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Montalvo SK, Ravella R, Zhang-Velten ER, Li X, Desai NB, Dan T, Timmerman RD, Jiang SB, Gu X, Parsons DDM, Kumar KA. Cardiac Sparing with Volumetric Modulated Arc Therapy Enabled Total Body Irradiation (CS VMAT-TBI). Int J Radiat Oncol Biol Phys 2023; 117:e477-e478. [PMID: 37785513 DOI: 10.1016/j.ijrobp.2023.06.1693] [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) Volumetric modulated arc therapy (VMAT) enabled total body irradiation (TBI) has replaced conventional TBI in our institution given the improved treatment accuracy, patient comfort, and dose modulation ability. The risk of cardiovascular disease is several folds higher among transplant patients who receive TBI, likely related to dose to the heart. We hypothesize that a cardiac-sparing (CS) VMAT-TBI technique is feasible and can meaningfully reduce dose to the heart while still adequately covering nearby lymphatic tissue. MATERIALS/METHODS VMAT-TBI is delivered via multi-isocentric external beams in a frame-based setup. Heart is contoured as per published guidelines. A lymph node contour, which includes tonsils, neck nodal stations, mediastinal, abdominal, retroperitoneal, and pelvic nodes is created. Coverage of the lymph node contour is prioritized over organ-sparing during inverse optimization; with a goal of V90% greater than 99.5% and mean dose less than 800 cGy for the lymph nodes and heart, respectively. An IRB-approved retrospective review was performed with mean heart dose collected for all patients treated with CS VMAT-TBI and compared to a representative cohort of five patients treated with VMAT-TBI without cardiac sparing. RESULTS Thirty-one patients were treated with CS VMAT-TBI between 2020-2022 with a median follow up time of 11.5 months. Mean heart dose was 796 ± 71 cGy in the CS VMAT-TBI compared to 1247 ± 29 cGy in the VMAT-TBI group without cardiac sparing (p < 0.001). Of those treated with CS VMAT-TBI, three patients relapsed; one relapse occurred in bone marrow only, one relapse occurred in bone marrow and cervical, thoracic, and intra-abdominal lymphoid tissues, and one patient was simulated but never received induction therapy due to overt progression. 100-day relapse-free survival and overall survival were 82.5% and 86.2%, respectively. Median survival time has not been met. CONCLUSION Cardiac sparing is feasible in VMAT-TBI and is associated with significant decrease in mean heart dose of ∼450 cGy. This is estimated to confer a 33.3% decreased absolute risk for lifetime major coronary events compared to patients treated with VMAT-TBI without cardiac sparing. Although limited by short follow-up time, there does not appear to be a significant risk for early relapse despite de-escalating cardiac tissue, likely due to prioritizing coverage of lymph nodes. Prospective clinical studies are needed to further validate cardiac and other organ at risk sparing VMAT-TBI techniques.
