients with brain metastases, including advanced radiation therapy techniques such as stereotactic radiosurgery (SRS) and hippocampal avoidance whole brain radiation therapy and the emergence of systemic therapies with central nervous system activity. METHODS The American Society for Radiation Oncology convened a task force to address 4 key questions focused on the radiotherapeutic management of intact and resected brain metastases from nonhematologic solid tumors. The guideline is based on a systematic review provided by the Agency for Healthcare Research and Quality. Recommendations were created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength. RESULTS Strong recommendations are made for SRS for patients with limited brain metastases and Eastern Cooperative Oncology Group performance status 0 to 2. Multidisciplinary discussion with neurosurgery is conditionally recommended to consider surgical resection for all tumors causing mass effect and/or that are greater than 4 cm. For patients with symptomatic brain metastases, upfront local therapy is strongly recommended. For patients with asymptomatic brain metastases eligible for central nervous system-active systemic therapy, multidisciplinary and patient-centered decision-making to determine whether local therapy may be safely deferred is conditionally recommended. For patients with resected brain metastases, SRS is strongly recommended to improve local control. For patients with favorable prognosis and brain metastases receiving whole brain radiation therapy, hippocampal avoidance and memantine are strongly recommended. For patients with poor prognosis, early introduction of palliative care for symptom management and caregiver support are strongly recommended. CONCLUSIONS The task force has proposed recommendations to inform best clinical practices on the use of radiation therapy for brain metastases with strong emphasis on multidisciplinary care.
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Affiliation(s)
- Vinai Gondi
- Department of Radiation Oncology, Northwestern Medicine Cancer Center and Proton Center, Warrenville, Illinois.
| | - Glenn Bauman
- Division of Radiation Oncology, Department of Oncology, London Health Sciences Centre & Western University, London, Ontario, Canada
| | - Lisa Bradfield
- American Society for Radiation Oncology, Arlington, Virginia
| | - Stuart H Burri
- Department of Radiation Oncology, Atrium Health, Charlotte, North Carolina
| | - Alvin R Cabrera
- Department of Radiation Oncology, Kaiser Permanente, Seattle, Washington
| | | | - Bree R Eaton
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | | | - Michelle M Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | | | - Jing Li
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Seema Nagpal
- Division of Neuro-oncology, Department of Neurology, Stanford University, Stanford, California
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado, Aurora, Colorado
| | - John H Suh
- Department of Radiation Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio
| | - Wolfgang A Tomé
- Department of Radiation Oncology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Tony J C Wang
- Department of Radiation Oncology, Columbia University, New York, New York
| | - Alexandra S Zimmer
- Women's Malignancies Branch, National Institutes of Health/National Cancer Institute, Bethesda, Maryland
| | - Mateo Ziu
- Department of Neurosciences, INOVA Neuroscience and INOVA Schar Cancer Institute, Falls Church, Virginia
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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25
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Laucis AM, Selwa K, Sun Y, Kim MM, Cuneo KC, Lawrence TS, Wahl DR, Junck L, Umemura Y. Efficacy and toxicity with radiation field designs and concurrent temozolomide for CNS lymphoma. Neurooncol Pract 2022; 9:536-544. [DOI: 10.1093/nop/npac052] [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
Background
There is no consensus on the treatment of central nervous system (CNS) lymphoma refractory to first-line methotrexate-based chemotherapy. Whole brain radiotherapy (WBRT) is sometimes used but may result in unacceptable neurocognitive dysfunction. We examined the efficacy and toxicities of WBRT with or without concurrent temozolomide in CNS lymphoma treatment.
Methods
This single-institution IRB-approved retrospective study included adults with CNS lymphoma who received WBRT, either consolidative low-dose WBRT alone or low-dose WBRT with a focal boost to residual disease and were previously treated with high-dose methotrexate. The relationships between the WBRT regimen, concurrent temozolomide, and clinical outcomes and toxicities were assessed using proportional hazards and logistic regression models.
Results
A total of 45 patients with a median age of 64 years (range 24–74) treated from 2004 to 2019 were included. In total, 20 patients received concurrent temozolomide. In the WBRT + Boost cohort (n = 32), concurrent temozolomide resulted in better 2-year overall survival (OS) and progression free survival (PFS) (73% OS and 66% PFS) compared to patients treated without concurrent temozolomide (44% OS and 24% PFS). On multivariate analysis, concurrent temozolomide was associated with significantly better PFS (HR 0.28, P = .02). There were no significant differences between the two radiation groups or between those treated with or without concurrent temozolomide, with respect to significant acute hematologic, non-hematologic, and long-term neurocognitive toxicities (P > .05).
Conclusions
In this study, concurrent temozolomide with radiotherapy in CNS lymphoma was associated with better PFS and was well tolerated. Low-dose WBRT with a boost is a safe and reasonable treatment approach for focal refractory disease. Prospective research that includes rigorous neurocognitive assessments is now warranted.
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Affiliation(s)
- Anna M Laucis
- Department of Radiation Oncology, University of Michigan Rogel Cancer Center , Ann Arbor, MI , USA
| | - Katherine Selwa
- Department of Neurology, University of Michigan Hospital , Ann Arbor, MI , USA
| | - Yilun Sun
- Department of Radiation Oncology, University of Michigan Rogel Cancer Center , Ann Arbor, MI , USA
| | - Michelle M Kim
- Department of Radiation Oncology, University of Michigan Rogel Cancer Center , Ann Arbor, MI , USA
| | - Kyle C Cuneo
- Department of Radiation Oncology, University of Michigan Rogel Cancer Center , Ann Arbor, MI , USA
| | - Theodore S Lawrence
- Department of Radiation Oncology, University of Michigan Rogel Cancer Center , Ann Arbor, MI , USA
| | - Daniel R Wahl
- Department of Radiation Oncology, University of Michigan Rogel Cancer Center , Ann Arbor, MI , USA
| | - Larry Junck
- Department of Neurology, University of Michigan Hospital , Ann Arbor, MI , USA
| | - Yoshie Umemura
- Department of Neurology, University of Michigan Hospital , Ann Arbor, MI , USA
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26
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Galldiks N, Langen KJ, Albert NL, Law I, Kim MM, Villanueva-Meyer JE, Soffietti R, Wen PY, Weller M, Tonn JC. Investigational PET tracers in neuro-oncology-What's on the horizon? A report of the PET/RANO group. Neuro Oncol 2022; 24:1815-1826. [PMID: 35674736 DOI: 10.1093/neuonc/noac131] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [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: 11/14/2022] Open
Abstract
Many studies in patients with brain tumors evaluating innovative PET tracers have been published in recent years, and the initial results are promising. Here, the Response Assessment in Neuro-Oncology (RANO) PET working group provides an overview of the literature on novel investigational PET tracers for brain tumor patients. Furthermore, newer indications of more established PET tracers for the evaluation of glucose metabolism, amino acid transport, hypoxia, cell proliferation, and others are also discussed. Based on the preliminary findings, these novel investigational PET tracers should be further evaluated considering their promising potential. In particular, novel PET probes for imaging of translocator protein and somatostatin receptor overexpression as well as for immune system reactions appear to be of additional clinical value for tumor delineation and therapy monitoring. Progress in developing these radiotracers may contribute to improving brain tumor diagnostics and advancing clinical translational research.
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Affiliation(s)
- Norbert Galldiks
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener St. 62, 50937 Cologne, Germany.,Institute of Neuroscience and Medicine (INM-3, -4), Research Center Juelich, Juelich, Germany.,Center of Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne, and Düsseldorf, Germany
| | - Karl-Josef Langen
- Institute of Neuroscience and Medicine (INM-3, -4), Research Center Juelich, Juelich, Germany.,Center of Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne, and Düsseldorf, Germany.,Department of Nuclear Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Nathalie L Albert
- Department of Nuclear Medicine, Ludwig Maximilians-University of Munich, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site Munich, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Ian Law
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Michelle M Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Javier E Villanueva-Meyer
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California, USA
| | - Riccardo Soffietti
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
| | - Patrick Y Wen
- Center for Neuro-Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts, USA
| | - Michael Weller
- Department of Neurology, Clinical Neuroscience Center University Hospital and University of Zurich, Zurich, Switzerland
| | - Joerg C Tonn
- Department of Neurosurgery, University Hospital of Munich (LMU), Munich, Germany.,German Cancer Consortium (DKTK), Partner Site Munich, German Cancer Research Center (DKFZ), Heidelberg, Germany
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27
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Tan AC, Boggs DH, Lee EQ, Kim MM, Mehta MP, Khasraw M. Clinical Trial Eligibility Criteria and Recently Approved Cancer Therapies for Patients With Brain Metastases. Front Oncol 2022; 11:780379. [PMID: 35047397 PMCID: PMC8761732 DOI: 10.3389/fonc.2021.780379] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 09/21/2021] [Accepted: 12/09/2021] [Indexed: 12/24/2022] Open
Abstract
Brain metastases cause significant morbidity and mortality in patients with advanced cancer. In the era of precision oncology and immunotherapy, there are rapidly evolving systemic treatment options. These novel therapies may have variable intracranial efficacy, and patients with brain metastases remain a population of special interest. Typically, only patients with stable, asymptomatic and/or treated brain metastases are enrolled in clinical trials, or may be excluded altogether, particularly in the setting of leptomeningeal carcinomatosis. Consequently, this leads to significant concerns on the external validity of clinical trial evidence to real-world clinical practice. Here we describe the current trends in cancer clinical trial eligibility for patients with brain metastases in both early and late phase trials, with a focus on targeted and immunotherapies. We evaluate recent newly FDA approved therapies and the clinical trial evidence base leading to approval. This includes analysis of inclusion and exclusion criteria, requirements for baseline screening for brain metastases, surveillance cerebral imaging and incorporation of trial endpoints for patients with brain metastases. Finally, the use of alternative sources of data such as real-world evidence with registries and collaborative studies will be discussed.
