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Chang E, Wong FCL, Chasen BA, Erwin WD, Das P, Holliday EB, Koong AC, Ludmir EB, Minsky BD, Noticewala SS, Smith GL, Taniguchi CM, Rodriguez MJ, Beddar S, Martin-Paulpeter RM, Niedzielski JS, Sawakuchi GO, Schueler E, Perles LA, Xiao L, Szklaruk J, Park PC, Dasari AN, Kaseb AO, Kee BK, Lee SS, Overman MJ, Willis JA, Wolff RA, Tzeng CWD, Vauthey JN, Koay EJ. Phase I Trial of SPECT-Guided Liver-Directed Radiotherapy for Patients with Low Functional Liver Volume. JNCI Cancer Spectr 2024:pkae037. [PMID: 38730548 DOI: 10.1093/jncics/pkae037] [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: 12/29/2023] [Revised: 03/28/2024] [Accepted: 05/03/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND Traditional constraints specify that 700 cc of liver should be spared a hepatotoxic dose when delivering liver-directed radiotherapy to reduce the risk of inducing liver failure. We investigated the role of single photon emission computed tomography (SPECT) to identify and preferentially avoid functional liver during liver-directed radiation treatment planning in patients with preserved liver function but limited functional liver volume after receiving prior hepatotoxic chemotherapy or surgical resection. METHODS This phase I trial with a 3 + 3 design evaluated the safety of liver-directed radiotherapy using escalating functional liver radiation dose constraints in patients with liver metastases. Dose limiting toxicities (DLTs) were assessed 6-8 weeks and 6 months after completing radiotherapy. RESULTS All twelve patients had colorectal liver metastases and received prior hepatotoxic chemotherapy. Eight patients underwent prior liver resection. Median computed tomography (CT) anatomical non-tumor liver volume was 1,584 cc (range 764-2,699 cc). Median SPECT functional liver volume was 1,117 cc (range 570-1,928cc). Median non-target CT and SPECT liver volumes below the volumetric dose constraint were 997 cc (range 544-1,576 cc) and 684 cc (range 429-1,244 cc), respectively. The prescription dose was 67.5-75 Gy in 15 fractions or 75-100 Gy in 25 fractions. No DLTs were observed during follow-up. One-year in-field control was 57%. One-year overall survival was 73%. CONCLUSION Liver-directed radiotherapy can be safely delivered to high doses when incorporating functional SPECT into the radiation treatment planning process which may enable sparing of lower volumes of liver than traditionally accepted in patients with preserved liver function. TRIAL REGISTRATION NCT02626312.
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Affiliation(s)
- Enoch Chang
- Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Franklin C L Wong
- Nuclear Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Beth A Chasen
- Nuclear Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William D Erwin
- Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Emma B Holliday
- Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Albert C Koong
- Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ethan B Ludmir
- Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bruce D Minsky
- Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sonal S Noticewala
- Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Grace L Smith
- Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cullen M Taniguchi
- Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maria J Rodriguez
- Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sam Beddar
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Joshua S Niedzielski
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gabriel O Sawakuchi
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Emil Schueler
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Luis A Perles
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lianchun Xiao
- Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Janio Szklaruk
- Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Peter C Park
- Radiology Physics, University of California, Davis, Davis, CA, USA
| | - Arvind N Dasari
- Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ahmed O Kaseb
- Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bryan K Kee
- Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sunyoung S Lee
- Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael J Overman
- Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jason A Willis
- Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Robert A Wolff
- Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ching-Wei D Tzeng
- Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jean-Nicolas Vauthey
- Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eugene J Koay
- Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Cazacu IM, Singh BS, Martin-Paulpeter RM, Beddar S, Chun S, Holliday EB, Koong AC, Das P, Koay EJ, Taniguchi C, Herman JM, Bhutani MS. Endoscopic Ultrasound-Guided Fiducial Placement for Stereotactic Body Radiation Therapy in Patients with Pancreatic Cancer. Cancers (Basel) 2023; 15:5355. [PMID: 38001615 PMCID: PMC10670468 DOI: 10.3390/cancers15225355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/18/2023] [Accepted: 10/26/2023] [Indexed: 11/26/2023] Open
Abstract
Accurate delivery of stereotactic body radiotherapy (SBRT) to pancreatic tumors relies on successful EUS-guided placement of fiducial markers. The aim of this study is to report the technical feasibility and safety of EUS-guided fiducial placement and to evaluate the characteristics and technical benefit of SBRT in a cohort of patients with pancreatic cancer (PC). A retrospective chart review was performed for all (n = 82) PC patients referred for EUS-guided fiducial placement by a single endosonographer at a tertiary cancer center. Data regarding EUS-related technical details, SBRT characteristics, adverse events, and continuous visibility of fiducials were recorded and analyzed. Most patients included in the study had either locally advanced disease (32 patients, 39%) or borderline resectable disease (29 patients, 35%). Eighty-two PC patients underwent the placement of 230 fiducial markers under EUS guidance. The technical success rate of the fiducial placement was 98%. No immediate EUS-related adverse events were reported. The average time to the simulation CT after fiducial placement was 3.1 days. Of the 216 fiducial markers used for the SBRT delivery, 202 fiducial markers were visible on both the simulation CT and the cone beam CT scan. A median dose of 40cGY was given to all the patients in five fractions. Of these, 41% of the patients reported no SBRT-related toxicities during the follow-up. Fatigue and nausea were the most reported SBRT-related toxicities, which were seen in 35% of the patients post-SBRT. Our results demonstrate that EUS-guided fiducial placement is safe and effective in target volume delineation, facilitating SBRT delivery in PC patients. Further clinical trials are needed to determine the SBRT-related survival benefits in patients with pancreatic cancer.
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Affiliation(s)
- Irina M. Cazacu
- Department of Oncology, Fundeni Clinical Institute, 022328 Bucharest, Romania;
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Ben S. Singh
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Rachael M. Martin-Paulpeter
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (R.M.M.-P.); (S.B.)
| | - Sam Beddar
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (R.M.M.-P.); (S.B.)
| | - Stephen Chun
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (S.C.); (E.B.H.); (A.C.K.); (P.D.); (E.J.K.); (C.T.)
| | - Emma B. Holliday
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (S.C.); (E.B.H.); (A.C.K.); (P.D.); (E.J.K.); (C.T.)
| | - Albert C. Koong
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (S.C.); (E.B.H.); (A.C.K.); (P.D.); (E.J.K.); (C.T.)
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (S.C.); (E.B.H.); (A.C.K.); (P.D.); (E.J.K.); (C.T.)
| | - Eugene J. Koay
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (S.C.); (E.B.H.); (A.C.K.); (P.D.); (E.J.K.); (C.T.)
| | - Cullen Taniguchi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (S.C.); (E.B.H.); (A.C.K.); (P.D.); (E.J.K.); (C.T.)
| | - Joseph M. Herman
- Department of Radiation Oncology, Northwell Health Cancer Institute, New Hyde Park, NY 11042, USA;
| | - Manoop S. Bhutani
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
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