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Affiliation(s)
- S K Montalvo
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - R Ravella
- UT Southwestern Medical Center, Dallas, TX
| | - E R Zhang-Velten
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - X Li
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - N B Desai
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - T Dan
- University of Texas Southwestern Department of Radiation Oncology, Dallas, TX
| | - R D Timmerman
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - S B Jiang
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - X Gu
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA
| | - D D M Parsons
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - K A Kumar
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX
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Kumar KA, Ravella R, Geethakumari PR, Awan F, Aguilera TA, Li X, Öz OK, Kandathil A, Chen W, Fuda F, Ahn C, Iyengar P, Desai NB, Timmerman RD. Phase I Trial of 'Re-Priming' Radiation Therapy for Relapsed/Refractory Non-Hodgkin Lymphoma Patients in Incomplete Response after Chimeric Antigen Receptor T-Cell (CAR-T) Therapy. Int J Radiat Oncol Biol Phys 2023; 117:S51-S52. [PMID: 37784517 DOI: 10.1016/j.ijrobp.2023.06.334] [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) Inpatients with relapsed/refractory non-Hodgkin lymphoma (R/R NHL) treated with CD19-directed CAR-T, only ∼40% achieve complete response (CR) by day 30 PET/CT evaluation. Of those who do not, the large majority (∼70%) ultimately fail, providing an ideal target for early therapeutic intervention to 're-prime' CAR-T. Preclinical and early clinical studies suggest potential synergy and immune augmentation when combining RT with CAR-T. Here we report the phase I results of a prospective phase I/II clinical trial hypothesizing that early salvage focal RT to poor responding sites of disease after CAR-T in R/R NHL patients is safe (phase I) and will improve conversion to CR by day 90 post-CAR-T PET/CT from 29% (historical control) to 58% (phase II). MATERIALS/METHODS Weopened a single-arm open-label phase I/II prospective clinical trial at our institution for R/R NHL patients treated with CD19-directed CAR-T with incomplete response on day 30 post-CAR-T PET/CT scan (defined as Lugano > = 4). The phase I component used a 'Rolling 6' design with 6 patients enrolled concurrently at the "definitive" dose level (40-50 Gy EQD2 [i.e., 30 Gy in 5 fractions], with de-escalation to "palliative" dose level (20-32.5 Gy EQD2 [i.e., 20 Gy in 5 fractions]) if >2 dose-limiting toxicities (DLT) observed. Hypofractionated regimens (i.e., 5 fractions) directed only to residual FDG-avid disease were recommended to minimize lymphopenia and potentially result in a more favorable immune microenvironment. DLT rate was defined within 60 days of RT by CTCAE v5.0 grade 4+ hematologic, grade 3+ dermatitis/burn, pneumonitis, enteritis, or other toxicity attributable to RT, as well as new grade 3+ cytokine release syndrome (CRS) per ASTCT consensus guidelines or grade 3+ neurotoxicity per ASTCT ICANS consensus guidelines for adults. RESULTS BetweenApril 2021 and July 2022, 6 patients were enrolled. All 6 patients had diffuse large B-cell lymphoma (DLBCL), with 3/6 (50%) transformed from low-grade follicular lymphoma. 2/6 had primary refractory DLBL, while the other 4/6 had median 2.5 lines of treatment prior to CAR-T. No patient had prior RT to a site of residual FDG-avid disease on day 30 post-CAR-T PET/CT. 5/6 patients were treated to 30 Gy in 5 fractions, with the remainder patient treated to 36 Gy in 10 fractions. No grade 3+ DLTs related to RT were observed in the 60-day post-RT period. RT related toxicities included grad 1 alopecia, grade 1 radiation pneumonitis, grade 1 nausea & vomiting, and grade 2 skin infection. CONCLUSION Early salvage focal "definitive" dose RT to sites of incomplete response on day 30 post-CAR-T PET/CT for R/R/ NHL patients was safe with no de-escalation of dose needed. This dose will used in the subsequent phase II component of the trial.
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Affiliation(s)
- K A Kumar
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - R Ravella
- UT Southwestern Medical Center, Dallas, TX
| | | | - F Awan
- Division of Hematologic Malignancies and Stem Cell Transplantation, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - T A Aguilera
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - X Li
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - O K Öz
- University of Texas Southwestern Department of Radiation Oncology, Dallas, TX
| | | | - W Chen
- University of Texas Southwestern Medical Center, Dallas, TX
| | - F Fuda
- UT Southwestern, Dallas, TX
| | - C Ahn
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX
| | - P Iyengar
- University of Texas Southwestern Department of Radiation Oncology, Dallas, TX
| | - N B Desai
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - R D Timmerman
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX
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Nayak JK, Kedare SB, Banerjee R, Bandyopadhyay S, Desai NB, Paul S, Kapila A. A1 MW National Solar Thermal Research Cum Demonstration Facility at Gwalpahari, Haryana, India. CURR SCI INDIA 2015. [DOI: 10.18520/cs/v109/i8/1445-1457] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Nayak JK, Kedare SB, Banerjee R, Bandyopadhyay S, Desai NB, Paul S, Kapila A. A1 MW National Solar Thermal Research Cum Demonstration Facility at Gwalpahari, Haryana, India. CURR SCI INDIA 2015. [DOI: 10.18520/v109/i8/1445-1457] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Abstract
A right pulmonary artery to left atrial communication is a very rare vascular congenital anomaly. Patients most commonly present in the neonatal period with congestive cardiac failure or at a later stage with central cyanosis and its complications. Various diagnostic modalities are available but angiography is the most important decision-making tool for the management of this lesion. We present an unusual case of right pulmonary artery to left atrial communication in a 14-year-old patient, who underwent successful surgical repair through a bicameral approach.