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Affiliation(s)
- Aaron C Tan
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore, Singapore.,Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Drexell H Boggs
- Department of Radiation Oncology, University of Alabama at Birmingham School of Medicine, Birmingham, AL, United States
| | - Eudocia Q Lee
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
| | - Michelle M Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, United States
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, United States
| | - Mustafa Khasraw
- Duke Cancer Institute, Duke University, Durham, NC, United States
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28
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Kim MM, Hattangadi-Gluth JA, Redmond KJ, Trifiletti DM, Soltys SG, Milano MT. Back to the Future: Charting the Direction of Lower Grade Glioma Trials With Lessons From the Present and Past. Int J Radiat Oncol Biol Phys 2022; 112:30-34. [PMID: 34919877 DOI: 10.1016/j.ijrobp.2021.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 10/05/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Michelle M Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
| | - Jona A Hattangadi-Gluth
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California
| | - Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic Florida, Jacksonville, Florida
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Michael T Milano
- Department of Radiation Oncology, University of Rochester, Rochester, New York
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29
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Kim MM, Ladi-Seyedian SS, Ginsberg DA, Kreydin EI. The Association of Physical Activity and Urinary Incontinence in US Women: Results from a Multi-Year National Survey. Urology 2021; 159:72-77. [PMID: 34644590 DOI: 10.1016/j.urology.2021.09.022] [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: 06/28/2021] [Revised: 09/05/2021] [Accepted: 09/07/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To evaluate the relationships between physical activity, both work and recreational, and urinary incontinence among women. METHODS We assessed women aged 20 years and older in 2008-2018 NHANES (National Health and Nutrition Examination Survey) cycles who answered self-reported urinary incontinence and physical activity questions. Weighted, multivariate logistic regression model was used to determine the association between incontinence and physical activity levels after adjusting for age, body mass index, diabetes, race, parity, menopause and smoking. RESULTS A total of 30,213 women were included in analysis, of whom 23.15% had stress incontinence, 23.16% had urge incontinence, and 8.42% had mixed incontinence (answered "yes" to both stress and urge incontinence). Women who engaged in moderate recreational activity were less likely to report stress and urge incontinence (OR 0.79, 95% CI 0.62-0.99 and OR 0.66, 95% CI 0.48-0.90, respectively). Similarly, women who engaged in moderate activity work were less likely to report stress, urge and mixed incontinence (OR 0.84, 95% CI 0.70-0.99; OR 0.84, 95% CI 0.72-0.99; and OR 0.66 95% CI 0.45-0.97, respectively). CONCLUSIONS Moderate physical activity and greater time spent participating in moderate physical activity are associated with a decreased likelihood of stress, urge and mixed incontinence in women. This relationship holds for both recreational and work-related activity. We hypothesize that the mechanism of this relationship is multifactorial, with moderate physical activity improving pelvic floor strength and modifying neurophysiological mediators (such as stress) involved in the pathogenesis of incontinence.
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Affiliation(s)
- Michelle M Kim
- Department of Urology, Massachusetts General Hospital, Boston, MA
| | | | - David A Ginsberg
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Evgeniy I Kreydin
- Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA.
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30
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Connor M, Kim MM, Cao Y, Hattangadi-Gluth J. Precision Radiotherapy for Gliomas: Implementing Novel Imaging Biomarkers to Improve Outcomes With Patient-Specific Therapy. Cancer J 2021; 27:353-363. [PMID: 34570449 PMCID: PMC8480523 DOI: 10.1097/ppo.0000000000000546] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
ABSTRACT Gliomas are the most common primary brain cancer, yet are extraordinarily challenging to treat because they can be aggressive and infiltrative, locally recurrent, and resistant to standard treatments. Furthermore, the treatments themselves, including radiation therapy, can affect patients' neurocognitive function and quality of life. Noninvasive imaging is the standard of care for primary brain tumors, including diagnosis, treatment planning, and monitoring for treatment response. This article explores the ways in which advanced imaging has and will continue to transform radiation treatment for patients with gliomas, with a focus on cognitive preservation and novel biomarkers, as well as precision radiotherapy and treatment adaptation. Advances in novel imaging techniques continue to push the field forward, to more precisely guided treatment planning, radiation dose escalation, measurement of therapeutic response, and understanding of radiation-associated injury.
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Affiliation(s)
- Michael Connor
- From the Department of Radiation Medicine and Applied Sciences, UC San Diego, Moores Cancer Center, La Jolla, CA
| | - Michelle M Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Yue Cao
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Jona Hattangadi-Gluth
- From the Department of Radiation Medicine and Applied Sciences, UC San Diego, Moores Cancer Center, La Jolla, CA
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Abstract
QUESTION The effect of acute coronavirus disease 2019 (COVID-19) on morbidity and mortality in children has been relatively small. If a child presents to my office with persistent fever and systemic hyperinflammation but no known exposure to COVID-19, how likely are they to have multisystem inflammatory syndrome in children (MIS-C)? What is currently known about MIS-C and what is the prognosis for children affected by it? ANSWER Amid the COVID-19 pandemic, the emergence of a novel condition presents yet another challenge to clinicians, public health professionals, and the pediatric population. Multisystem inflammatory syndrome in children is a rare but potentially severe condition seen in children with evidence of COVID-19 approximately 2 to 6 weeks before symptom onset. Common signs and symptoms include persistent fever, systemic hyperinflammation, gastrointestinal symptoms (eg, abdominal pain, vomiting, diarrhea), mucocutaneous changes (eg, rash, conjunctivitis), headache, or cardiac dysfunction. As many children present as asymptomatic or with mild symptoms of COVID-19, the development of MIS-C can seem sudden and surprising to families and providers. Although children with MIS-C usually require hospitalization, the outcomes are largely favourable with prompt recognition and intense therapy.
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Kim MM, Murthy S, Goldman RD. Le syndrome inflammatoire multisystémique post-COVID-19 chez les enfants. Can Fam Physician 2021; 67:e224-e226. [PMID: 34385216 PMCID: PMC9683419 DOI: 10.46747/cfp.6708e224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Les répercussions de la maladie au coronavirus 2019 (COVID-19) sur la morbidité et la mortalité chez les enfants se sont révélées relativement faibles. Si un enfant se présente à ma clinique avec une fièvre persistante et une hyperinflammation systémique sans aucune exposition connue à la COVID-19, quelle est la probabilité qu'il soit atteint du syndrome inflammatoire multisystémique de l'enfant (MIS-C)? Que sait-on actuellement du MIS-C et quel est le pronostic pour les enfants qui en souffrent? RÉPONSE: En plein cœur de la pandémie de la COVID-19, l'émergence d'un nouveau problème présente encore une fois un défi additionnel aux cliniciens, aux professionnels de la santé publique et à la population pédiatrique. Le syndrome inflammatoire multisystémique chez les enfants est rare, mais potentiellement grave, et il a été observé chez des enfants dont la maladie à la COVID-19 a été confirmée environ 2 à 6 semaines avant l'apparition des symptômes. Au nombre des signes et des symptômes courants figurent une fièvre persistante, une hyperinflammation systémique, des malaises gastro-intestinaux (p. ex. douleurs abdominales, vomissements, diarrhée), des changements mucocutanés (p. ex. éruptions cutanées, conjonctivite), une céphalée ou une dysfonction cardiaque. Étant donné que de nombreux enfants sont asymptomatiques ou ne présentent que des symptômes légers de la COVID-19, le développement du MIS-C peut sembler soudain et surprenant aux familles et aux médecins. Même si les enfants atteints du MIS-C nécessitent habituellement une hospitalisation, les issues sont largement favorables grâce à une reconnaissance rapide du syndrome et à une thérapie intense.
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Li Y, Kim MM, Wahl DR, Lawrence TS, Parmar H, Cao Y. Survival Prediction Analysis in Glioblastoma With Diffusion Kurtosis Imaging. Front Oncol 2021; 11:690036. [PMID: 34336676 PMCID: PMC8316991 DOI: 10.3389/fonc.2021.690036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 06/24/2021] [Indexed: 11/13/2022] Open
Abstract
SIMPLE SUMMARY Glioblastoma (GBM) is the most common and aggressive primary brain tumor. Diffusion kurtosis imaging (DKI) has characterized non-Gaussian diffusion behaviors in brain normal tissue and gliomas, but there are very limited efforts in investigating treatment responses of kurtosis in GBM. This study aimed to investigate whether any parameter derived from the DKI is a significant predictor of overall survival (OS). We found that the large mean, 80 and 90 percentile kurtosis values in the contrast enhanced gross tumor volume (Gd-GTV) on post-Gd T1-weighted images pre-RT were significantly associated with reduced OS. In the multivariate Cox model, the mean kurtosis Gd-GTV pre-RT after considering effects of age, extent of surgery, and methylation were significant predictors of OS. In addition, the 80 and 90 percentile kurtosis values in Gd-GTV post RT were significantly associated with progression free survival (PFS). The DKI model demonstrates the potential to predict outcomes in the patients with GBM. PURPOSE Non-Gaussian diffusion behaviors in gliomas have been characterized by diffusion kurtosis imaging (DKI). But there are very limited efforts in investigating the kurtosis in glioblastoma (GBM) and its prognostic and predictive values. This study aimed to investigate whether any of the diffusion kurtosis parameters derived from DKI is a significant predictor of overall survival. METHODS AND MATERIALS Thirty-three patients with GBM had pre-radiation therapy (RT) and mid-RT diffusion weighted (DW) images. Kurtosis and diffusion coefficient (DC) values in the contrast enhanced gross tumor volume (Gd-GTV) on post-Gd T1 weighted images pre-RT and mid-RT were calculated. Univariate and multivariate Cox models were used to evaluate the DKI parameters and clinical factors for prediction of OS and PFS. RESULTS The large mean kurtosis values in the Gd-GTV pre-RT were significantly associated with reduced OS (p = 0.02), but the values at mid-RT were not (p > 0.8). In the multivariate Cox model, the mean kurtosis in the Gd-GTV pre-RT (p = 0.009) was still a significant predictor of OS after adjusting effects of age, O6-Methylguanine-DNA Methyl transferase (MGMT) methylation and extent of resection. In Gd-GTV post-RT, 80 and 90 percentile kurtosis values were significant predictors (p ≤ 0.05) for progression free survival (PFS). CONCLUSION The DKI model demonstrates the potential to predict OS and PFS in the patients with GBM. Further development and histopathological validation of the DKI model will warrant its role in clinical management of GBM.
