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Daugherty EC, Zhang Y, Xiao Z, Mascia AE, Sertorio M, Woo J, McCann C, Russell KJ, Sharma RA, Khuntia D, Bradley JD, Simone CB, Breneman JC, Perentesis JP. FLASH radiotherapy for the treatment of symptomatic bone metastases in the thorax (FAST-02): protocol for a prospective study of a novel radiotherapy approach. Radiat Oncol 2024; 19:34. [PMID: 38475815 PMCID: PMC10935811 DOI: 10.1186/s13014-024-02419-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 02/08/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND FLASH therapy is a treatment technique in which radiation is delivered at ultra-high dose rates (≥ 40 Gy/s). The first-in-human FAST-01 clinical trial demonstrated the clinical feasibility of proton FLASH in the treatment of extremity bone metastases. The objectives of this investigation are to assess the toxicities of treatment and pain relief in study participants with painful thoracic bone metastases treated with FLASH radiotherapy, as well as workflow metrics in a clinical setting. METHODS This single-arm clinical trial is being conducted under an FDA investigational device exemption (IDE) approved for 10 patients with 1-3 painful bone metastases in the thorax, excluding bone metastases in the spine. Treatment will be 8 Gy in a single fraction administered at ≥ 40 Gy/s on a FLASH-enabled proton therapy system delivering a single transmission proton beam. Primary study endpoints are efficacy (pain relief) and safety. Patient questionnaires evaluating pain flare at the treatment site will be completed for 10 consecutive days post-RT. Pain response and adverse events (AEs) will be evaluated on the day of treatment and on day 7, day 15, months 1, 2, 3, 6, 9, and 12, and every 6 months thereafter. The outcomes for clinical workflow feasibility are the occurrence of any device issues as well as time on the treatment table. DISCUSSION This prospective clinical trial will provide clinical data for evaluating the efficacy and safety of proton FLASH for palliation of bony metastases in the thorax. Positive findings will support the further exploration of FLASH radiation for other clinical indications including patient populations treated with curative intent. REGISTRATION ClinicalTrials.gov NCT05524064.
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Affiliation(s)
- E C Daugherty
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - Y Zhang
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH, USA
- Cancer and Blood Disease Institute , Cincinnati Children's Hospital , Cincinnati, OH, USA
| | - Z Xiao
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH, USA
- Cancer and Blood Disease Institute , Cincinnati Children's Hospital , Cincinnati, OH, USA
| | - A E Mascia
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH, USA
- Cancer and Blood Disease Institute , Cincinnati Children's Hospital , Cincinnati, OH, USA
| | - M Sertorio
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - J Woo
- Varian, a Siemens Healthineers Company, Palo Alto, USA
| | - C McCann
- Varian, a Siemens Healthineers Company, Palo Alto, USA
| | - K J Russell
- Varian, a Siemens Healthineers Company, Palo Alto, USA
| | - R A Sharma
- Varian, a Siemens Healthineers Company, Palo Alto, USA
| | - D Khuntia
- Varian, a Siemens Healthineers Company, Palo Alto, USA
| | - J D Bradley
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - C B Simone
- Department of Radiation Oncology, New York Proton Center , New York, NY, USA
| | - J C Breneman
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - J P Perentesis
- Cancer and Blood Disease Institute , Cincinnati Children's Hospital , Cincinnati, OH, USA.
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Mascia A, McCauley S, Speth J, Nunez SA, Boivin G, Vilalta M, Sharma RA, Perentesis JP, Sertorio M. Impact of Multiple Beams on the FLASH Effect in Soft Tissue and Skin in Mice. Int J Radiat Oncol Biol Phys 2024; 118:253-261. [PMID: 37541394 DOI: 10.1016/j.ijrobp.2023.07.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 01/12/2023] [Revised: 06/19/2023] [Accepted: 07/14/2023] [Indexed: 08/06/2023]
Abstract
PURPOSE FLASH proton pencil beam scanning (p-PBS) showed a reduction in mouse skin toxicity and fibrosis when delivered as a single, uninterrupted, high-dose fraction. Clinical p-PBS treatment usually requires multiple beams to achieve good conformality, and these beams are separated by minutes to allow patient and equipment repositioning. We evaluate the impact of multibeam versus single-beam proton radiation on the FLASH sparing effect on skin toxicity. METHODS AND MATERIALS The right hind leg of 10-week-old female C57Bl/6j mice was irradiated using a Varian ProBeam proton beam scanning gantry system at conventional (1 Gy/s) or FLASH (100 Gy/s) average field dose rate. We scored the skin toxicity after different doses for 7 weeks. The treatment was delivered as 1, 2, or 3 equal beams with an interruption of 2 minutes. For each beam delivery, the equipment remained in the same position so that there was a full overlap of beams administered. RESULTS Single-beam delivery confirmed a benefit for p-PBS FLASH in this model at 30, 35, and 40 Gy. At 30 and 35 Gy, a single beam interruption of 2 minutes (2 × 15 Gy or 2 × 17.5 Gy) reduced the FLASH sparing effect, which remained significant (P < .001). However, 2 interruptions (3 × 10 Gy or 3 × 11.6 Gy) abrogated the normal tissue sparing effect. CONCLUSIONS Our results indicate that the FLASH sparing effect in areas of beam overlap can be compromised by interruptions in delivery time. Time gap between overlapping beams and spatial arrangement of the delivered beams are important parameters for FLASH studies. The effect of multibeam needs to be studied on different organs of interest.
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Affiliation(s)
- Anthony Mascia
- Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati, Ohio; Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Shelby McCauley
- Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Joseph Speth
- Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati, Ohio; Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Stefanno Alarcon Nunez
- Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati, Ohio; Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Gael Boivin
- Varian, a Siemens Healthineers Company, Palo Alto, California
| | - Marta Vilalta
- Varian, a Siemens Healthineers Company, Palo Alto, California
| | - Ricky A Sharma
- Varian, a Siemens Healthineers Company, Palo Alto, California
| | | | - Mathieu Sertorio
- Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati, Ohio; Department of Radiation Oncology, University of Cincinnati Cancer Center, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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Akimoto T, Aoyama H, Chua ML, Jayamanne D, Mizowaki T, Morris L, Onishi H, Song SY, Zeidan YH, Sharma RA. Challenges and Opportunities With the Use of Hypofractionated Radiation Therapy in Cancer Care: Regional Perspectives From South Korea, Japan, Singapore, and Australia. Adv Radiat Oncol 2023; 8:101291. [PMID: 37457823 PMCID: PMC10344660 DOI: 10.1016/j.adro.2023.101291] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 06/07/2023] [Indexed: 07/18/2023] Open
Abstract
Hypofractionated radiotherapy schedules provide higher per-fraction radiation doses delivered in fewer fractions than conventional schedules. This novel delivery method is supported by a large body of clinical trial evidence across various cancer sites in both curative and palliative settings. Hypofractionation is associated with benefits such as lower costs, improved patient access and increased treatment precision, which has led to its inclusion in various treatment guidelines. Despite this, utilization is not uniform across cancer sites and geographic regions due to reasons such as reimbursement models, nuances in healthcare systems, and professional culture. Key factors to ensure patients benefit from access to high quality radiotherapy include publishing clinical evidence, cross-country collaboration to fill knowledge gaps, reviewing reimbursement models, and improving patient advocacy in treatment decision-making.
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Affiliation(s)
- Tetsuo Akimoto
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital East, Chiba, Japan
| | - Hidefumi Aoyama
- Department of Radiation Oncology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Melvin L.K. Chua
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
- Division of Medical Sciences, National Cancer Centre Singapore, Singapore
- Oncology Academic Programme, Duke-NUS Medical School, Singapore
| | - Dasantha Jayamanne
- Department of Radiation Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Takashi Mizowaki
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Lucinda Morris
- Department of Radiation Oncology, St George Hospital, Sydney, New South Wales, Australia
| | | | - Si Yeol Song
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Youssef H. Zeidan
- Department of Radiation Oncology, American University of Beirut Medical Center, Beirut, Lebanon
- Baptist Health, Lynn Cancer Institute, Boca Raton, Florida
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Dubail M, Heinrich S, Portier L, Bastian J, Giuliano L, Aggar L, Berthault N, Londoño-Vallejo JA, Vilalta M, Boivin G, Sharma RA, Dutreix M, Fouillade C. Lung Organotypic Slices Enable Rapid Quantification of Acute Radiotherapy Induced Toxicity. Cells 2023; 12:2435. [PMID: 37887279 PMCID: PMC10605600 DOI: 10.3390/cells12202435] [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: 09/13/2023] [Revised: 10/03/2023] [Accepted: 10/07/2023] [Indexed: 10/28/2023] Open
Abstract
To rapidly assess healthy tissue toxicities induced by new anti-cancer therapies (i.e., radiation alone or in combination with drugs), there is a critical need for relevant and easy-to-use models. Consistent with the ethical desire to reduce the use of animals in medical research, we propose to monitor lung toxicity using an ex vivo model. Briefly, freshly prepared organotypic lung slices from mice were irradiated, with or without being previously exposed to chemotherapy, and treatment toxicity was evaluated by analysis of cell division and viability of the slices. When exposed to different doses of radiation, this ex vivo model showed a dose-dependent decrease in cell division and viability. Interestingly, monitoring cell division was sensitive enough to detect a sparing effect induced by FLASH radiotherapy as well as the effect of combined treatment. Altogether, the organotypic lung slices can be used as a screening platform to rapidly determine in a quantitative manner the level of lung toxicity induced by different treatments alone or in combination with chemotherapy while drastically reducing the number of animals. Translated to human lung samples, this ex vivo assay could serve as an innovative method to investigate patients' sensitivity to radiation and drugs.