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Affiliation(s)
- T P Gajjar
- Department of Cardiothoracic and Vascular Surgery, Sri Sathya Sai Institute of Higher Medical Sciences, Prasanthigram, District Anantapur, Andhra Pradesh, India.
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Ramirez F, Desai NB. CRYSTALLINE 1:1 ADDUCTS FROM THE REACTION OF TERTIARY PHOSPHITE ESTERS WITH ortho-QUINONES AND WITH alpha-DIKETONES. NEW ROUTES TO QUINOL-MONOPHOSPHATES AND TO KETOL-MONOPHOSPHATES1. J Am Chem Soc 2002. [DOI: 10.1021/ja01495a074] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ramirez F, Desai NB. Organic Compounds with Pentavalent Phosphorus. VIII.1 Cyclic Unsaturated Oxyphosphoranes from the Reaction of Tertiary Phosphite Esters with o-Quinones and with α-Diketones. J Am Chem Soc 2002. [DOI: 10.1021/ja00903a044] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ramirez F, Ramanathan N, Desai NB. Cyclic Saturated Oxyphosphoranes and their Hydrolysis to Cyclic Phosphate Esters. the Diastereomeric 2:1 Biacetyl-Trimethyl Phosphite Adducts. J Am Chem Soc 2002. [DOI: 10.1021/ja00904a036] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ramirez F, Tasaka K, Desai NB, Smith CP. Nucleophilic substitutions at pentavalent phosphorus. Reaction of 2,2,2-trialkoxy-2,2-dihydro-1,3,2-dioxaphospholenes with alcohols. J Am Chem Soc 2002. [DOI: 10.1021/ja01005a035] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ramirez F, Patwardhan AV, Desai NB, Ramanathan N, Greco CV. A New Synthesis of α,β-Dihydroxy-γ-ketoesters and of α,β-Dihydroxyketones via Cyclic Oxyphosphoranes. J Am Chem Soc 2002. [DOI: 10.1021/ja00902a064] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ramirez F, Mitra RB, Desai NB. A CARBON-SKELETON REARRANGEMENT DURING THE OXIDATIVE DEPHOSPHORYLATION OF A NEW TYPE OF PHOSPHORUS COMPOUND. REACTION OF MOLECULAR OXYGEN WITH THE CRYSTALLINE 1:1 ADDUCTS DERIVED FROM TERTIARY PHOSPHITE ESTERS AND alpha-DIKETONES1. J Am Chem Soc 2002. [DOI: 10.1021/ja01495a073] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ramirez F, Desai NB, Mitra RB. A NEW SYNTHESIS OF CYCLIC DIACYL PEROXIDES. DIPHENOYL PEROXIDE FROM PHENANTHRENE-QUINONE via A PHOSPHORANE DERIVATIVE1. J Am Chem Soc 2002. [DOI: 10.1021/ja01463a060] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ramirez F, Patwardhan AV, Desai NB, Heller SR. The Hydrolysis of Five-Membered Cyclic Oxyphosphoranes to Cyclic Phosphate Esters. P31 Nuclear Magnetic Resonance and Stereoisomerism at Phosphorus in Cyclic Phosphates1,2. J Am Chem Soc 2002. [DOI: 10.1021/ja01081a028] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ramirez F, Desai NB, Ramanathan N. Cyclic Phosphate Esters from the Hydrolysis of Cyclic Oxyphosphoranes. Evidence for Pentavalent Phosphorus in the Oxyphosphoranes. J Am Chem Soc 2002. [DOI: 10.1021/ja00895a042] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ramirez F, Mitra RB, Desai NB. THE REACTION OF PHOSPHORANE DERIVATIVES WITH OZONE. BENZIL-TRIALKYL PHOSPHITE ADDUCTS AND PHOSPHINEACYLMETHYLENES1. J Am Chem Soc 2002. [DOI: 10.1021/ja01506a059] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ramirez F, Madan OP, Desai NB, Meyerson S, Banas EM. The Hydrolysis of Five-Membered Cyclic Phosphotriesters to Cyclic Phosphodiesters. J Am Chem Soc 2002. [DOI: 10.1021/ja00900a047] [Citation(s) in RCA: 31] [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] [Indexed: 11/29/2022]