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Affiliation(s)
- Yuan Li
- Departments of Radiation Oncology, University of Michigan, Ann Arbor, MI, United States
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States
| | - Michelle M. Kim
- Departments of Radiation Oncology, University of Michigan, Ann Arbor, MI, United States
| | - Daniel R. Wahl
- Departments of Radiation Oncology, University of Michigan, Ann Arbor, MI, United States
| | - Theodore S. Lawrence
- Departments of Radiation Oncology, University of Michigan, Ann Arbor, MI, United States
| | - Hemant Parmar
- Department of Radiology, University of Michigan, Ann Arbor, MI, United States
| | - Yue Cao
- Departments of Radiation Oncology, University of Michigan, Ann Arbor, MI, United States
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States
- Department of Radiology, University of Michigan, Ann Arbor, MI, United States
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Galldiks N, Niyazi M, Grosu AL, Kocher M, Langen KJ, Law I, Minniti G, Kim MM, Tsien C, Dhermain F, Soffietti R, Mehta MP, Weller M, Tonn JC. Contribution of PET imaging to radiotherapy planning and monitoring in glioma patients - a report of the PET/RANO group. Neuro Oncol 2021; 23:881-893. [PMID: 33538838 DOI: 10.1093/neuonc/noab013] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The management of patients with glioma usually requires multimodality treatment including surgery, radiotherapy, and systemic therapy. Accurate neuroimaging plays a central role for radiotherapy planning and follow-up after radiotherapy completion. In order to maximize the radiation dose to the tumor and to minimize toxic effects on the surrounding brain parenchyma, reliable identification of tumor extent and target volume delineation is crucial. The use of positron emission tomography (PET) for radiotherapy planning and monitoring in gliomas has gained considerable interest over the last several years, but Class I data are not yet available. Furthermore, PET has been used after radiotherapy for response assessment and to distinguish tumor progression from pseudoprogression or radiation necrosis. Here, the Response Assessment in Neuro-Oncology (RANO) working group provides a summary of the literature and recommendations for the use of PET imaging for radiotherapy of patients with glioma based on published studies, constituting levels 1-3 evidence according to the Oxford Centre for Evidence-based Medicine.
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Affiliation(s)
- Norbert Galldiks
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.,Institute of Neuroscience and Medicine (INM-3,-4), Research Center Juelich, Juelich, Germany.,Center for Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne, and Düsseldorf, Cologne and Aachen, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany.,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Anca L Grosu
- Department of Radiation Oncology, University Hospital Freiburg, Freiburg, Germany
| | - Martin Kocher
- Institute of Neuroscience and Medicine (INM-3,-4), Research Center Juelich, Juelich, Germany.,Department of Stereotaxy and Functional Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Karl-Josef Langen
- Institute of Neuroscience and Medicine (INM-3,-4), Research Center Juelich, Juelich, Germany.,Center for Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne, and Düsseldorf, Cologne and Aachen, Germany.,Department of Nuclear Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Ian Law
- Department of Clinical Physiology, Nuclear Medicine and PET, University Hospital Copenhagen, Copenhagen, Denmark
| | - Giuseppe Minniti
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy.,IRCCS Istituto Neurologico Mediterraneo Neuromed, Pozzilli, Italy
| | - Michelle M Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Christina Tsien
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Frederic Dhermain
- Department of Radiation Therapy, Institut de Cancerologie Gustave Roussy, Villejuif, France
| | - Riccardo Soffietti
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA.,Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Michael Weller
- Department of Neurology & Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Jörg-Christian Tonn
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany.,Department of Neurosurgery, University Hospital, LMU Munich, Munich, Germany
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Redmond KJ, Milano MT, Kim MM, Trifiletti DM, Soltys SG, Hattangadi-Gluth JA. Reducing Radiation-Induced Cognitive Toxicity: Sparing the Hippocampus and Beyond. Int J Radiat Oncol Biol Phys 2021; 109:1131-1136. [PMID: 33714520 DOI: 10.1016/j.ijrobp.2021.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 01/03/2021] [Indexed: 12/25/2022]
Affiliation(s)
- Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland.
| | - Michael T Milano
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - Michelle M Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic Florida, Jacksonville, Florida
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Jona A Hattangadi-Gluth
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California
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Kim MM, Aryal MP, Sun Y, Parmar HA, Li P, Schipper M, Wahl DR, Lawrence TS, Cao Y. Response assessment during chemoradiation using a hypercellular/hyperperfused imaging phenotype predicts survival in patients with newly diagnosed glioblastoma. Neuro Oncol 2021; 23:1537-1546. [PMID: 33599755 DOI: 10.1093/neuonc/noab038] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Adversely prognostic hypercellular and hyperperfused regions of glioblastoma (GBM) predict progression-free survival, and are a novel target for dose-intensified chemoradiation (chemoRT) recently implemented in a phase II clinical trial. As a secondary aim, we hypothesized that dose-intensified chemoRT would induce greater mid-treatment response of hypercellular/hyperperfused tumor regions vs standard chemoradiation, and that early response would improve overall survival (OS). METHODS Forty-nine patients with newly diagnosed GBM underwent prospective, multiparametric high b value diffusion-weighted MRI (DW-MRI) and perfusion dynamic contrast-enhanced MRI (DCE-MRI) pre-RT and 3-4 weeks into RT. The hypercellular tumor volume (TVHCV, mean contralateral normal brain + 2SD) and hyperperfused tumor volume (TVCBV, contralateral normal frontal gray matter + 1SD) were generated using automated thresholding. Twenty-six patients were enrolled on a dose-escalation trial targeting TVHCV/TVCBV with 75 Gy in 30 fractions, and 23 non-trial patients comprised the control group. OS was estimated using the Kaplan-Meier method and compared using the log-rank test. The effect of TVHCV/TVCBV and Gd-enhanced tumor volume on OS was assessed using multivariable Cox proportional-hazard regression. RESULTS Most patients had gross total (47%) or subtotal resection (37%), 25% were MGMT-methylated. Patients treated on the dose-escalation trial had significantly greater reduction in TVHCV/TVCBV (41% reduction, IQR 17%-75%) vs non-trial patients (6% reduction, IQR 6%-22%, P = .002). An increase in TVHCV/TVCBV during chemoRT was associated with worse OS (adjusted hazard ratio [aHR] 1.2, 95%CI 1.0-1.4, P = .02), while pre-treatment tumor volumes (P > .5) and changes in Gd-enhanced volume (P = .9) were not. CONCLUSIONS Multiparametric MRI permits identification of therapeutic resistance during chemoRT and supports adaptive strategies in future trials.
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Affiliation(s)
- Michelle M Kim
- Department of Radiation Oncology, The University of Michigan, Ann Arbor, Michigan, USA
| | - Madhava P Aryal
- Department of Radiation Oncology, The University of Michigan, Ann Arbor, Michigan, USA
| | - Yilun Sun
- Department of Radiation Oncology, The University of Michigan, Ann Arbor, Michigan, USA.,Department of Biostatistics, The University of Michigan, Ann Arbor, Michigan, USA
| | - Hemant A Parmar
- Department of Radiology, The University of Michigan, Ann Arbor, Michigan, USA
| | - Pin Li
- Department of Biostatistics, The University of Michigan, Ann Arbor, Michigan, USA
| | - Matthew Schipper
- Department of Biostatistics, The University of Michigan, Ann Arbor, Michigan, USA
| | - Daniel R Wahl
- Department of Radiation Oncology, The University of Michigan, Ann Arbor, Michigan, USA
| | - Theodore S Lawrence
- Department of Radiation Oncology, The University of Michigan, Ann Arbor, Michigan, USA
| | - Yue Cao
- Department of Radiation Oncology, The University of Michigan, Ann Arbor, Michigan, USA.,Department of Radiology, The University of Michigan, Ann Arbor, Michigan, USA.,Department of Biomedical Engineering, The University of Michigan, Ann Arbor, Michigan, USA
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Zhao SG, Yu M, Spratt DE, Chang SL, Feng FY, Kim MM, Speers CW, Carlson BL, Mladek AC, Lawrence TS, Sarkaria JN, Wahl DR. Xenograft-based, platform-independent gene signatures to predict response to alkylating chemotherapy, radiation, and combination therapy for glioblastoma. Neuro Oncol 2020; 21:1141-1149. [PMID: 31121035 DOI: 10.1093/neuonc/noz090] [Citation(s) in RCA: 16] [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] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Predictive molecular biomarkers to select optimal treatment for patients with glioblastoma and other cancers are lacking. New strategies are needed when large randomized trials with correlative molecular data are not feasible. METHODS Gene signatures (GS) were developed from 31 orthotopic glioblastoma patient-derived xenografts (PDXs), treated with standard therapies, to predict benefit from radiotherapy (RT-GS), temozolomide (Chemo-GS), or the combination (ChemoRT-GS). Independent validation was performed in a heterogeneously treated clinical cohort of 502 glioblastoma patients with overall survival as the primary endpoint. Multivariate Cox analysis was used to adjust for confounding variables and evaluate interactions between signatures and treatment. RESULTS PDX models recapitulated the clinical heterogeneity of glioblastoma patients. RT-GS, Chemo-GS, and ChemoRT-GS were correlated with benefit from treatment in the PDX models. In independent clinical validation, higher RT-GS scores were associated with increased survival only in patients receiving RT (P = 0.0031, hazard ratio [HR] = 0.78 [0.66-0.92]), higher Chemo-GS scores were associated with increased survival only in patients receiving chemotherapy (P < 0.0001, HR = 0.66 [0.55-0.8]), and higher ChemoRT-GS scores were associated with increased survival only in patients receiving ChemoRT (P = 0.0001, HR = 0.54 [0.4-0.74]). RT-GS and ChemoRT-GS had significant interactions with treatment on multivariate analysis (P = 0.0009 and 0.02, respectively), indicating that they are bona fide predictive biomarkers. CONCLUSIONS Using a novel PDX-driven methodology, we developed and validated 3 platform-independent molecular signatures that predict benefit from standard of care therapies for glioblastoma. These signatures may be useful to personalize glioblastoma treatment in the clinic and this approach may be a generalizable method to identify predictive biomarkers without resource-intensive randomized trials.