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Affiliation(s)
- Maxime Dubail
- Institut Curie, Inserm U1021-CNRS UMR 3347, Paris Saclay University, Centre Universitaire, 91405 Orsay Cedex, France
- Institut Curie, PSL Research University, 75006 Paris, France
| | - Sophie Heinrich
- Institut Curie, Inserm U1021-CNRS UMR 3347, Paris Saclay University, Centre Universitaire, 91405 Orsay Cedex, France
- Institut Curie, PSL Research University, 75006 Paris, France
| | - Lucie Portier
- Institut Curie, Inserm U1021-CNRS UMR 3347, Paris Saclay University, Centre Universitaire, 91405 Orsay Cedex, France
- Institut Curie, PSL Research University, 75006 Paris, France
| | - Jessica Bastian
- Institut Curie, Inserm U1021-CNRS UMR 3347, Paris Saclay University, Centre Universitaire, 91405 Orsay Cedex, France
- Institut Curie, PSL Research University, 75006 Paris, France
| | - Lucia Giuliano
- SBAI Department, Sapienza University of Rome, 00161 Rome, Italy
| | - Lilia Aggar
- Institut Curie, Inserm U1021-CNRS UMR 3347, Paris Saclay University, Centre Universitaire, 91405 Orsay Cedex, France
- Institut Curie, PSL Research University, 75006 Paris, France
| | - Nathalie Berthault
- Institut Curie, Inserm U1021-CNRS UMR 3347, Paris Saclay University, Centre Universitaire, 91405 Orsay Cedex, France
- Institut Curie, PSL Research University, 75006 Paris, France
| | - José-Arturo Londoño-Vallejo
- Institut Curie, Inserm U1021-CNRS UMR 3347, Paris Saclay University, Centre Universitaire, 91405 Orsay Cedex, France
- Institut Curie, PSL Research University, 75006 Paris, France
| | - Marta Vilalta
- Global Translational Science, Varian, a Siemens Healthineers Company, Palo Alto, CA 94304, USA
| | - Gael Boivin
- Global Translational Science, Varian, a Siemens Healthineers Company, Palo Alto, CA 94304, USA
| | - Ricky A. Sharma
- Global Translational Science, Varian, a Siemens Healthineers Company, Palo Alto, CA 94304, USA
- UCL Cancer Institute, University College London, London WC1E 6DD, UK
| | - Marie Dutreix
- Institut Curie, Inserm U1021-CNRS UMR 3347, Paris Saclay University, Centre Universitaire, 91405 Orsay Cedex, France
- Institut Curie, PSL Research University, 75006 Paris, France
| | - Charles Fouillade
- Institut Curie, Inserm U1021-CNRS UMR 3347, Paris Saclay University, Centre Universitaire, 91405 Orsay Cedex, France
- Institut Curie, PSL Research University, 75006 Paris, France
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Little MW, Harrison R, MacGill S, Speirs A, Briggs JH, Tayton E, Davies NLC, Hausen HS, McCann C, Levine LL, Sharma RA, Gibson M. Genicular Artery Embolisation in Patients with Osteoarthritis of the Knee (GENESIS 2): Protocol for a Double-Blind Randomised Sham-Controlled Trial. Cardiovasc Intervent Radiol 2023; 46:1276-1282. [PMID: 37337060 PMCID: PMC10471661 DOI: 10.1007/s00270-023-03477-z] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/23/2023] [Indexed: 06/21/2023]
Abstract
Knee osteoarthritis is a leading cause of chronic disability and economic burden. In many patients who are not surgical candidates, existing treatment options are insufficient. Clinical evidence for a new treatment approach, genicular artery embolisation (GAE), is currently limited to single arm cohort, or small population randomised studies. This trial will investigate the use of a permanent embolic agent for embolisation of abnormal genicular arterial vasculature to reduce pain in patients with mild to moderate knee osteoarthritis. Up to 110 participants, 45 years or older, with knee pain for ≥ 3 months resistant to conservative treatment will be randomised (1:1) to GAE or a sham procedure. The treatment group will receive embolisation using 100-micron Embozene™ microspheres (Varian, a Siemens Healthineers Company) (investigational use for this indication in the UK), and the sham group will receive 0.9% saline in an otherwise identical procedure. Patients will be followed for 24 months. At 6 months, sham participants will be offered crossover to GAE. The primary endpoint is change of 4 Knee Injury and OA Outcome Score subscales (KOOS4) at 6 months post-randomisation. The study will also evaluate quality of life, health economics, imaging findings, and psychosocial pain outcomes. The primary manuscript will be submitted for publication after all participants complete 6 months of follow-up. The trial is expected to run for 3.5 years. Trial Registration: ClinicalTrials.gov, Identifier: NCT05423587.
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Affiliation(s)
- Mark W Little
- University Department of Radiology, Royal Berkshire Hospital, London Road, Reading, RG1 5AN, UK.
- Centre for Integrative Neuroscience and Neurodynamics, University of Reading, Reading, UK.
| | - Richard Harrison
- Centre for Integrative Neuroscience and Neurodynamics, University of Reading, Reading, UK
| | - Sarah MacGill
- University Department of Radiology, Royal Berkshire Hospital, London Road, Reading, RG1 5AN, UK
| | - Archie Speirs
- University Department of Radiology, Royal Berkshire Hospital, London Road, Reading, RG1 5AN, UK
| | - James H Briggs
- University Department of Radiology, Royal Berkshire Hospital, London Road, Reading, RG1 5AN, UK
| | - Edward Tayton
- Department of Orthopaedics, Royal Berkshire Hospital, Reading, UK
| | - Nev L C Davies
- Department of Orthopaedics, Royal Berkshire Hospital, Reading, UK
| | | | - Claire McCann
- Varian, a Siemens Healthineers Company, Palo Alto, USA
| | - Lisa L Levine
- Varian, a Siemens Healthineers Company, Palo Alto, USA
| | | | - Matthew Gibson
- University Department of Radiology, Royal Berkshire Hospital, London Road, Reading, RG1 5AN, UK
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Mascia AE, Daugherty EC, Zhang Y, Lee E, Xiao Z, Sertorio M, Woo J, Backus LR, McDonald JM, McCann C, Russell K, Levine L, Sharma RA, Khuntia D, Bradley JD, Simone CB, Perentesis JP, Breneman JC. Proton FLASH Radiotherapy for the Treatment of Symptomatic Bone Metastases: The FAST-01 Nonrandomized Trial. JAMA Oncol 2023; 9:62-69. [PMID: 36273324 PMCID: PMC9589460 DOI: 10.1001/jamaoncol.2022.5843] [Citation(s) in RCA: 62] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 09/26/2022] [Indexed: 01/24/2023]
Abstract
Importance To our knowledge, there have been no clinical trials of ultra-high-dose-rate radiotherapy delivered at more than 40 Gy/sec, known as FLASH therapy, nor first-in-human use of proton FLASH. Objectives To assess the clinical workflow feasibility and treatment-related toxic effects of FLASH and pain relief at the treatment sites. Design, Setting, and Participants In the FAST-01 nonrandomized trial, participants treated at Cincinnati Children's/UC Health Proton Therapy Center underwent palliative FLASH radiotherapy to extremity bone metastases. Patients 18 years and older with 1 to 3 painful extremity bone metastases and life expectancies of 2 months or more were eligible. Patients were excluded if they had foot, hand, and wrist metastases; metastases locally treated in the 2 weeks prior; metal implants in the treatment field; known enhanced tissue radiosensitivity; and implanted devices at risk of malfunction with radiotherapy. One of 11 patients who consented was excluded based on eligibility. The end points were evaluated at 3 months posttreatment, and patients were followed up through death or loss to follow-up for toxic effects and pain assessments. Of the 10 included patients, 2 died after the 2-month follow-up but before the 3-month follow-up; 8 participants completed the 3-month evaluation. Data were collected from November 3, 2020, to January 28, 2022, and analyzed from January 28, 2022, to September 1, 2022. Interventions Bone metastases were treated on a FLASH-enabled (≥40 Gy/sec) proton radiotherapy system using a single-transmission proton beam. This is consistent with standard of care using the same prescription (8 Gy in a single fraction) but on a conventional-dose-rate (approximately 0.03 Gy/sec) photon radiotherapy system. Main Outcome and Measures Main outcomes included patient time on the treatment couch, device-related treatment delays, adverse events related to FLASH, patient-reported pain scores, and analgesic use. Results A total of 10 patients (age range, 27-81 years [median age, 63 years]; 5 [50%] male) underwent FLASH radiotherapy at 12 metastatic sites. There were no FLASH-related technical issues or delays. The average (range) time on the treatment couch was 18.9 (11-33) minutes per patient and 15.8 (11-22) minutes per treatment site. Median (range) follow-up was 4.8 (2.3-13.0) months. Adverse events were mild and consistent with conventional radiotherapy. Transient pain flares occurred in 4 of the 12 treated sites (33%). In 8 of the 12 sites (67%) patients reported pain relief, and in 6 of the 12 sites (50%) patients reported a complete response (no pain). Conclusions and Relevance In this nonrandomized trial, clinical workflow metrics, treatment efficacy, and safety data demonstrated that ultra-high-dose-rate proton FLASH radiotherapy was clinically feasible. The treatment efficacy and the profile of adverse events were comparable with those of standard-of-care radiotherapy. These findings support the further exploration of FLASH radiotherapy in patients with cancer. Trial Registration ClinicalTrials.gov Identifier: NCT04592887.