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Ramirez F, Bhatia SB, Mitra RB, Hamlet Z, Desai NB. Reaction of the o-Quinone-Trialkyl Phosphite and the α-Diketone-Trialkyl Phosphie 1:1 Adducts with Ozone and with Oxygen. A New Synthesis of Cyclic Diacyl Peroxides via Oxyphosphoranes. J Am Chem Soc 2002. [DOI: 10.1021/ja01074a034] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ramirez F, Patwardhan AV, Ramanathan N, Desai NB, Greco CV, Heller SR. A New Synthesis of α,β-Dihydroxy Ketones via Oxyphosphoranes. Condensation of Aliphatic α-Diketones with Aldehydes by means of Trialkyl Phosphites. P31 and H1 Nuclear Magnetic Resonance Spectra1,2. J Am Chem Soc 2002. [DOI: 10.1021/ja01081a027] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Jagtap PM, Desai NB, Bansal NO, Vaidya SV, Pathak L. Left ventricular aneurysm: angiographic determinants. J Assoc Physicians India 1995; 43:331-3. [PMID: 9081962] [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] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
To determine antiographic factors involved in left ventricular aneurysm formation after myocardial infarction, 50 patients with a first anterior wall myocardial infarction who underwent cardiac catheterisation within 6 months of infarction were evaluated. Extent of coronary artery disease and status of collateral circulation were studied in detail. Thirty patients had aneurysm in apical region while 20 patients showed aneurysm in anteroapical region. Coronary angiography revealed single-vessel disease in 17 patients, double-vessel disease in 17 patients and triple-vessel disease in 15 patients while in one patient coronary angiogram was normal. Fortynine patients showed significant involvement of left anterior descending artery which was poorly collateralised. Left anterior descending artery disease in association with inherent poor collateral blood supply may predispose for aneurysm formation after anterior wall myocardial infarction.
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Affiliation(s)
- P M Jagtap
- Department of Cardiology, Grant Medical College, Byculla, Bombay
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Pande AK, Ambardekar SS, Desai NB, Tulpule AT, Pathak L, Goyal BK. Unusual presentation of aneurysm of aorta. J Assoc Physicians India 1989; 37:387-8. [PMID: 2592331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
An unusual case of a saccular aneurysm of arch of aorta, masquerading as pulmonary artery branch stenosis, proved by cardiac catheterisation and angio cardiography is presented.
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Pande AK, Pendkar RG, Desai NB, Ambardekar SS, Kumar A, Tulpule AT, Pathak L, Mehta VI, Goyal BK. Closed mitral valvotomy: a second look. Indian Heart J 1985; 37:386-9. [PMID: 3836943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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Desai NB, McKelvie N, Ramirez F. A New Synthesis of 1,1-Dibromoölefins via Phosphine-Dibromomethylenes. the Reaction of Triphenylphosphine with Carbon Tetrabromide. J Am Chem Soc 1962. [DOI: 10.1021/ja00868a057] [Citation(s) in RCA: 350] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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