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Affiliation(s)
- Shuang G Zhao
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Menggang Yu
- Department of Biostatistics, University of Wisconsin, Madison, Wisconsin
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - S Laura Chang
- Department of Urology, Medicine, and Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Felix Y Feng
- Department of Urology, Medicine, and Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Michelle M Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Corey W Speers
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Brett L Carlson
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Ann C Mladek
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Theodore S Lawrence
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Jann N Sarkaria
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Daniel R Wahl
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
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Galldiks N, Langen KJ, Albert NL, Chamberlain M, Soffietti R, Kim MM, Law I, Le Rhun E, Chang S, Schwarting J, Combs SE, Preusser M, Forsyth P, Pope W, Weller M, Tonn JC. PET imaging in patients with brain metastasis-report of the RANO/PET group. Neuro Oncol 2020; 21:585-595. [PMID: 30615138 DOI: 10.1093/neuonc/noz003] [Citation(s) in RCA: 111] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Revised: 10/11/2018] [Accepted: 01/03/2019] [Indexed: 12/23/2022] Open
Abstract
Brain metastases (BM) from extracranial cancer are associated with significant morbidity and mortality. Effective local treatment options are stereotactic radiotherapy, including radiosurgery or fractionated external beam radiotherapy, and surgical resection. The use of systemic treatment for intracranial disease control also is improving. BM diagnosis, treatment planning, and follow-up is most often based on contrast-enhanced magnetic resonance imaging (MRI). However, anatomic imaging modalities including standard MRI have limitations in accurately characterizing posttherapeutic reactive changes and treatment response. Molecular imaging techniques such as positron emission tomography (PET) characterize specific metabolic and cellular features of metastases, potentially providing clinically relevant information supplementing anatomic MRI. Here, the Response Assessment in Neuro-Oncology working group provides recommendations for the use of PET imaging in the clinical management of patients with BM based on evidence from studies validated by histology and/or clinical outcome.
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Affiliation(s)
- Norbert Galldiks
- Department of Neurology, University Hospital Cologne, Cologne, Germany.,Institute of Neuroscience and Medicine 3, 4, Research Center Juelich, Juelich, Germany.,Center of Integrated Oncology, Universities of Cologne and Bonn, Cologne, Germany
| | - Karl-Josef Langen
- Institute of Neuroscience and Medicine 3, 4, Research Center Juelich, Juelich, Germany.,Department of Nuclear Medicine, University Hospital Aachen, Aachen, Germany
| | - Nathalie L Albert
- Department of Nuclear Medicine, Ludwig Maximilians-University of Munich, Munich, Germany
| | - Marc Chamberlain
- Departments of Neurology and Neurological Surgery, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington, USA
| | - Riccardo Soffietti
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
| | - Michelle M Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Ian Law
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University of Copenhagen, Denmark
| | - Emilie Le Rhun
- Department of Neurosurgery, University Hospital Lille, Lille, France
| | - Susan Chang
- Department of Neurosurgery, University of California, San Francisco, California, USA
| | - Julian Schwarting
- Department of Neurosurgery, Ludwig Maximilians-University of Munich, Munich, Germany.,German Cancer Consortium, Partner Site Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Technical University Munich, Munich, Germany
| | - Matthias Preusser
- Department of Medicine I and Comprehensive Cancer Centre CNS Tumours Unit, Medical University of Vienna, Vienna, Austria
| | - Peter Forsyth
- Moffitt Cancer Center, University of South Florida, Tampa, Florida, USA
| | - Whitney Pope
- Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, California , USA
| | - Michael Weller
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Jörg C Tonn
- Department of Neurosurgery, Ludwig Maximilians-University of Munich, Munich, Germany.,German Cancer Consortium, Partner Site Munich, Germany
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39
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Kim MM, Parmar HA, Schipper M, Devasia T, Aryal MP, Kesari S, O'Day S, Morikawa A, Spratt DE, Junck L, Mammoser A, Hayman JA, Lawrence TS, Tsien CI, Aiken R, Goyal S, Abrouk N, Trimble M, Cao Y, Lao CD. BRAINSTORM: A Multi-Institutional Phase 1/2 Study of RRx-001 in Combination With Whole Brain Radiation Therapy for Patients With Brain Metastases. Int J Radiat Oncol Biol Phys 2020; 107:478-486. [PMID: 32169409 DOI: 10.1016/j.ijrobp.2020.02.639] [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] [Received: 08/22/2019] [Revised: 02/19/2020] [Accepted: 02/29/2020] [Indexed: 01/05/2023]
Abstract
PURPOSE To determine the recommended phase 2 dose of RRx-001, a radiosensitizer with vascular normalizing properties, when used with whole-brain radiation therapy (WBRT) for brain metastases and to assess whether quantitative changes in perfusion magnetic resonance imaging (MRI) after RRx-001 correlate with response. METHODS AND MATERIALS Five centers participated in this phase 1/2 trial of RRx-001 given once pre-WBRT and then twice weekly during WBRT. Four dose levels were planned (5 mg/m2, 8.4 mg/m2, 16.5 mg/m2, 27.5 mg/m2). Dose escalation was managed by the time-to-event continual reassessment method algorithm. Linear mixed models were used to correlate change in 24-hour T1, Ktrans (capillary permeability), and fractional plasma volume with change in tumor volume. RESULTS Between 2015 and 2017, 31 patients were enrolled. Two patients dropped out before any therapy. Median age was 60 years (range, 30-76), and 12 were male. The most common tumor types were melanoma (59%) and non-small cell lung cancer (18%). No dose limiting toxicities were observed. The most common severe adverse event was grade 3 asthenia (6.9%, 2 of 29). The median intracranial response rate was 46% (95% confidence interval, 24-68) and median overall survival was 5.2 months (95% confidence interval, 4.5-9.4). No neurologic deaths occurred. Among 10 patients undergoing dynamic contrast-enhanced MRI, a reduction in Vp 24 hours after RRx-001 was associated with reduced tumor volume at 1 and 4 months (P ≤ .01). CONCLUSIONS The addition of RRx-001 to WBRT is well tolerated with favorable intracranial response rates. Because activity was observed across all dose levels, the recommended phase 2 dose is 10 mg twice weekly. A reduction in fractional plasma volume on dynamic contrast-enhanced MRI 24 hours after RRx-001 suggests antiangiogenic activity associated with longer-term tumor response.
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Affiliation(s)
- Michelle M Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
| | - Hemant A Parmar
- Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Matthew Schipper
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Theresa Devasia
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Madhava P Aryal
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Santosh Kesari
- Providence Saint John's Health Center, John Wayne Cancer Institute, Santa Monica, California
| | - Steven O'Day
- Providence Saint John's Health Center, John Wayne Cancer Institute, Santa Monica, California
| | - Aki Morikawa
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Larry Junck
- Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Aaron Mammoser
- Department of Neurosurgery, Louisiana State University, New Orleans, Louisiana
| | - James A Hayman
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Theodore S Lawrence
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Christina I Tsien
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Robert Aiken
- The Cancer Institute of New Jersey/Rutgers University, New Brunswick, New Jersey
| | - Sharad Goyal
- Department of Radiation Oncology, George Washington University, Washington, DC
| | - Nacer Abrouk
- Clinical Trials Innovations, Mountain View, California
| | | | - Yue Cao
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Christopher D Lao
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
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Kim MM, Parmar HA, Aryal MP, Mayo CS, Balter JM, Lawrence TS, Cao Y. Developing a Pipeline for Multiparametric MRI-Guided Radiation Therapy: Initial Results from a Phase II Clinical Trial in Newly Diagnosed Glioblastoma. ACTA ACUST UNITED AC 2020; 5:118-126. [PMID: 30854449 PMCID: PMC6403045 DOI: 10.18383/j.tom.2018.00035] [Citation(s) in RCA: 16] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Quantitative mapping of hyperperfused and hypercellular regions of glioblastoma has been proposed to improve definition of tumor regions at risk for local recurrence following conventional radiation therapy. As the processing of the multiparametric dynamic contrast-enhanced (DCE-) and diffusion-weighted (DW-) magnetic resonance imaging (MRI) data for delineation of these subvolumes requires additional steps that go beyond the standard practices of target definition, we sought to devise a workflow to support the timely planning and treatment of patients. A phase II study implementing a multiparametric imaging biomarker for tumor hyperperfusion and hypercellularity consisting of DCE-MRI and high b-value DW-MRI to guide intensified (75 Gy/30 fractions) radiation therapy (RT) in patients with newly diagnosed glioblastoma was launched. In this report, the workflow and the initial imaging outcomes of the first 12 patients are described. Among all the first 12 patients, treatment was initiated within 6 weeks of surgery and within 2 weeks of simulation. On average, the combined hypercellular volume and high cerebral blood volume/tumor perfusion volume were 1.8 times smaller than the T1 gadolinium abnormality and 10 times smaller than the FLAIR abnormality. Hypercellular volume and high cerebral blood volume/tumor perfusion volume each identified largely distinct regions and showed 57% overlap with the enhancing abnormality, and minimal-to-no extension outside of the FLAIR. These results show the feasibility of implementing a workflow for multiparametric magnetic resonance-guided radiation therapy into clinical trials with a coordinated multidisciplinary team, and the unique and complementary tumor subregions identified by the combination of high b-value DW-MRI and DCE-MRI.
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Affiliation(s)
| | | | | | | | | | | | - Yue Cao
- Departments of Radiation Oncology and
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41
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Beeler WH, Speth KA, Broderick MT, Jairath NK, Ballouz D, Gharzai LA, Jackson WC, Kim MM, Owen D, Szerlip NJ, Paradis KC, Spratt DE. Local Control and Toxicity of Multilevel Spine Stereotactic Body Radiotherapy. Neurosurgery 2020; 86:E164-E172. [PMID: 31541240 DOI: 10.1093/neuros/nyz348] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 06/16/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Spine stereotactic body radiotherapy (sSBRT) is commonly limited to 1 or 2 vertebral levels given a paucity of efficacy and toxicity data when more than 2 levels are treated. OBJECTIVE To prove our hypothesis that multilevel sSBRT could provide similar rates of local control (LC) (primary endpoint) and toxicity as single-level treatment using the same clinical target, planning target, and planning organ-at-risk volumes. METHODS We analyzed consecutive cases of sSBRT treated from 2013 to 2017. Time-to-event outcomes for single-level and multilevel cases were compared using mixed effect Cox models and differences in toxicity rates were evaluated using linear mixed effect models. All models incorporate a patient-level random intercept to account for any within-patient correlation across cases. RESULTS There were 101 single-level and 84 multilevel sSBRT cases (2-7 continuous vertebral levels). One-year LC was 95% vs 85%, respectively. After adjusting for baseline covariates, dose delivered, and accounting for within-patient correlation, there was no significant difference in time to local failure (hazard ratio, HR 1.79 [0.59-5.4]; P = .30). Pain improved in 83.5% of the 139 initially symptomatic tumors. There were no significant differences in grade 2+ acute or late toxicities between single-level and multilevel sSBRT. CONCLUSION With rigorous patient immobilization, quality assurance, and image guidance, multilevel sSBRT provides high rates of LC, similar to single-level treatment, without need for larger planning volume margins. Efforts to improve prognostication and case selection for multilevel sSBRT are warranted to ensure that the benefits of improved LC over palliative radiation are justified.