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Affiliation(s)
- Anthony E. Mascia
- Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
- Department of Radiation Oncology, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Emily C. Daugherty
- Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
- Department of Radiation Oncology, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Yongbin Zhang
- Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
- Department of Radiation Oncology, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Eunsin Lee
- Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
- Department of Radiation Oncology, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Zhiyan Xiao
- Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
- Department of Radiation Oncology, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Mathieu Sertorio
- Department of Radiation Oncology, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Jennifer Woo
- Varian Medical Systems, Siemens Healthineers, Palo Alto, California
| | - Lori R. Backus
- Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | - Julie M. McDonald
- Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | - Claire McCann
- Varian Medical Systems, Siemens Healthineers, Palo Alto, California
| | - Kenneth Russell
- Varian Medical Systems, Siemens Healthineers, Palo Alto, California
| | - Lisa Levine
- Varian Medical Systems, Siemens Healthineers, Palo Alto, California
| | - Ricky A. Sharma
- Varian Medical Systems, Siemens Healthineers, Palo Alto, California
| | - Dee Khuntia
- Varian Medical Systems, Siemens Healthineers, Palo Alto, California
| | - Jeffrey D. Bradley
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Charles B. Simone
- Department of Radiation Oncology, New York Proton Center, New York, New York
| | - John P. Perentesis
- Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | - John C. Breneman
- Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
- Department of Radiation Oncology, College of Medicine, University of Cincinnati, Cincinnati, Ohio
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7
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Beaton L, Tregidgo HFJ, Znati SA, Forsyth S, Counsell N, Clarkson MJ, Bandula S, Chouhan M, Lowe HL, Thin MZ, Hague J, Sharma D, Pollok JM, Davidson BR, Raja J, Munneke G, Stuckey DJ, Bascal ZA, Wilde PE, Cooper S, Ryan S, Czuczman P, Boucher E, Hartley JA, Atkinson D, Lewis AL, Jansen M, Meyer T, Sharma RA. Phase 0 Study of Vandetanib-Eluting Radiopaque Embolics as a Preoperative Embolization Treatment in Patients with Resectable Liver Malignancies. J Vasc Interv Radiol 2022; 33:1034-1044.e29. [PMID: 35526675 DOI: 10.1016/j.jvir.2022.04.033] [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: 09/24/2021] [Revised: 04/03/2022] [Accepted: 04/21/2022] [Indexed: 11/19/2022] Open
Abstract
PURPOSE To assess the safety and tolerability of a vandetanib-eluting radiopaque embolic (BTG-002814) for transarterial chemoembolization (TACE) in patients with resectable liver malignancies. MATERIALS AND METHODS The VEROnA clinical trial was a first-in-human, phase 0, single-arm, window-of-opportunity study. Eligible patients were aged ≥18 years and had resectable hepatocellular carcinoma (HCC) (Child-Pugh A) or metastatic colorectal cancer (mCRC). Patients received 1 mL of BTG-002814 transarterially (containing 100 mg of vandetanib) 7-21 days prior to surgery. The primary objectives were to establish the safety and tolerability of BTG-002814 and determine the concentrations of vandetanib and the N-desmethyl vandetanib metabolite in the plasma and resected liver after treatment. Biomarker studies included circulating proangiogenic factors, perfusion computed tomography, and dynamic contrast-enhanced magnetic resonance imaging. RESULTS Eight patients were enrolled: 2 with HCC and 6 with mCRC. There was 1 grade 3 adverse event (AE) before surgery and 18 after surgery; 6 AEs were deemed to be related to BTG-002814. Surgical resection was not delayed. Vandetanib was present in the plasma of all patients 12 days after treatment, with a mean maximum concentration of 24.3 ng/mL (standard deviation ± 13.94 ng/mL), and in resected liver tissue up to 32 days after treatment (441-404,000 ng/g). The median percentage of tumor necrosis was 92.5% (range, 5%-100%). There were no significant changes in perfusion imaging parameters after TACE. CONCLUSIONS BTG-002814 has an acceptable safety profile in patients before surgery. The presence of vandetanib in the tumor specimens up to 32 days after treatment suggests sustained anticancer activity, while the low vandetanib levels in the plasma suggest minimal release into the systemic circulation. Further evaluation of this TACE combination is warranted in dose-finding and efficacy studies.
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Affiliation(s)
- Laura Beaton
- University College London Cancer Institute, University College London, London, United Kingdom.
| | - Henry F J Tregidgo
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Sami A Znati
- University College London Cancer Institute, University College London, London, United Kingdom
| | - Sharon Forsyth
- Cancer Research UK and University College London Cancer Trials Centre, University College London, London, United Kingdom
| | - Nicholas Counsell
- Cancer Research UK and University College London Cancer Trials Centre, University College London, London, United Kingdom
| | - Matthew J Clarkson
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Steven Bandula
- University College London Centre for Medical Imaging, University College London, London, United Kingdom
| | - Manil Chouhan
- University College London Centre for Medical Imaging, University College London, London, United Kingdom
| | - Helen L Lowe
- University College London Experimental Cancer Medicine Centre Good Clinical Laboratory Practice Facility, University College London, London, United Kingdom
| | - May Zaw Thin
- Centre for Advanced Biomedical Imaging, University College London, London, United Kingdom
| | - Julian Hague
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Dinesh Sharma
- Division of Transplantation and Immunology, Royal Free Hospital NHS Foundation Trust, London, United Kingdom
| | - Joerg-Matthias Pollok
- Division of Surgery and Interventional Science, University College London, London, United Kingdom; Hepatopancreatobiliary Surgery and Liver Transplantation, Royal Free Hospital NHS Foundation Trust, London, United Kingdom
| | - Brian R Davidson
- Division of Surgery and Interventional Science, University College London, London, United Kingdom; Hepatopancreatobiliary Surgery and Liver Transplantation, Royal Free Hospital NHS Foundation Trust, London, United Kingdom
| | - Jowad Raja
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Graham Munneke
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Daniel J Stuckey
- Centre for Advanced Biomedical Imaging, University College London, London, United Kingdom
| | - Zainab A Bascal
- Biocompatibles UK Ltd, Lakeview, Riverside Way, Watchmoor Park, Camberley, Surrey, United Kingdom
| | - Paul E Wilde
- Biocompatibles UK Ltd, Lakeview, Riverside Way, Watchmoor Park, Camberley, Surrey, United Kingdom
| | - Sarah Cooper
- Biocompatibles UK Ltd, Lakeview, Riverside Way, Watchmoor Park, Camberley, Surrey, United Kingdom
| | - Samantha Ryan
- Biocompatibles UK Ltd, Lakeview, Riverside Way, Watchmoor Park, Camberley, Surrey, United Kingdom
| | - Peter Czuczman
- Biocompatibles UK Ltd, Lakeview, Riverside Way, Watchmoor Park, Camberley, Surrey, United Kingdom
| | - Eveline Boucher
- Biocompatibles UK Ltd, Lakeview, Riverside Way, Watchmoor Park, Camberley, Surrey, United Kingdom
| | - John A Hartley
- University College London Cancer Institute, University College London, London, United Kingdom; University College London Experimental Cancer Medicine Centre Good Clinical Laboratory Practice Facility, University College London, London, United Kingdom
| | - David Atkinson
- University College London Centre for Medical Imaging, University College London, London, United Kingdom
| | - Andrew L Lewis
- Biocompatibles UK Ltd, Lakeview, Riverside Way, Watchmoor Park, Camberley, Surrey, United Kingdom
| | - Marnix Jansen
- University College London Cancer Institute, University College London, London, United Kingdom; University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Tim Meyer
- University College London Cancer Institute, University College London, London, United Kingdom; Department of Oncology, Royal Free Hospital NHS Foundation Trust, London, United Kingdom
| | - Ricky A Sharma
- National Institute for Health Research University College London Hospitals Biomedical Centre, University College London Cancer Institute, London, United Kingdom
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Beaton L, Daly M, Tregidgo HF, Grimes H, Moinuddin S, Stacey C, Znati S, Hague J, Bascal ZA, Wilde PE, Cooper S, Bandula S, Lewis AL, Clarkson MJ, Sharma RA. Radiopaque drug-eluting embolisation beads as fiducial markers for stereotactic liver radiotherapy. Br J Radiol 2021; 95:20210594. [PMID: 34762499 PMCID: PMC8822567 DOI: 10.1259/bjr.20210594] [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: 11/10/2022] Open
Abstract
Objective: To determine the feasibility of using radiopaque (RO) beads as direct tumour surrogates for image-guided radiotherapy (IGRT) in patients with liver tumours after transarterial chemoembolisation (TACE). Methods: A novel vandetanib-eluting RO bead was delivered via TACE as part of a first-in-human clinical trial in patients with either hepatocellular carcinoma or liver metastases from colorectal cancer. Following TACE, patients underwent simulated radiotherapy imaging with four-dimensional computed tomography (4D-CT) and cone-beam CT (CBCT) imaging. RO beads were contoured using automated thresholding, and feasibility of matching between the simulated radiotherapy planning dataset (AVE-IP image from 4D data) and CBCT scans assessed. Additional kV, MV, helical CT and CBCT images of RO beads were obtained using an in-house phantom. Stability of RO bead position was assessed by comparing 4D-CT imaging to CT scans taken 6–20 days following TACE. Results: Eight patients were treated and 4D-CT and CBCT images acquired. RO beads were visible on 4D-CT and CBCT images in all cases and matching successfully performed. Differences in centre of mass of RO beads between CBCT and simulated radiotherapy planning scans (AVE-IP dataset) were 2.0 mm mediolaterally, 1.7 mm anteroposteriorally and 3.5 mm craniocaudally. RO beads in the phantom were visible on all imaging modalities assessed. RO bead position remained stable up to 29 days post TACE. Conclusion: RO beads are visible on IGRT imaging modalities, showing minimal artefact. They can be used for on-set matching with CBCT and remain stable over time. Advances in knowledge: The role of RO beads as fiducial markers for stereotactic liver radiotherapy is feasible and warrants further exploration as a combination therapy approach.