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Affiliation(s)
- Whitney H Beeler
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Kelly A Speth
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | | | - Neil K Jairath
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Dena Ballouz
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Laila A Gharzai
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - William C Jackson
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Michelle M Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Dawn Owen
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | | | - Kelly C Paradis
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
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Danhauer SC, Brenes GA, Levine BJ, Young L, Tindle HA, Addington EL, Wallace RB, Naughton MJ, Garcia L, Safford M, Kim MM, LeBlanc ES, Snively BM, Snetselaar LG, Shumaker S. Variability in sleep disturbance, physical activity and quality of life by level of depressive symptoms in women with Type 2 diabetes. Diabet Med 2019; 36:1149-1157. [PMID: 30552780 PMCID: PMC6571069 DOI: 10.1111/dme.13878] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/13/2018] [Indexed: 12/20/2022]
Abstract
AIMS To examine (1) the prevalence of depressive symptoms in women with Type 2 diabetes, (2) the associations between depressive symptoms and the following dependent variables: sleep disturbance; physical activity; physical health-related; and global quality of life, and (3) the potential moderating effects of antidepressants and optimism on the relationship between depressive symptoms and dependent variables. METHODS Participants in the Women's Health Initiative who had Type 2 diabetes and data on depressive symptoms (N=8895) were included in the analyses. In multivariable linear regression models controlling for sociodemographic, medical and psychosocial covariates, we examined the main effect of depressive symptoms, as well as the interactions between depressive symptoms and antidepressant use, and between depressive symptoms and optimism, on sleep disturbance, physical activity, physical health-related quality of life; and global quality of life. RESULTS In all, 16% of women with Type 2 diabetes reported elevated depressive symptoms. In multivariable analyses, women with depressive symptoms had greater sleep disturbance (P<0.0001) and lower global quality of life (P<.0001). We found evidence of significant statistical interaction in the models for quality-of-life outcomes: the increased risk of poor physical health-related quality of life associated with antidepressant use was stronger in women without vs with depressive symptoms, and the association between greater optimism and higher global quality of life was stronger in women with vs without depressive symptoms. CONCLUSIONS To improve health behaviours and quality of life in women with Type 2 diabetes, sociodemographic and medical characteristics may identify at-risk populations, while psychosocial factors including depression and optimism may be important targets for non-pharmacological intervention.
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Affiliation(s)
- S C Danhauer
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston Salem, NC
| | - G A Brenes
- Department of Internal Medicine, Section on Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Winston Salem, NC
| | - B J Levine
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston Salem, NC
| | - L Young
- Department of Medicine, Division of Endocrinology and Metabolism, Section on Gerontology and Geriatric Medicine, UNC School of Medicine, Chapel Hill, NC
| | - H A Tindle
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - E L Addington
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - R B Wallace
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA
| | - M J Naughton
- Division of Cancer Prevention and Control, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | - L Garcia
- Department of Public Health Sciences, University of California Davis School of Medicine, Davis, CA
| | - M Safford
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - M M Kim
- Center for Biobehavioral Health Disparities Research, Department of Community and Family Medicine, Duke University, Durham, NC
| | - E S LeBlanc
- Kaiser Permanente Center for Health Research NW, Portland, OR, USA
| | - B M Snively
- Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, WinstonSalem, NC, USA
| | - L G Snetselaar
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA
| | - S Shumaker
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston Salem, NC
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43
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Swartz LK, Holste KG, Kim MM, Morikawa A, Heth J. Outcomes in Patients Treated with Laser Interstitial Thermal Therapy for Primary Brain Cancer and Brain Metastases. Oncologist 2019; 24:e1467-e1470. [PMID: 31439811 DOI: 10.1634/theoncologist.2019-0213] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 08/06/2019] [Indexed: 11/17/2022] Open
Abstract
Laser interstitial thermal therapy (LITT) is an emerging modality to treat benign and malignant brain lesions. LITT is a minimally invasive method to ablate tissue using laser-induced tissue heating and serves as both a diagnostic and therapeutic modality for progressive brain lesions. We completed a single-center retrospective analysis of all patients with progressive brain lesions treated with LITT since its introduction at our center in August of 2015. Twelve patients have been treated for a total of 13 procedures, of which 10 patients had brain metastases and 2 patients had primary malignant gliomas. Biopsies were obtained immediately prior to laser-induced tissue heating in 10 procedures (76.9%), of which seven biopsies showed treatment-related changes without viable tumor. After laser ablation, two of three patients previously on steroids were successfully weaned on first attempt. The results of this analysis indicate that LITT is a well-tolerated procedure enabling some patients to discontinue steroids that may be effective for diagnosing and treating radiation necrosis and tumor progression.
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Affiliation(s)
- Leigh Klaus Swartz
- Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Katherine G Holste
- Department of Neurosurgery, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Michelle M Kim
- Department of Radiation Oncology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Aki Morikawa
- Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Jason Heth
- Department of Neurosurgery, University of Michigan Health System, Ann Arbor, Michigan, USA
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44
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Kim MM, Speers C, Li P, Schipper M, Junck L, Leung D, Orringer D, Heth J, Umemura Y, Spratt DE, Wahl DR, Cao Y, Lawrence TS, Tsien CI. Dose-intensified chemoradiation is associated with altered patterns of failure and favorable survival in patients with newly diagnosed glioblastoma. J Neurooncol 2019; 143:313-319. [PMID: 30977058 DOI: 10.1007/s11060-019-03166-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 04/08/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE We evaluated whether dose-intensified chemoradiation alters patterns of failure and is associated with favorable survival in the temozolomide era. MATERIALS AND METHODS Between 2003 and 2015, 82 patients with newly diagnosed glioblastoma were treated with 66-81 Gy in 30 fractions using conventional magnetic resonance imaging. Progression-free (PFS) and overall survival (OS) were calculated using Kaplan-Meier methods. Factors associated with improved PFS, OS, and time to progression were assessed using multivariate Cox model and linear regression. RESULTS Median follow-up was 23 months (95% CI 4-124 months). Sixty-one percent of patients underwent subtotal resection or biopsy, and 38% (10/26) of patients with available data had MGMT promoter methylation. Median PFS was 8.4 months (95% CI 7.3-11.0) and OS was 18.7 months (95% CI 13.1-25.3). Only 30 patients (44%) experienced central recurrence, 6 (9%) in-field, 16 (23.5%) marginal and 16 (23.5%) distant. On multivariate analysis, younger age (HR 0.95, 95% CI 0.93-0.97, p = 0.0001), higher performance status (HR 0.39, 95% CI 0.16-0.95, p = 0.04), gross total resection (GTR) versus biopsy (HR 0.37, 95% CI 0.16-0.85, p = 0.02) and MGMT methylation (HR 0.25, 95% CI 0.09-0.71, p = 0.009) were associated with improved OS. Only distant versus central recurrence (p = 0.03) and GTR (p = 0.02) were associated with longer time to progression. Late grade 3 neurologic toxicity was rare (6%) in patients experiencing long-term survival. CONCLUSION Dose-escalated chemoRT resulted in lower rates of central recurrence and prolonged time to progression compared to historical controls, although a significant number of central recurrences were still observed. Advanced imaging and correlative molecular studies may enable targeted treatment advances that reduce rates of in- and out-of-field progression.
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Affiliation(s)
- Michelle M Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA.
| | - Corey Speers
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Pin Li
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Matthew Schipper
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Larry Junck
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Denise Leung
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Daniel Orringer
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Jason Heth
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Yoshie Umemura
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Daniel R Wahl
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Yue Cao
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Theodore S Lawrence
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Christina I Tsien
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO, USA
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45
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Kruser TJ, Bosch WR, Badiyan SN, Bovi JA, Ghia AJ, Kim MM, Solanki AA, Sachdev S, Tsien C, Wang TJC, Mehta MP, McMullen KP. NRG brain tumor specialists consensus guidelines for glioblastoma contouring. J Neurooncol 2019; 143:157-166. [PMID: 30888558 DOI: 10.1007/s11060-019-03152-9] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 03/11/2019] [Indexed: 01/19/2023]
Abstract
INTRODUCTION NRG protocols for glioblastoma allow for clinical target volume (CTV) reductions at natural barriers; however, literature examining CTV contouring and the relevant white matter pathways is lacking. This study proposes consensus CTV guidelines, with a focus on areas of controversy while highlighting common errors in glioblastoma target delineation. METHODS Ten academic radiation oncologists specializing in brain tumor treatment contoured CTVs on four glioblastoma cases. CTV expansions were based on NRG trial guidelines. Contour consensus was assessed and summarized by kappa statistics. A meeting was held to discuss the mathematically averaged contours and form consensus contours and recommendations. RESULTS Contours of the cavity plus enhancement (mean kappa 0.69) and T2-FLAIR signal (mean kappa 0.74) showed moderate to substantial agreement. Experts were asked to trim off anatomic barriers while respecting pathways of spread to develop their CTVs. Submitted CTV_4600 (mean kappa 0.80) and CTV_6000 (mean kappa 0.81) contours showed substantial to near perfect agreement. Simultaneous truth and performance level estimation (STAPLE) contours were then reviewed and modified by group consensus. Anatomic trimming reduced the amount of total brain tissue planned for radiation targeting by a 13.6% (range 8.7-17.9%) mean proportional reduction. Areas for close scrutiny of target delineation were described, with accompanying recommendations. CONCLUSIONS Consensus contouring guidelines were established based on expert contours. Careful delineation of anatomic pathways and barriers to spread can spare radiation to uninvolved tissue without compromising target coverage. Further study is necessary to accurately define optimal target volumes beyond isometric expansion techniques for individual patients.
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Affiliation(s)
- Tim J Kruser
- Department of Radiation Oncology, Northwestern Memorial Hospital, 251 E Huron St, LC-178, Galter Pavilion, Chicago, IL, 60611, USA.
| | - Walter R Bosch
- Department of Radiation Oncology, Washington University, St. Louis, MO, USA
| | - Shahed N Badiyan
- Department of Radiation Oncology, Washington University, St. Louis, MO, USA
| | - Joseph A Bovi
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Amol J Ghia
- Department of Radiation Oncology, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Michelle M Kim
- Department of Radiation Oncology, University of Michigan Hospital, Ann Arbor, MI, USA
| | - Abhishek A Solanki
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
| | - Sean Sachdev
- Department of Radiation Oncology, Northwestern Memorial Hospital, 251 E Huron St, LC-178, Galter Pavilion, Chicago, IL, 60611, USA
| | - Christina Tsien
- Department of Radiation Oncology, Washington University, St. Louis, MO, USA
| | - Tony J C Wang
- Department of Radiation Oncology, Columbia University Medical Center, New York, NY, USA
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Weindorf SC, Taylor AS, Kumar-Sinha C, Robinson D, Wu YM, Cao X, Spratt DE, Kim MM, Lagstein A, Chinnaiyan AM, Mehra R. Metastatic castration resistant prostate cancer with squamous cell, small cell, and sarcomatoid elements-a clinicopathologic and genomic sequencing-based discussion. Med Oncol 2019; 36:27. [PMID: 30712214 DOI: 10.1007/s12032-019-1250-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 12/18/2018] [Accepted: 01/23/2019] [Indexed: 12/19/2022]
Abstract
Histologic variants are uncommon but well reported amongst cases of prostatic adenocarcinoma, including those in the setting of hormonal and/or chemoradiation therapy and castration resistance. However, the spectrum of morphologic phenotypes and molecular alterations present in such histologic variants are still incompletely understood. Herein, we describe a case of metastatic prostatic adenocarcinoma with hormonal and chemoradiation therapy-associated differentiation, displaying a combination of squamous cell, small cell, and sarcomatoid elements. The morphologic, immunohistochemical, and molecular observations are discussed with attention given to the gene alterations present, including in TP53, NF1, AR, PTEN, and RB1. Finally, we will compare our findings with those observed in uncommonly reported similar cases so as to detail the molecular underpinnings of such processes which may carry therapeutic implications.
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Affiliation(s)
- Steven C Weindorf
- Department of Pathology, University of Michigan Medical School, 2800 Plymouth Road, Building 35, Ann Arbor, MI, USA
| | - Alexander S Taylor
- Department of Pathology, University of Michigan Medical School, 2800 Plymouth Road, Building 35, Ann Arbor, MI, USA
| | - Chandan Kumar-Sinha
- Department of Pathology, University of Michigan Medical School, 2800 Plymouth Road, Building 35, Ann Arbor, MI, USA.,Michigan Center for Translational Pathology, Ann Arbor, MI, USA
| | - Dan Robinson
- Department of Pathology, University of Michigan Medical School, 2800 Plymouth Road, Building 35, Ann Arbor, MI, USA.,Michigan Center for Translational Pathology, Ann Arbor, MI, USA
| | - Yi-Mi Wu
- Department of Pathology, University of Michigan Medical School, 2800 Plymouth Road, Building 35, Ann Arbor, MI, USA.,Michigan Center for Translational Pathology, Ann Arbor, MI, USA
| | - Xuhong Cao
- Michigan Center for Translational Pathology, Ann Arbor, MI, USA
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan Medical School, Ann Arbor, MI, USA.,Rogel Cancer Center, Michigan Medicine, 1400 East Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Michelle M Kim
- Department of Radiation Oncology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Amir Lagstein
- Department of Pathology, University of Michigan Medical School, 2800 Plymouth Road, Building 35, Ann Arbor, MI, USA
| | - Arul M Chinnaiyan
- Department of Pathology, University of Michigan Medical School, 2800 Plymouth Road, Building 35, Ann Arbor, MI, USA.,Department of Urology, University of Michigan Medical School, Ann Arbor, MI, 48109, USA.,Rogel Cancer Center, Michigan Medicine, 1400 East Medical Center Drive, Ann Arbor, MI, 48109, USA.,Michigan Center for Translational Pathology, Ann Arbor, MI, USA.,Howard Hughes Medical Institute, Ann Arbor, MI, USA
| | - Rohit Mehra
- Department of Pathology, University of Michigan Medical School, 2800 Plymouth Road, Building 35, Ann Arbor, MI, USA. .,Rogel Cancer Center, Michigan Medicine, 1400 East Medical Center Drive, Ann Arbor, MI, 48109, USA. .,Michigan Center for Translational Pathology, Ann Arbor, MI, USA.
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47
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Beeler WH, Paradis KC, Gemmete JJ, Chaudhary N, Kim MM, Smith SR, Paradis E, Matuszak MM, Park P, Archer PG, Szerlip NJ, Spratt DE. Computed Tomography Myelosimulation Versus Magnetic Resonance Imaging Registration to Delineate the Spinal Cord During Spine Stereotactic Radiosurgery. World Neurosurg 2019; 122:e655-e666. [DOI: 10.1016/j.wneu.2018.10.118] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 10/17/2018] [Accepted: 10/19/2018] [Indexed: 11/25/2022]
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48
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Kim MM, Audet J. On-demand serum-free media formulations for human hematopoietic cell expansion using a high dimensional search algorithm. Commun Biol 2019; 2:48. [PMID: 30729186 PMCID: PMC6358607 DOI: 10.1038/s42003-019-0296-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 01/09/2019] [Indexed: 12/13/2022] Open
Abstract
Substitution of serum and other clinically incompatible reagents is requisite for controlling product quality in a therapeutic cell manufacturing process. However, substitution with chemically defined compounds creates a complex, large-scale optimization problem due to the large number of possible factors and dose levels, making conventional process optimization methods ineffective. We present a framework for high-dimensional optimization of serum-free formulations for the expansion of human hematopoietic cells. Our model-free approach utilizes evolutionary computing principles to drive an experiment-based feedback control platform. We validate this method by optimizing serum-free formulations for first, TF-1 cells and second, primary T-cells. For each cell type, we successfully identify a set of serum-free formulations that support cell expansions similar to the serum-containing conditions commonly used to culture these cells, by experimentally testing less than 1 × 10-5 % of the total search space. We also demonstrate how this iterative search process can provide insights into factor interactions that contribute to supporting cell expansion.
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Affiliation(s)
- Michelle M. Kim
- Institute of Biomaterials and Biomedical Engineering, University of Toronto, 164 College St, Toronto, ON M5S 3G9 Canada
| | - Julie Audet
- Institute of Biomaterials and Biomedical Engineering, University of Toronto, 164 College St, Toronto, ON M5S 3G9 Canada
- Department of Chemical Engineering and Applied Chemistry, University of Toronto, 200 College St, Toronto, ON M5S 3E5 Canada
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49
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Blumenthal DT, Gorlia T, Gilbert MR, Kim MM, Burt Nabors L, Mason WP, Hegi ME, Zhang P, Golfinopoulos V, Perry JR, Hyun Nam D, Erridge SC, Corn BW, Mirimanoff RO, Brown PD, Baumert BG, Mehta MP, van den Bent MJ, Reardon DA, Weller M, Stupp R. Is more better? The impact of extended adjuvant temozolomide in newly diagnosed glioblastoma: a secondary analysis of EORTC and NRG Oncology/RTOG. Neuro Oncol 2018; 19:1119-1126. [PMID: 28371907 DOI: 10.1093/neuonc/nox025] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [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: 11/14/2022] Open
Abstract
Background Radiation with concurrent and adjuvant (6 cycles) temozolomide (TMZ) is the established standard of postsurgical care for newly diagnosed glioblastoma (GBM). This regimen has been adopted with variations, including extending TMZ beyond 6 cycles. The optimal duration of maintenance therapy remains controversial. Methods We performed pooled analysis of individual patient data from 4 randomized trials for newly diagnosed GBM. All patients who were progression free 28 days after cycle 6 were included. The decision to continue TMZ was per local practice and standards, and at the discretion of the treating physician. Patients were grouped into those treated with 6 cycles and those who continued beyond 6 cycles. Progression-free and overall survival were compared, adjusted by age, performance status, resection extent, and MGMT methylation. Results A total of 2214 GBM patients were included in the 4 trials. Of these, 624 qualified for analysis 291 continued maintenance TMZ until progression or up to 12 cycles, while 333 discontinued TMZ after 6 cycles. Adjusted for prognostic factors, treatment with more than 6 cycles of TMZ was associated with a somewhat improved progression-free survival (hazard ratio [HR] 0.80 [0.65-0.98], P = .03), in particular for patients with methylated MGMT (n = 342, HR 0.65 [0.50-0.85], P < .01). However, overall survival was not affected by the number of TMZ cycles (HR = 0.92 [0.71-1.19], P = .52), including the MGMT methylated subgroup (HR = 0.89 [0.63-1.26], P = .51). Conclusions Continuing TMZ beyond 6 cycles was not shown to increase overall survival for newly diagnosed GBM.