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Affiliation(s)
- Laura Beaton
- University College London Cancer Institute, University College London, London, United Kingdom
| | - Mairead Daly
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Henry Fj Tregidgo
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Helen Grimes
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Syed Moinuddin
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Chris Stacey
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Sami Znati
- University College London Cancer Institute, University College London, London, United Kingdom
| | - Julian Hague
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Zainab A Bascal
- Biocompatibles UK Ltd, Lakeview, Riverside Way, Watchmoor Park, Camberley, Surrey, United Kingdom
| | - Paul E Wilde
- Biocompatibles UK Ltd, Lakeview, Riverside Way, Watchmoor Park, Camberley, Surrey, United Kingdom
| | - Sarah Cooper
- Biocompatibles UK Ltd, Lakeview, Riverside Way, Watchmoor Park, Camberley, Surrey, United Kingdom
| | - Steven Bandula
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Andrew L Lewis
- Biocompatibles UK Ltd, Lakeview, Riverside Way, Watchmoor Park, Camberley, Surrey, United Kingdom
| | - Matthew J Clarkson
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Ricky A Sharma
- University College London Cancer Institute, University College London, London, United Kingdom.,National Institute for Health Research University College London Hospitals Biomedical Centre, University College London Cancer Institute, London, United Kingdom
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Hagan AE, Znati SA, Carter R, Westhorpe A, Macfarlane WM, Phillips GJ, Lloyd AW, Sharma RA, Lewis AL. Vandetanib-eluting radiopaque beads for chemoembolization: physicochemical evaluation and biological activity of vandetanib in hypoxia. Anticancer Drugs 2021; 32:897-908. [PMID: 33929994 DOI: 10.1097/cad.0000000000001082] [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] [Indexed: 11/26/2022]
Abstract
Vandetanib-eluting radiopaque beads (VERB) have been developed for use in transarterial chemoembolization of liver tumours, with the goal of combining embolization with local delivery of antiangiogenic therapy. The objective of this study was to investigate how embolization-induced hypoxia may affect antitumoural activity of vandetanib, an inhibitor of vascular endothelial growth factor receptor (VEGFR) and epidermal growth factor receptor (EGFR), in the context of hepatocellular carcinoma (HCC) treatment. We studied the effect of vandetanib on proliferation, cell cycle and apoptosis of HCC cells, in hypoxic conditions, as well as the direct effects of the beads on 3D HCC spheroids. Vandetanib suppressed proliferation and induced apoptosis of HCC cells in vitro and was equipotent in hypoxic and normoxic conditions. High degrees of apoptosis were observed among cell lines in which vandetanib suppressed ERK1/2 phosphorylation and upregulated the proapoptotic protein Bim, but this did not appear essential for vandetanib-induced cell death in all cell lines. Vandetanib also suppressed the hypoxia-induced secretion of VEGF from HCC cells and inhibited proliferation of endothelial cells. Incubation of tumour spheroids with VERB led to sustained growth inhibition equivalent to the effect of free drug. We conclude that vandetanib has both antiangiogenic and direct anticancer activity against HCC cells even in hypoxic conditions, warranting the further evaluation of VERB as novel anticancer agents.
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Affiliation(s)
- Alice E Hagan
- Biocompatibles UK Ltd, a BTG International group company, Lakeview, Riverside Way, Watchmoor Park, Camberley, (now a Boston Scientific Corp. company)
- School of Pharmacy and Biomolecular Sciences, University of Brighton, Moulsecoomb, Brighton
| | - Sami A Znati
- NIHR University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, Paul O'Gorman Building, London, UK
| | - Rebecca Carter
- NIHR University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, Paul O'Gorman Building, London, UK
| | - Adam Westhorpe
- NIHR University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, Paul O'Gorman Building, London, UK
| | - Wendy M Macfarlane
- School of Pharmacy and Biomolecular Sciences, University of Brighton, Moulsecoomb, Brighton
| | - Gary J Phillips
- School of Pharmacy and Biomolecular Sciences, University of Brighton, Moulsecoomb, Brighton
| | - Andrew W Lloyd
- School of Pharmacy and Biomolecular Sciences, University of Brighton, Moulsecoomb, Brighton
| | - Ricky A Sharma
- NIHR University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, Paul O'Gorman Building, London, UK
| | - Andrew L Lewis
- Biocompatibles UK Ltd, a BTG International group company, Lakeview, Riverside Way, Watchmoor Park, Camberley, (now a Boston Scientific Corp. company)
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10
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Singh J, Hatcher S, Ku AA, Ding Z, Feng FY, Sharma RA, Pfister SX. Model Selection for the Preclinical Development of New Drug-Radiotherapy Combinations. Clin Oncol (R Coll Radiol) 2021; 33:694-704. [PMID: 34474951 DOI: 10.1016/j.clon.2021.08.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 07/13/2021] [Accepted: 08/11/2021] [Indexed: 12/12/2022]
Abstract
Radiotherapy plays an essential role in the treatment of more than half of all patients with cancer. In recent decades, advances in devices that deliver radiation and the development of treatment planning software have helped radiotherapy attain precise tumour targeting with minimal toxicity to surrounding tissues. Simultaneously, as more targeted drug therapies are being brought into the market, there has been significant interest in improving cure rates for cancer by adding drugs to radiotherapy to widen the therapeutic window, the difference between normal tissue toxicity and treatment efficacy. The development of new combination therapies will require judicious adaptation of preclinical models that are routinely used for traditional drug discovery. Here we highlight the strengths and weaknesses of each of these preclinical models and discuss how they can be used optimally to identify new and clinically beneficial drug-radiotherapy combinations.
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Affiliation(s)
- J Singh
- Global Translational Science, Varian, a Siemens Healthineers company, Palo Alto, California, USA
| | - S Hatcher
- Global Translational Science, Varian, a Siemens Healthineers company, Palo Alto, California, USA
| | - A A Ku
- Global Translational Science, Varian, a Siemens Healthineers company, Palo Alto, California, USA
| | - Z Ding
- Global Translational Science, Varian, a Siemens Healthineers company, Palo Alto, California, USA
| | - F Y Feng
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, California, USA; Division of Hematology and Oncology, Department of Medicine, University of California, San Francisco, California, USA; Department of Radiation Oncology, University of California, San Francisco, California, USA; Department of Urology, University of California, San Francisco, California, USA
| | - R A Sharma
- Global Translational Science, Varian, a Siemens Healthineers company, Palo Alto, California, USA; UCL Cancer Institute, University College London, London, UK
| | - S X Pfister
- Global Translational Science, Varian, a Siemens Healthineers company, Palo Alto, California, USA.