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Affiliation(s)
- Deborah T Blumenthal
- Tel-Aviv Sourasky Medical Center, Tel-Aviv University; European Organization for Research and Treatment of Cancer, Brussels (EORTC); National Institutes of Health (M.R.M.); University of Alabama at Birmingham; Princess Margaret Cancer Centre, University of Toronto; Lausanne University Hospital; NRG Oncology Statistics and Data Management Center; Odette Cancer Centre and Sunnybrook Health Sciences Centre, University of Toronto; Samsung Medical Center, Sungkyunkwan University School of Medicine; Edinburgh Cancer Centre; Mayo Clinic; Robert-Janker Clinic at the University of Bonn Medical Centre, and MAASTRO clinic, GROW School for Oncology, Maastricht University Medical Centre; Miami Cancer Institute; Erasmus University Hospital; Dana-Farber Cancer Institute and Harvard Medical School; University of Zurich
| | - Thierry Gorlia
- Tel-Aviv Sourasky Medical Center, Tel-Aviv University; European Organization for Research and Treatment of Cancer, Brussels (EORTC); National Institutes of Health (M.R.M.); University of Alabama at Birmingham; Princess Margaret Cancer Centre, University of Toronto; Lausanne University Hospital; NRG Oncology Statistics and Data Management Center; Odette Cancer Centre and Sunnybrook Health Sciences Centre, University of Toronto; Samsung Medical Center, Sungkyunkwan University School of Medicine; Edinburgh Cancer Centre; Mayo Clinic; Robert-Janker Clinic at the University of Bonn Medical Centre, and MAASTRO clinic, GROW School for Oncology, Maastricht University Medical Centre; Miami Cancer Institute; Erasmus University Hospital; Dana-Farber Cancer Institute and Harvard Medical School; University of Zurich
| | - Mark R Gilbert
- Tel-Aviv Sourasky Medical Center, Tel-Aviv University; European Organization for Research and Treatment of Cancer, Brussels (EORTC); National Institutes of Health (M.R.M.); University of Alabama at Birmingham; Princess Margaret Cancer Centre, University of Toronto; Lausanne University Hospital; NRG Oncology Statistics and Data Management Center; Odette Cancer Centre and Sunnybrook Health Sciences Centre, University of Toronto; Samsung Medical Center, Sungkyunkwan University School of Medicine; Edinburgh Cancer Centre; Mayo Clinic; Robert-Janker Clinic at the University of Bonn Medical Centre, and MAASTRO clinic, GROW School for Oncology, Maastricht University Medical Centre; Miami Cancer Institute; Erasmus University Hospital; Dana-Farber Cancer Institute and Harvard Medical School; University of Zurich
| | - Michelle M Kim
- Tel-Aviv Sourasky Medical Center, Tel-Aviv University; European Organization for Research and Treatment of Cancer, Brussels (EORTC); National Institutes of Health (M.R.M.); University of Alabama at Birmingham; Princess Margaret Cancer Centre, University of Toronto; Lausanne University Hospital; NRG Oncology Statistics and Data Management Center; Odette Cancer Centre and Sunnybrook Health Sciences Centre, University of Toronto; Samsung Medical Center, Sungkyunkwan University School of Medicine; Edinburgh Cancer Centre; Mayo Clinic; Robert-Janker Clinic at the University of Bonn Medical Centre, and MAASTRO clinic, GROW School for Oncology, Maastricht University Medical Centre; Miami Cancer Institute; Erasmus University Hospital; Dana-Farber Cancer Institute and Harvard Medical School; University of Zurich
| | - L Burt Nabors
- Tel-Aviv Sourasky Medical Center, Tel-Aviv University; European Organization for Research and Treatment of Cancer, Brussels (EORTC); National Institutes of Health (M.R.M.); University of Alabama at Birmingham; Princess Margaret Cancer Centre, University of Toronto; Lausanne University Hospital; NRG Oncology Statistics and Data Management Center; Odette Cancer Centre and Sunnybrook Health Sciences Centre, University of Toronto; Samsung Medical Center, Sungkyunkwan University School of Medicine; Edinburgh Cancer Centre; Mayo Clinic; Robert-Janker Clinic at the University of Bonn Medical Centre, and MAASTRO clinic, GROW School for Oncology, Maastricht University Medical Centre; Miami Cancer Institute; Erasmus University Hospital; Dana-Farber Cancer Institute and Harvard Medical School; University of Zurich
| | - Warren P Mason
- Tel-Aviv Sourasky Medical Center, Tel-Aviv University; European Organization for Research and Treatment of Cancer, Brussels (EORTC); National Institutes of Health (M.R.M.); University of Alabama at Birmingham; Princess Margaret Cancer Centre, University of Toronto; Lausanne University Hospital; NRG Oncology Statistics and Data Management Center; Odette Cancer Centre and Sunnybrook Health Sciences Centre, University of Toronto; Samsung Medical Center, Sungkyunkwan University School of Medicine; Edinburgh Cancer Centre; Mayo Clinic; Robert-Janker Clinic at the University of Bonn Medical Centre, and MAASTRO clinic, GROW School for Oncology, Maastricht University Medical Centre; Miami Cancer Institute; Erasmus University Hospital; Dana-Farber Cancer Institute and Harvard Medical School; University of Zurich
| | - Monika E Hegi
- Tel-Aviv Sourasky Medical Center, Tel-Aviv University; European Organization for Research and Treatment of Cancer, Brussels (EORTC); National Institutes of Health (M.R.M.); University of Alabama at Birmingham; Princess Margaret Cancer Centre, University of Toronto; Lausanne University Hospital; NRG Oncology Statistics and Data Management Center; Odette Cancer Centre and Sunnybrook Health Sciences Centre, University of Toronto; Samsung Medical Center, Sungkyunkwan University School of Medicine; Edinburgh Cancer Centre; Mayo Clinic; Robert-Janker Clinic at the University of Bonn Medical Centre, and MAASTRO clinic, GROW School for Oncology, Maastricht University Medical Centre; Miami Cancer Institute; Erasmus University Hospital; Dana-Farber Cancer Institute and Harvard Medical School; University of Zurich
| | - Peixin Zhang
- Tel-Aviv Sourasky Medical Center, Tel-Aviv University; European Organization for Research and Treatment of Cancer, Brussels (EORTC); National Institutes of Health (M.R.M.); University of Alabama at Birmingham; Princess Margaret Cancer Centre, University of Toronto; Lausanne University Hospital; NRG Oncology Statistics and Data Management Center; Odette Cancer Centre and Sunnybrook Health Sciences Centre, University of Toronto; Samsung Medical Center, Sungkyunkwan University School of Medicine; Edinburgh Cancer Centre; Mayo Clinic; Robert-Janker Clinic at the University of Bonn Medical Centre, and MAASTRO clinic, GROW School for Oncology, Maastricht University Medical Centre; Miami Cancer Institute; Erasmus University Hospital; Dana-Farber Cancer Institute and Harvard Medical School; University of Zurich
| | - Vassilis Golfinopoulos
- Tel-Aviv Sourasky Medical Center, Tel-Aviv University; European Organization for Research and Treatment of Cancer, Brussels (EORTC); National Institutes of Health (M.R.M.); University of Alabama at Birmingham; Princess Margaret Cancer Centre, University of Toronto; Lausanne University Hospital; NRG Oncology Statistics and Data Management Center; Odette Cancer Centre and Sunnybrook Health Sciences Centre, University of Toronto; Samsung Medical Center, Sungkyunkwan University School of Medicine; Edinburgh Cancer Centre; Mayo Clinic; Robert-Janker Clinic at the University of Bonn Medical Centre, and MAASTRO clinic, GROW School for Oncology, Maastricht University Medical Centre; Miami Cancer Institute; Erasmus University Hospital; Dana-Farber Cancer Institute and Harvard Medical School; University of Zurich
| | - James R Perry
- Tel-Aviv Sourasky Medical Center, Tel-Aviv University; European Organization for Research and Treatment of Cancer, Brussels (EORTC); National Institutes of Health (M.R.M.); University of Alabama at Birmingham; Princess Margaret Cancer Centre, University of Toronto; Lausanne University Hospital; NRG Oncology Statistics and Data Management Center; Odette Cancer Centre and Sunnybrook Health Sciences Centre, University of Toronto; Samsung Medical Center, Sungkyunkwan University School of Medicine; Edinburgh Cancer Centre; Mayo Clinic; Robert-Janker Clinic at the University of Bonn Medical Centre, and MAASTRO clinic, GROW School for Oncology, Maastricht University Medical Centre; Miami Cancer Institute; Erasmus University Hospital; Dana-Farber Cancer Institute and Harvard Medical School; University of Zurich
| | - Do Hyun Nam
- Tel-Aviv Sourasky Medical Center, Tel-Aviv University; European Organization for Research and Treatment of Cancer, Brussels (EORTC); National Institutes of Health (M.R.M.); University of Alabama at Birmingham; Princess Margaret Cancer Centre, University of Toronto; Lausanne University Hospital; NRG Oncology Statistics and Data Management Center; Odette Cancer Centre and Sunnybrook Health Sciences Centre, University of Toronto; Samsung Medical Center, Sungkyunkwan University School of Medicine; Edinburgh Cancer Centre; Mayo Clinic; Robert-Janker Clinic at the University of Bonn Medical Centre, and MAASTRO clinic, GROW School for Oncology, Maastricht University Medical Centre; Miami Cancer Institute; Erasmus University Hospital; Dana-Farber Cancer Institute and Harvard Medical School; University of Zurich
| | - Sara C Erridge
- Tel-Aviv Sourasky Medical Center, Tel-Aviv University; European Organization for Research and Treatment of Cancer, Brussels (EORTC); National Institutes of Health (M.R.M.); University of Alabama at Birmingham; Princess Margaret Cancer Centre, University of Toronto; Lausanne University Hospital; NRG Oncology Statistics and Data Management Center; Odette Cancer Centre and Sunnybrook Health Sciences Centre, University of Toronto; Samsung Medical Center, Sungkyunkwan University School of Medicine; Edinburgh Cancer Centre; Mayo Clinic; Robert-Janker Clinic at the University of Bonn Medical Centre, and MAASTRO clinic, GROW School for Oncology, Maastricht University Medical Centre; Miami Cancer Institute; Erasmus University Hospital; Dana-Farber Cancer Institute and Harvard Medical School; University of Zurich
| | - Benjamin W Corn