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11
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Mukherjee S, Hurt C, Radhakrishna G, Gwynne S, Bateman A, Gollins S, Hawkins MA, Canham J, Grabsch HI, Falk S, Sharma RA, Ray R, Roy R, Cox C, Maynard N, Nixon L, Sebag-Montefiore DJ, Maughan T, Griffiths GO, Crosby TDL. Oxaliplatin/capecitabine or carboplatin/paclitaxel-based preoperative chemoradiation for resectable oesophageal adenocarcinoma (NeoSCOPE): Long-term results of a randomised controlled trial. Eur J Cancer 2021; 153:153-161. [PMID: 34157617 PMCID: PMC8330696 DOI: 10.1016/j.ejca.2021.05.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/26/2021] [Accepted: 05/08/2021] [Indexed: 12/15/2022]
Abstract
AIM This is the first randomised study to evaluate toxicity and survival outcomes of two neoadjuvant chemoradiotherapy (CRT) regimens for patients with localised oesophageal adenocarcinoma (OAC) or gastro-oesophageal junction (GOJ) adenocarcinoma. The initial results showed comparable toxicity between regimens and pathological complete response (pCR) rate favouring CarPacRT. Herein, we report survival, progression patterns, and long-term toxicity after a median follow-up of 40.7 months. METHODS NeoSCOPE was an open-label, UK multicentre, randomised, phase II trial. Eighty-five patients with resectable OAC or GOJ adenocarcinoma, ≥cT3 and/or ≥cN1 (TNM v7), suitable for neoadjuvant CRT, were recruited between October 2013 and February 2015. Patients were randomised to OxCapRT (oxaliplatin 85 mg/m2 on Days 1, 15, and 29; capecitabine 625 mg/m2 orally twice daily on days of radiotherapy [RT]) or CarPacRT (carboplatin AUC2; paclitaxel 50 mg/m2 on Days 1, 8, 15, 22, and 29). RT dose was 45 Gy/25 fractions/5 weeks. Both arms received induction chemotherapy (two cycles oxaliplatin 130 mg/m2 on Day 1, capecitabine 625 mg/m2 orally twice daily on Days 1-21) before CRT. Surgery was performed 6-8 weeks after CRT. The primary end-point was pCR. Secondary end-points were toxicity, progression-free survival (PFS), overall survival (OS), and patterns of progression. RESULTS Eighty-five patients were recruited from 17 UK centres. The median OS was 41.7 months (95% confidence interval [CI] 19.6 to not reached) in the OxCapRT arm and was not reached in the CarPacRT arm (multivariable hazard ratio [HR] = 0.48, 95% CIs: 0.24-0.95, P = 0.035). The median PFS was 32.6 months (95% CIs: 17.1 to not reached) in the OxCapRT arm and was not reached in the CarPacRT arm (multivariable HR = 0.54, 95% CIs: 0.29-1.01, P = 0.053). In both arms, the distant progression was twice as common as locoregional progression. CONCLUSIONS OS and PFS favoured neoadjuvant CarPacRT over OxCapRT. Distant was more common than locoregional progression; therefore, priority should be given to optimising the systemic treatment component. CLINICAL TRIAL INFORMATION EudraCT Number: 2012-000640-10; ClinicalTrials.gov: NCT01843829.
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Affiliation(s)
- Somnath Mukherjee
- Oxford Institute for Radiation Oncology, Oxford University, Oxford, OX3 7DQ, UK; Department of Oncology, Oxford University Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 7LE, UK
| | - Christopher Hurt
- Centre for Trials Research, Cardiff University, Cardiff, CF14 4YS, UK.
| | | | - Sarah Gwynne
- South West Wales Cancer Centre, Singleton Hospital, Swansea Bay University Health Board, Swansea, SA2 8QA, UK
| | - Andrew Bateman
- Clinical Oncology, University Hospital Southampton, Southampton, SO16 6YD, UK
| | - Simon Gollins
- North Wales Cancer Treatment Centre, Betsi Cadwaladr University Health Board, Rhyl, LL18 5UJ, UK
| | - Maria A Hawkins
- Cancer Institute, University College London, London, WC1E 6DD, UK
| | - Joanne Canham
- Centre for Trials Research, Cardiff University, Cardiff, CF14 4YS, UK
| | - Heike I Grabsch
- Department of Pathology, Maastricht University Medical Center, Maastricht, the Netherlands; Leeds Institute of Medical Research, University of Leeds, Leeds, LS9 7TF, UK
| | - Stephen Falk
- Bristol Haematology and Oncology Centre, University Hospitals Bristol, Bristol, BS2 8ED, UK
| | - Ricky A Sharma
- Cancer Institute, University College London, London, WC1E 6DD, UK
| | - Ruby Ray
- Centre for Trials Research, Cardiff University, Cardiff, CF14 4YS, UK
| | - Rajarshi Roy
- Castle Hill Hospital, Hull University Teaching Hospitals NHS Trust, Hull, HU16 5JQ, UK
| | - Catrin Cox
- Centre for Trials Research, Cardiff University, Cardiff, CF14 4YS, UK
| | - Nick Maynard
- Department of Oncology, Oxford University Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 7LE, UK
| | - Lisette Nixon
- Centre for Trials Research, Cardiff University, Cardiff, CF14 4YS, UK
| | | | - Timothy Maughan
- Oxford Institute for Radiation Oncology, Oxford University, Oxford, OX3 7DQ, UK
| | - Gareth O Griffiths
- Southampton Clinical Trials Unit, University of Southampton, Southampton, SO16 6YD, UK
| | - Tom D L Crosby
- Velindre Cancer Centre, Velindre University NHS Trust, Cardiff, CF14 2TL, UK
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J Seager M, F Jakobs T, A Sharma R, Bandula S. Combination of ablation and embolization for intermediate-sized liver metastases from colorectal cancer: what can we learn from treating primary liver cancer? ACTA ACUST UNITED AC 2021; 27:677-683. [PMID: 34318754 DOI: 10.5152/dir.2021.20520] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Colorectal cancer liver metastases (CRLMs) are common. Treating CRLMs with thermal ablation can prolong survival, but compared to lesions smaller than 3 cm, local control rates and overall survival are relatively worse with larger, intermediate (3-5 cm) lesions. Local recurrence rates range between 1.7%-20.2% and 6.7%-68.9% for CRLMs less than 3 cm and greater than 3 cm, respectively. Worse outcomes are also present when ablating intermediate size hepatocellular carcinoma (HCC) and there are some pathological similarities with CRLMs, namely the presence of micrometastatic disease. Combining ablation with transarterial chemoembolization is more effective in treating intermediate-size HCC than ablation alone. A meta-analysis of robust randomized controlled trials demonstrated long-term improved survival with combination therapy compared to ablation alone (odds ratio at 1, 3 and 5 years of 2.74, 2.77 and 5.23, respectively). There is, however, minimal evidence for combination therapy in CRLMs, limited to a handful of studies that are predominantly retrospective and have heterogeneous inclusion criteria. Given the difficulty in successfully treating intermediate CRLMs, the strong evidence for combination therapy in intermediate HCC and potential pathological similarities, formal evaluation of combination treatment in CRLM is merited. This review highlights existing evidence for treatment of intermediate-size liver lesions and highlights where trials in CRLMs should focus.
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Affiliation(s)
- Matthew J Seager
- Interventional Oncology Service, University College Hospital, London, UK
| | - Tobias F Jakobs
- Clinic of Interventional Radiology, Hospital Barmherzige Brueder, Munich, Germany
| | - Ricky A Sharma
- UCL Cancer Institute, National Institute for Health Research, University College London Hospitals Biomedical Research Centre, University College London, London, UK
| | - Steve Bandula
- Interventional Oncology Service, University College Hospital, London, UK;Centre for Medical Imaging, University College London, London, UK
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13
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Sharma RA. Abstract IA-011: Translation to clinical trials: Are we shooting the right arrows at the target? Clin Cancer Res 2021. [DOI: 10.1158/1557-3265.radsci21-ia-011] [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: 11/16/2022]
Abstract
Abstract
Dependent on the stage of the cancer, 25-40% of patients require curative or palliative radiotherapy as part of their primary care treatment. The DNA Damage response (DDR) pathways have been a major area of interest for drug development as tumors often harbor mutations in the DDR pathways. The development of new DDR inhibitors offers wide-ranging opportunities to combine DDR inhibition with radiation therapy. Emerging evidence also supports the use of DDR inhibitors to promote immune stimulatory effects of radiation therapy by further activating the DNA sensing cGAS-STING pathway. DDR inhibitors in combination with RT have been shown to alter PDL-1 expression and have also been linked to modulating cytokine expression to alter the tumor microenvironment. This should be considered in the context of over 300 clinical trials ongoing which are combining immunotherapy with radiotherapy and important clinical studies of this combination therapy which have been published in patients with lung cancer. Significant progress is being made in understanding new drug-radiotherapy combinations and advancing them towards the clinic.
Citation Format: Ricky A. Sharma. Translation to clinical trials: Are we shooting the right arrows at the target? [abstract]. In: Proceedings of the AACR Virtual Special Conference on Radiation Science and Medicine; 2021 Mar 2-3. Philadelphia (PA): AACR; Clin Cancer Res 2021;27(8_Suppl):Abstract nr IA-011.