- Tel-Aviv Sourasky Medical Center, Tel-Aviv University; European Organization for Research and Treatment of Cancer, Brussels (EORTC); National Institutes of Health (M.R.M.); University of Alabama at Birmingham; Princess Margaret Cancer Centre, University of Toronto; Lausanne University Hospital; NRG Oncology Statistics and Data Management Center; Odette Cancer Centre and Sunnybrook Health Sciences Centre, University of Toronto; Samsung Medical Center, Sungkyunkwan University School of Medicine; Edinburgh Cancer Centre; Mayo Clinic; Robert-Janker Clinic at the University of Bonn Medical Centre, and MAASTRO clinic, GROW School for Oncology, Maastricht University Medical Centre; Miami Cancer Institute; Erasmus University Hospital; Dana-Farber Cancer Institute and Harvard Medical School; University of Zurich
| | - René O Mirimanoff
- Tel-Aviv Sourasky Medical Center, Tel-Aviv University; European Organization for Research and Treatment of Cancer, Brussels (EORTC); National Institutes of Health (M.R.M.); University of Alabama at Birmingham; Princess Margaret Cancer Centre, University of Toronto; Lausanne University Hospital; NRG Oncology Statistics and Data Management Center; Odette Cancer Centre and Sunnybrook Health Sciences Centre, University of Toronto; Samsung Medical Center, Sungkyunkwan University School of Medicine; Edinburgh Cancer Centre; Mayo Clinic; Robert-Janker Clinic at the University of Bonn Medical Centre, and MAASTRO clinic, GROW School for Oncology, Maastricht University Medical Centre; Miami Cancer Institute; Erasmus University Hospital; Dana-Farber Cancer Institute and Harvard Medical School; University of Zurich
| | - Paul D Brown
- Tel-Aviv Sourasky Medical Center, Tel-Aviv University; European Organization for Research and Treatment of Cancer, Brussels (EORTC); National Institutes of Health (M.R.M.); University of Alabama at Birmingham; Princess Margaret Cancer Centre, University of Toronto; Lausanne University Hospital; NRG Oncology Statistics and Data Management Center; Odette Cancer Centre and Sunnybrook Health Sciences Centre, University of Toronto; Samsung Medical Center, Sungkyunkwan University School of Medicine; Edinburgh Cancer Centre; Mayo Clinic; Robert-Janker Clinic at the University of Bonn Medical Centre, and MAASTRO clinic, GROW School for Oncology, Maastricht University Medical Centre; Miami Cancer Institute; Erasmus University Hospital; Dana-Farber Cancer Institute and Harvard Medical School; University of Zurich
| | - Brigitta G Baumert
- Tel-Aviv Sourasky Medical Center, Tel-Aviv University; European Organization for Research and Treatment of Cancer, Brussels (EORTC); National Institutes of Health (M.R.M.); University of Alabama at Birmingham; Princess Margaret Cancer Centre, University of Toronto; Lausanne University Hospital; NRG Oncology Statistics and Data Management Center; Odette Cancer Centre and Sunnybrook Health Sciences Centre, University of Toronto; Samsung Medical Center, Sungkyunkwan University School of Medicine; Edinburgh Cancer Centre; Mayo Clinic; Robert-Janker Clinic at the University of Bonn Medical Centre, and MAASTRO clinic, GROW School for Oncology, Maastricht University Medical Centre; Miami Cancer Institute; Erasmus University Hospital; Dana-Farber Cancer Institute and Harvard Medical School; University of Zurich
| | - Minesh P Mehta
- Tel-Aviv Sourasky Medical Center, Tel-Aviv University; European Organization for Research and Treatment of Cancer, Brussels (EORTC); National Institutes of Health (M.R.M.); University of Alabama at Birmingham; Princess Margaret Cancer Centre, University of Toronto; Lausanne University Hospital; NRG Oncology Statistics and Data Management Center; Odette Cancer Centre and Sunnybrook Health Sciences Centre, University of Toronto; Samsung Medical Center, Sungkyunkwan University School of Medicine; Edinburgh Cancer Centre; Mayo Clinic; Robert-Janker Clinic at the University of Bonn Medical Centre, and MAASTRO clinic, GROW School for Oncology, Maastricht University Medical Centre; Miami Cancer Institute; Erasmus University Hospital; Dana-Farber Cancer Institute and Harvard Medical School; University of Zurich
| | - Martin J van den Bent
- Tel-Aviv Sourasky Medical Center, Tel-Aviv University; European Organization for Research and Treatment of Cancer, Brussels (EORTC); National Institutes of Health (M.R.M.); University of Alabama at Birmingham; Princess Margaret Cancer Centre, University of Toronto; Lausanne University Hospital; NRG Oncology Statistics and Data Management Center; Odette Cancer Centre and Sunnybrook Health Sciences Centre, University of Toronto; Samsung Medical Center, Sungkyunkwan University School of Medicine; Edinburgh Cancer Centre; Mayo Clinic; Robert-Janker Clinic at the University of Bonn Medical Centre, and MAASTRO clinic, GROW School for Oncology, Maastricht University Medical Centre; Miami Cancer Institute; Erasmus University Hospital; Dana-Farber Cancer Institute and Harvard Medical School; University of Zurich
| | - David A Reardon
- Tel-Aviv Sourasky Medical Center, Tel-Aviv University; European Organization for Research and Treatment of Cancer, Brussels (EORTC); National Institutes of Health (M.R.M.); University of Alabama at Birmingham; Princess Margaret Cancer Centre, University of Toronto; Lausanne University Hospital; NRG Oncology Statistics and Data Management Center; Odette Cancer Centre and Sunnybrook Health Sciences Centre, University of Toronto; Samsung Medical Center, Sungkyunkwan University School of Medicine; Edinburgh Cancer Centre; Mayo Clinic; Robert-Janker Clinic at the University of Bonn Medical Centre, and MAASTRO clinic, GROW School for Oncology, Maastricht University Medical Centre; Miami Cancer Institute; Erasmus University Hospital; Dana-Farber Cancer Institute and Harvard Medical School; University of Zurich
| | - Michael Weller
- Tel-Aviv Sourasky Medical Center, Tel-Aviv University; European Organization for Research and Treatment of Cancer, Brussels (EORTC); National Institutes of Health (M.R.M.); University of Alabama at Birmingham; Princess Margaret Cancer Centre, University of Toronto; Lausanne University Hospital; NRG Oncology Statistics and Data Management Center; Odette Cancer Centre and Sunnybrook Health Sciences Centre, University of Toronto; Samsung Medical Center, Sungkyunkwan University School of Medicine; Edinburgh Cancer Centre; Mayo Clinic; Robert-Janker Clinic at the University of Bonn Medical Centre, and MAASTRO clinic, GROW School for Oncology, Maastricht University Medical Centre; Miami Cancer Institute; Erasmus University Hospital; Dana-Farber Cancer Institute and Harvard Medical School; University of Zurich
| | - Roger Stupp
- Tel-Aviv Sourasky Medical Center, Tel-Aviv University; European Organization for Research and Treatment of Cancer, Brussels (EORTC); National Institutes of Health (M.R.M.); University of Alabama at Birmingham; Princess Margaret Cancer Centre, University of Toronto; Lausanne University Hospital; NRG Oncology Statistics and Data Management Center; Odette Cancer Centre and Sunnybrook Health Sciences Centre, University of Toronto; Samsung Medical Center, Sungkyunkwan University School of Medicine; Edinburgh Cancer Centre; Mayo Clinic; Robert-Janker Clinic at the University of Bonn Medical Centre, and MAASTRO clinic, GROW School for Oncology, Maastricht University Medical Centre; Miami Cancer Institute; Erasmus University Hospital; Dana-Farber Cancer Institute and Harvard Medical School; University of Zurich
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Oronsky B, Goyal S, Kim MM, Cabrales P, Lybeck M, Caroen S, Oronsky N, Burbano E, Carter C, Oronsky A. A Review of Clinical Radioprotection and Chemoprotection for Oral Mucositis. Transl Oncol 2018; 11:771-778. [PMID: 29698934 PMCID: PMC5918142 DOI: 10.1016/j.tranon.2018.03.014] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 03/28/2018] [Accepted: 03/30/2018] [Indexed: 12/20/2022] Open
Abstract
The first tenet of medicine, "primum non nocere" or "first, do no harm", is not always compatible with oncological interventions e.g., chemotherapy, targeted therapy and radiation, since they commonly result in significant toxicities. One of the more frequent and serious treatment-induced toxicities is mucositis and particularly oral mucositis (OM) described as inflammation, atrophy and breakdown of the mucosa or lining of the oral cavity. The sequelae of oral mucositis (OM), which include pain, odynodysphagia, dysgeusia, decreased oral intake and systemic infection, frequently require treatment delays, interruptions and discontinuations that not only negatively impact quality of life but also tumor control and survivorship. One potential strategy to reduce or prevent the development of mucositis, for which no effective therapies exist only best supportive empirical care measures, is the administration of agents referred to as radioprotectors and/or chemoprotectors, which are intended to differentially protect normal but not malignant tissue from cytotoxicity. This limited-scope review briefly summarizes the incidence, pathogenesis, symptoms and impact on patients of OM as well as the background and mechanisms of four clinical stage radioprotectors/chemoprotectors, amifostine, palifermin, GC4419 and RRx-001, with the proven or theoretical potential to minimize the development of mucositis particularly in the treatment of head and neck cancers.
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Affiliation(s)
- Bryan Oronsky
- EpicentRx Inc, 4445 Eastgate Mall, Suite 200, San Diego, CA 92121, USA.
| | - Sharad Goyal
- The George Washington University, Department of Radiation Oncology, 22nd & I Street, NW DC Level, Washington, DC 20037
| | - Michelle M Kim
- University of Michigan Health System, Radiation Oncology, 1500 E. Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Pedro Cabrales
- University of California San Diego, Moores Cancer Center, 3855 Health Sciences Dr, La Jolla, CA 92093, USA
| | - Michelle Lybeck
- EpicentRx Inc, 4445 Eastgate Mall, Suite 200, San Diego, CA 92121, USA
| | - Scott Caroen
- EpicentRx Inc, 4445 Eastgate Mall, Suite 200, San Diego, CA 92121, USA
| | - Neil Oronsky
- CFLS Data, 800 West El Camino Real, Suite 180, Mountain View, CA 94040
| | - Erica Burbano
- EpicentRx Inc, 4445 Eastgate Mall, Suite 200, San Diego, CA 92121, USA
| | - Corey Carter
- Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD 20889, USA
| | - Arnold Oronsky
- InterWest Partners, 2710 Sand Hill Road #200, Menlo Park, CA 94025, USA
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