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Cunningham S, McCauley S, Vairamani K, Speth J, Girdhani S, Abel E, Sharma RA, Perentesis JP, Wells SI, Mascia A, Sertorio M. FLASH Proton Pencil Beam Scanning Irradiation Minimizes Radiation-Induced Leg Contracture and Skin Toxicity in Mice. Cancers (Basel) 2021; 13:cancers13051012. [PMID: 33804336 PMCID: PMC7957631 DOI: 10.3390/cancers13051012] [Citation(s) in RCA: 97] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/18/2021] [Accepted: 02/22/2021] [Indexed: 02/07/2023] Open
Abstract
Simple Summary Dose and efficacy of radiation therapy are limited by the toxicity to normal tissue adjacent to the treated tumor region. Recently, ultra-high dose rate radiotherapy (FLASH radiotherapy) has shown beneficial reduction of normal tissue damage while preserving similar tumor efficacy with electron, photon and scattered proton beam irradiation in preclinical models. Proton therapy is increasingly delivered by pencil beam scanning (PBS) technology, and we therefore set out to test PBS FLASH radiotherapy on normal tissue toxicity and tumor control in vivo in mouse using a clinical proton delivery system. This validation of the FLASH normal tissue-sparing hypothesis with a clinical delivery system provides supporting data for PBS FLASH radiotherapy and its potential role in improving radiotherapy outcomes. Abstract Ultra-high dose rate radiation has been reported to produce a more favorable toxicity and tumor control profile compared to conventional dose rates that are used for patient treatment. So far, the so-called FLASH effect has been validated for electron, photon and scattered proton beam, but not yet for proton pencil beam scanning (PBS). Because PBS is the state-of-the-art delivery modality for proton therapy and constitutes a wide and growing installation base, we determined the benefit of FLASH PBS on skin and soft tissue toxicity. Using a pencil beam scanning nozzle and the plateau region of a 250 MeV proton beam, a uniform physical dose of 35 Gy (toxicity study) or 15 Gy (tumor control study) was delivered to the right hind leg of mice at various dose rates: Sham, Conventional (Conv, 1 Gy/s), Flash60 (57 Gy/s) and Flash115 (115 Gy/s). Acute radiation effects were quantified by measurements of plasma and skin levels of TGF-β1 and skin toxicity scoring. Delayed irradiation response was defined by hind leg contracture as a surrogate of irradiation-induced skin and soft tissue toxicity and by plasma levels of 13 different cytokines (CXCL1, CXCL10, Eotaxin, IL1-beta, IL-6, MCP-1, Mip1alpha, TNF-alpha, TNF-beta, VEGF, G-CSF, GM-CSF and TGF- β1). Plasma and skin levels of TGF-β1, skin toxicity and leg contracture were all significantly decreased in FLASH compared to Conv groups of mice. FLASH and Conv PBS had similar efficacy with regards to growth control of MOC1 and MOC2 head and neck cancer cells transplanted into syngeneic, immunocompetent mice. These results demonstrate consistent delivery of FLASH PBS radiation from 1 to 115 Gy/s in a clinical gantry. Radiation response following delivery of 35 Gy indicates potential benefits of FLASH versus conventional PBS that are related to skin and soft tissue toxicity.
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Affiliation(s)
- Shannon Cunningham
- Cincinnati Children’s Hospital Medical Center, Division of Oncology, Cincinnati, OH 45229, USA; (S.C.); (S.M.); (K.V.); (J.P.P.); (S.I.W.)
| | - Shelby McCauley
- Cincinnati Children’s Hospital Medical Center, Division of Oncology, Cincinnati, OH 45229, USA; (S.C.); (S.M.); (K.V.); (J.P.P.); (S.I.W.)
| | - Kanimozhi Vairamani
- Cincinnati Children’s Hospital Medical Center, Division of Oncology, Cincinnati, OH 45229, USA; (S.C.); (S.M.); (K.V.); (J.P.P.); (S.I.W.)
| | - Joseph Speth
- Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA; (J.S.); (A.M.)
| | - Swati Girdhani
- Varian Medical Systems, Inc., Palo Alto, CA 94304, USA; (S.G.); (E.A.); (R.A.S.)
| | - Eric Abel
- Varian Medical Systems, Inc., Palo Alto, CA 94304, USA; (S.G.); (E.A.); (R.A.S.)
| | - Ricky A. Sharma
- Varian Medical Systems, Inc., Palo Alto, CA 94304, USA; (S.G.); (E.A.); (R.A.S.)
| | - John P. Perentesis
- Cincinnati Children’s Hospital Medical Center, Division of Oncology, Cincinnati, OH 45229, USA; (S.C.); (S.M.); (K.V.); (J.P.P.); (S.I.W.)
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA
| | - Susanne I. Wells
- Cincinnati Children’s Hospital Medical Center, Division of Oncology, Cincinnati, OH 45229, USA; (S.C.); (S.M.); (K.V.); (J.P.P.); (S.I.W.)
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA
| | - Anthony Mascia
- Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA; (J.S.); (A.M.)
| | - Mathieu Sertorio
- Cincinnati Children’s Hospital Medical Center, Division of Oncology, Cincinnati, OH 45229, USA; (S.C.); (S.M.); (K.V.); (J.P.P.); (S.I.W.)
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA
- Correspondence:
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Wong SL, Alshaikhi J, Grimes H, Amos RA, Poynter A, Rompokos V, Gulliford S, Royle G, Liao Z, Sharma RA, Mendes R. Retrospective Planning Study of Patients with Superior Sulcus Tumours Comparing Pencil Beam Scanning Protons to Volumetric-Modulated Arc Therapy. Clin Oncol (R Coll Radiol) 2021; 33:e118-e131. [PMID: 32798157 PMCID: PMC7883303 DOI: 10.1016/j.clon.2020.07.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 05/30/2020] [Accepted: 07/22/2020] [Indexed: 12/25/2022]
Abstract
AIMS Twenty per cent of patients with non-small cell lung cancer present with stage III locally advanced disease. Precision radiotherapy with pencil beam scanning (PBS) protons may improve outcomes. However, stage III is a heterogeneous group and accounting for complex tumour motion is challenging. As yet, it remains unclear as to whom will benefit. In our retrospective planning study, we explored if patients with superior sulcus tumours (SSTs) are a select cohort who might benefit from this treatment. MATERIALS AND METHODS Patients with SSTs treated with radical radiotherapy using four-dimensional planning computed tomography between 2010 and 2015 were identified. Tumour motion was assessed and excluded if greater than 5 mm. Photon volumetric-modulated arc therapy (VMAT) and PBS proton single-field optimisation plans, with and without inhomogeneity corrections, were generated retrospectively. Robustness analysis was assessed for VMAT and PBS plans involving: (i) 5 mm geometric uncertainty, with an additional 3.5% range uncertainty for proton plans; (ii) verification plans at maximal inhalation and exhalation. Comparative dosimetric and robustness analyses were carried out. RESULTS Ten patients were suitable. The mean clinical target volume D95 was 98.1% ± 0.4 (97.5-98.8) and 98.4% ± 0.2 (98.1-98.9) for PBS and VMAT plans, respectively. All normal tissue tolerances were achieved. The same four PBS and VMAT plans failed robustness assessment. Inhomogeneity corrections minimally impacted proton plan robustness and made it worse in one case. The most important factor affecting target coverage and robustness was the clinical target volume entering the spinal canal. Proton plans significantly reduced the mean lung dose (by 21.9%), lung V5, V10, V20 (by 47.9%, 36.4%, 12.1%, respectively), mean heart dose (by 21.4%) and thoracic vertebra dose (by 29.2%) (P < 0.05). CONCLUSIONS In this planning study, robust PBS plans were achievable in carefully selected patients. Considerable dose reductions to the lung, heart and thoracic vertebra were possible without compromising target coverage. Sparing these lymphopenia-related organs may be particularly important in this era of immunotherapy.
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Affiliation(s)
- S-L Wong
- University College London Cancer Institute, London, UK; Department of Clinical Oncology, University College London Hospitals NHS Foundation Trust, London, UK.
| | - J Alshaikhi
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK; Department of Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, UK; Saudi Particle Therapy Centre, Riyadh, Saudi Arabia
| | - H Grimes
- Department of Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, UK
| | - R A Amos
- Department of Clinical Oncology, University College London Hospitals NHS Foundation Trust, London, UK; Department of Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, UK; Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - A Poynter
- Department of Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, UK
| | - V Rompokos
- Department of Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, UK
| | - S Gulliford
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK; Department of Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, UK
| | - G Royle
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Z Liao
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - R A Sharma
- University College London Cancer Institute, London, UK; Department of Clinical Oncology, University College London Hospitals NHS Foundation Trust, London, UK; NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - R Mendes
- Department of Clinical Oncology, University College London Hospitals NHS Foundation Trust, London, UK
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16
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Abbott EM, Falzone N, Lee BQ, Kartsonaki C, Winter H, Greenhalgh TA, McGowan DR, Syed N, Denis-Bacelar AM, Boardman P, Sharma RA, Vallis KA. The Impact of Radiobiologically Informed Dose Prescription on the Clinical Benefit of 90Y SIRT in Colorectal Cancer Patients. J Nucl Med 2020; 61:1658-1664. [PMID: 32358093 DOI: 10.2967/jnumed.119.233650] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 03/16/2020] [Indexed: 12/31/2022] Open
Abstract
The purpose of this study was to establish the dose-response relationship of selective internal radiation therapy (SIRT) in patients with metastatic colorectal cancer (mCRC), when informed by radiobiological sensitivity parameters derived from mCRC cell lines exposed to 90Y. Methods: Twenty-three mCRC patients with liver metastases refractory to chemotherapy were included. 90Y bremsstrahlung SPECT images were transformed into dose maps assuming the local dose deposition method. Baseline and follow-up CT scans were segmented to derive liver and tumor volumes. Mean, median, and D70 (minimum dose to 70% of tumor volume) values determined from dose maps were correlated with change in tumor volume and volumetric RECIST response using linear and logistic regression, respectively. Radiosensitivity parameters determined by clonogenic assays of mCRC cell lines HT-29 and DLD-1 after exposure to 90Y or external beam radiotherapy (EBRT; 6 MV photons) were used in biologically effective dose (BED) calculations. Results: Mean administered radioactivity was 1,469 ± 428 MBq (range, 847-2,185 MBq), achieving a mean absorbed radiation dose to tumor of 35.5 ± 9.4 Gy and mean normal liver dose of 26.4 ± 6.8 Gy. A 1.0 Gy increase in mean, median, and D70 absorbed dose was associated with a reduction in tumor volume of 1.8%, 1.8%, and 1.5%, respectively, and an increased probability of a volumetric RECIST response (odds ratio, 1.09, 1.09, and 1.10, respectively). Threshold mean, median and D70 doses for response were 48.3, 48.8, and 41.8 Gy, respectively. EBRT-equivalent BEDs for 90Y are up to 50% smaller than those calculated by applying protraction-corrected radiobiological parameters derived from EBRT alone. Conclusion: Dosimetric studies have assumed equivalence between 90Y SIRT and EBRT, leading to inflation of BED for SIRT and possible undertreatment. Radiobiological parameters for 90Y were applied to a BED model, providing a calculation method that has the potential to improve assessment of tumor control.
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Affiliation(s)
- Elliot M Abbott
- Oxford Institute for Radiation Oncology, Department of Oncology, Oxford University, Oxford, United Kingdom
| | - Nadia Falzone
- Oxford Institute for Radiation Oncology, Department of Oncology, Oxford University, Oxford, United Kingdom
| | - Boon Q Lee
- Oxford Institute for Radiation Oncology, Department of Oncology, Oxford University, Oxford, United Kingdom
| | | | - Helen Winter
- Department of Oncology, Oxford University, Oxford, United Kingdom
| | | | - Daniel R McGowan
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Nigar Syed
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | | | - Philip Boardman
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Ricky A Sharma
- Radiation Oncology, University College London, London, United Kingdom
| | - Katherine A Vallis
- Oxford Institute for Radiation Oncology, Department of Oncology, Oxford University, Oxford, United Kingdom
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17
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Chandy ETJ, Saxby HJ, Pang JW, Sharma RA. The multidisciplinary management of oligometastases from colorectal cancer: a narrative review. Ann Palliat Med 2020; 10:5988-6001. [PMID: 32921074 DOI: 10.21037/apm-20-919] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 08/05/2020] [Indexed: 11/06/2022]
Abstract
In the United States of America, almost 150,000 people are estimated to be diagnosed with colorectal cancer in 2020 and up to 35% of those are expected to present with oligometastatic disease. The term 'oligometastasis' was first used in 1995, however surgical literature describing liver resection for colorectal cancer dates back to the 1940s. Five-year survival rates of up to 42% with surgery alone for solitary lesions are reported. Modern trials have demonstrated median overall survival rates of over 80 months for patients with colorectal liver metastases treated with perioperative chemotherapy. Colorectal liver metastases have accordingly been described as 'proof of concept' for the oligometastatic theory.
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Affiliation(s)
| | | | | | - Ricky A Sharma
- UCL Cancer Institute, University College London, London, UK
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18
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Znati S, Carter R, Vasquez M, Westhorpe A, Shahbakhti H, Prince J, Vlckova P, De Vellis C, Bascal Z, Loizidou M, Sharma RA. Radiosensitisation of Hepatocellular Carcinoma Cells by Vandetanib. Cancers (Basel) 2020; 12:cancers12071878. [PMID: 32668592 PMCID: PMC7408860 DOI: 10.3390/cancers12071878] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/05/2020] [Accepted: 07/08/2020] [Indexed: 12/25/2022] Open
Abstract
Hepatocellular Carcinoma (HCC) is increasing in incidence worldwide and requires new approaches to therapy. The combination of anti-angiogenic drug therapy and radiotherapy is one promising new approach. The anti-angiogenic drug vandetanib is a tyrosine kinase inhibitor of vascular endothelial growth factor receptor-2 (VEGFR-2) and RET proto-oncogene with radio-enhancement potential. To explore the benefit of combined vandetanib and radiotherapy treatment for HCC, we studied outcomes following combined treatment in pre-clinical models. Methods: Vandetanib and radiation treatment were combined in HCC cell lines grown in vitro and in vivo. In addition to 2D migration and clonogenic assays, the combination was studied in 3D spheroids and a syngeneic mouse model of HCC. Results: Vandetanib IC50s were measured in 20 cell lines and the drug was found to significantly enhance radiation cell kill and to inhibit both cell migration and invasion in vitro. In vivo, combination therapy significantly reduced cancer growth and improved overall survival, an effect that persisted for the duration of vandetanib treatment. Conclusion: In 2D and 3D studies in vitro and in a syngeneic model in vivo, the combination of vandetanib plus radiotherapy was more efficacious than either treatment alone. This new combination therapy for HCC merits evaluation in clinical trials.
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Affiliation(s)
- Sami Znati
- University College London Cancer Institute, University College London, London WC1E 6BT, UK; (R.C.); (M.V.); (A.W.); (H.S.); (P.V.); (C.D.V.)
- Correspondence: (S.Z.); (R.A.S.)
| | - Rebecca Carter
- University College London Cancer Institute, University College London, London WC1E 6BT, UK; (R.C.); (M.V.); (A.W.); (H.S.); (P.V.); (C.D.V.)
| | - Marcos Vasquez
- University College London Cancer Institute, University College London, London WC1E 6BT, UK; (R.C.); (M.V.); (A.W.); (H.S.); (P.V.); (C.D.V.)
| | - Adam Westhorpe
- University College London Cancer Institute, University College London, London WC1E 6BT, UK; (R.C.); (M.V.); (A.W.); (H.S.); (P.V.); (C.D.V.)
| | - Hassan Shahbakhti
- University College London Cancer Institute, University College London, London WC1E 6BT, UK; (R.C.); (M.V.); (A.W.); (H.S.); (P.V.); (C.D.V.)
| | - Jessica Prince
- Department of Oncology, University of Oxford, Oxford OX3 7DQ, UK;
| | - Petra Vlckova
- University College London Cancer Institute, University College London, London WC1E 6BT, UK; (R.C.); (M.V.); (A.W.); (H.S.); (P.V.); (C.D.V.)
| | - Chiara De Vellis
- University College London Cancer Institute, University College London, London WC1E 6BT, UK; (R.C.); (M.V.); (A.W.); (H.S.); (P.V.); (C.D.V.)
- Scuola di Scienze Matematiche, Fisiche e Naturali, Università degli Studi di Firenze, 50121 Florence, Italy
| | - Zainab Bascal
- Biocompatibles UK Ltd. (A BTG International Group Company), Lakeview, Riverside Way, Watchmoor Park, Camberley, Surrey GU15 3YH, UK;
| | - Marilena Loizidou
- Division of Surgery and Interventional Science, Royal Free Campus, University College London, London NW3 2QG, UK;
| | - Ricky A. Sharma
- University College London Cancer Institute, University College London, London WC1E 6BT, UK; (R.C.); (M.V.); (A.W.); (H.S.); (P.V.); (C.D.V.)
- NIHR University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, University College London, London WC1E 6DD, UK
- Correspondence: (S.Z.); (R.A.S.)
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19
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Silvestre Patallo I, Subiel A, Westhorpe A, Gouldstone C, Tulk A, Sharma RA, Schettino G. Development and Implementation of an End-To-End Test for Absolute Dose Verification of Small Animal Preclinical Irradiation Research Platforms. Int J Radiat Oncol Biol Phys 2020; 107:587-596. [DOI: 10.1016/j.ijrobp.2020.03.001] [Citation(s) in RCA: 4] [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] [Received: 12/02/2019] [Revised: 02/11/2020] [Accepted: 03/02/2020] [Indexed: 10/24/2022]
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20
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Franklin JM, Irving B, Papiez BW, Kallehauge JF, Wang LM, Goldin RD, Harris AL, Anderson EM, Schnabel JA, Chappell MA, Brady M, Sharma RA, Gleeson FV. Tumour subregion analysis of colorectal liver metastases using semi-automated clustering based on DCE-MRI: Comparison with histological subregions and impact on pharmacokinetic parameter analysis. Eur J Radiol 2020; 126:108934. [PMID: 32217426 DOI: 10.1016/j.ejrad.2020.108934] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 01/21/2020] [Accepted: 03/01/2020] [Indexed: 12/29/2022]
Abstract
PURPOSE To use a novel segmentation methodology based on dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) to define tumour subregions of liver metastases from colorectal cancer (CRC), to compare these with histology, and to use these to compare extracted pharmacokinetic (PK) parameters between tumour subregions. MATERIALS AND METHODS This ethically-approved prospective study recruited patients with CRC and ≥1 hepatic metastases scheduled for hepatic resection. Patients underwent DCE-MRI pre-metastasectomy. Histological sections of resection specimens were spatially matched to DCE-MRI acquisitions and used to define histological subregions of viable and non-viable tumour. A semi-automated voxel-wise image segmentation algorithm based on the DCE-MRI contrast-uptake curves was used to define imaging subregions of viable and non-viable tumour. Overlap of histologically-defined and imaging subregions was compared using the Dice similarity coefficient (DSC). DCE-MRI PK parameters were compared for the whole tumour and histology-defined and imaging-derived subregions. RESULTS Fourteen patients were included in the analysis. Direct histological comparison with imaging was possible in nine patients. Mean DSC for viable tumour subregions defined by imaging and histology was 0.738 (range 0.540-0.930). There were significant differences between Ktrans and kep for viable and non-viable subregions (p < 0.001) and between whole lesions and viable subregions (p < 0.001). CONCLUSION We demonstrate good concordance of viable tumour segmentation based on pre-operative DCE-MRI with a post-operative histological gold-standard. This can be used to extract viable tumour-specific values from quantitative image analysis, and could improve treatment response assessment in clinical practice.
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Affiliation(s)
- James M Franklin
- Institute of Medical Imaging and Visualisation, Bournemouth University, UK; Radiology Department, Royal Bournemouth and Christchurch Hospitals NS Foundation Trust, UK.
| | - Benjamin Irving
- Institute of Biomedical Engineering (Department of Engineering Science), University of Oxford, UK
| | - Bartlomiej W Papiez
- Institute of Biomedical Engineering (Department of Engineering Science), University of Oxford, UK
| | - Jesper F Kallehauge
- Institute of Biomedical Engineering (Department of Engineering Science), University of Oxford, UK
| | - Lai Mun Wang
- Department of Cellular Pathology, Oxford University Hospitals NHS Foundation Trust, UK
| | | | | | - Ewan M Anderson
- Radiology Department, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, UK
| | - Julia A Schnabel
- Institute of Biomedical Engineering (Department of Engineering Science), University of Oxford, UK; School of Biomedical Engineering and Imaging Sciences, King's College London, UK
| | - Michael A Chappell
- Institute of Biomedical Engineering (Department of Engineering Science), University of Oxford, UK
| | | | - Ricky A Sharma
- NIHR University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, University College London, 72 Huntley Street, London, WC1E 6DD, UK
| | - Fergus V Gleeson
- Radiology Department, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, UK
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21
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Helmberger T, Arnold D, Bilbao JI, de Jong N, Maleux G, Nordlund A, Peynircioglu B, Sangro B, Sharma RA, Walk A. Clinical Application of Radioembolization in Hepatic Malignancies: Protocol for a Prospective Multicenter Observational Study. JMIR Res Protoc 2020; 9:e16296. [PMID: 32319960 PMCID: PMC7203613 DOI: 10.2196/16296] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 01/30/2020] [Accepted: 02/21/2020] [Indexed: 12/22/2022] Open
Abstract
Background Radioembolization, also known as transarterial radioembolization or selective internal radiation therapy with yttrium-90 (90Y) resin microspheres, is an established treatment modality for patients with primary and secondary liver tumors. However, large-scale prospective observational data on the application of this treatment in a real-life clinical setting is lacking. Objective The main objective is to collect data on the clinical application of radioembolization with 90Y resin microspheres to improve the understanding of the impact of this treatment modality in its routine practice setting. Methods Eligible patients are 18 years or older and receiving radioembolization for primary and secondary liver tumors as part of routine practice, as well as have signed informed consent. Data is collected at baseline, directly after treatment, and at every 3-month follow-up until 24 months or study exit. The primary objective of the Cardiovascular and Interventional Radiological Society of Europe Registry for SIR-Spheres Therapy (CIRT) is to observe the clinical application of radioembolization. Secondary objectives include safety, effectiveness in terms of overall survival, progression-free survival (PFS), liver-specific PFS, imaging response, and change in quality of life. Results Between January 2015 and December 2017, 1047 patients were included in the study. The 24-month follow-up period ended in December 2019. The first results are expected in the third quarter of 2020. Conclusions The CIRT is the largest observational study on radioembolization to date and will provide valuable insights to the clinical application of this treatment modality and its real-life outcomes. Trial Registration ClinicalTrials.gov NCT02305459; https://clinicaltrials.gov/ct2/show/NCT02305459 International Registered Report Identifier (IRRID) DERR1-10.2196/16296
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Affiliation(s)
- Thomas Helmberger
- Department of Radiology, Neuroradiology and Minimal-Invasive Therapy, Klinikum Bogenhausen, München, Germany
| | - Dirk Arnold
- Oncology and Hematology, Asklepios Tumorzentrum Hamburg, Asklepios Klinik Altona, Hamburg, Germany
| | - José I Bilbao
- Interventional Radiology, Clinica Universidad de Navarra, Pamplona, Spain
| | - Niels de Jong
- Cardiovascular and Interventional Radiological Society of Europe, Vienna, Austria
| | - Geert Maleux
- Radiologie, Universitair Ziekenhuis Leuven, Leuven, Belgium
| | | | - Bora Peynircioglu
- Department of Radiology, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Bruno Sangro
- Liver Unit, Clínica Universidad de Navarra, Pamplona, Spain.,Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain.,Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Pamplona, Spain
| | - Ricky A Sharma
- National Institute for Health Research University College London Hospitals Biomedical Research Centre, University College London Cancer Institute, University College London, London, United Kingdom
| | - Agnes Walk
- Cardiovascular and Interventional Radiological Society of Europe, Vienna, Austria
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22
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Mukherjee S, Hurt C, Cox C, Radhakrishna G, Gwynne S, Bateman AR, Gollins S, Hawkins MA, Canham J, Grabsch HI, Falk S, Sharma RA, Ray R, Roy R, Wade W, Maggs R, sebag-Montefiore DJ, Maughan T, Griffiths GO, Crosby TDL. Induction oxaliplatin capecitabine followed by switch to carboplatin-paclitaxel based RT versus continuing oxaliplatin capecitabine RT in operable esophageal adenocarcinoma: Survival analysis of the randomized phase II neoscope trial. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.4_suppl.373] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
373 Background: Initial results of the NEOSCOPE trial comparing pre-operative CarPac vs OxCap based chemoradiotherapy (CRT) in patients with adenocarcinoma of the oesophagus or oesophagogastric junction showed comparable toxicity and improvement in pathological complete response (pCR) in favour of the CarPacRT. Here we report survival after a median follow-up of 40.7 months (95% CI: 45.1-53.6). Methods: NEOSCOPE was an open, randomised, ‘pick a winner’ phase II trial. Patients with resectable oesophageal adenocarcinoma ≥ cT3 and/or ≥ cN1 were randomised to OxCapRT (oxaliplatin 85 mg/m2 day 1, 15, 29; capecitabine 625 mg/m2 bd on days of RT) or CarPacRT (carboplatin AUC2; paclitaxel 50 mg/m2 day 1, 8, 15, 22, 29). RT dose was 45 Gy/25 fractions/5 weeks. Induction OxCap (2 cycles) was given prior to CRT. Surgery was performed 6–8 weeks after CRT.The primary endpoint was pCR, secondary endpoints were toxicity, PFS and OS. Results: Between Oct 2013 and Feb 2015, 85 patients were recruited from 17 UK centres. Median OS was not reached in the CarPacRT group and was 41.72 months (95% CI 19.58-.)in the OxCap group (HR 0.56[95% CI 0.29-1.07]; p=0.079). 3-year and 5-year OS rates were 74% (95% CI 58%-85%) and 54% (95% CI 34%-71%) (CarPacRT), and 52% (95% CI 35%-67%) and 39% (95% CI 21%-56%) (OxCapRT). Median PFS (not reached vs 35.3 months, HR=0.61 [95% CI 0.33-1.12]; p=0.111) and metastatic PFS (not reached vs 39.0 months, HR=0.61 [95% CI 0.32-1.14], p=0.118) both favoured the CarPacRT arm. Local recurrence rate was low (OxCapRT= 10%; CarPacRT= 7%). The OS benefit for CarPacRT was consistent across subgroups but not statistically significant. Conclusions: In this longer term analysis there was some evidence that induction OxCap followed by switch to CarPacRT was superior to continuing OxCapRT, with efficacy similar to that seen in other published studies such as ‘CROSS’ and ‘FLOT’. Taken together with the previously published pCR results CarPacRT rather than OxCapRT warrants inclusion in future trials. Funding: Cancer Research UK (C44694/A14614). Clinical trial information: NCT01843829.
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Affiliation(s)
| | - Chris Hurt
- Centre for Trials Research, Cardiff University, Cardiff, United Kingdom
| | - Catrin Cox
- Centre for Trials Research, Cardiff University, Cardiff, United Kingdom
| | | | - Sarah Gwynne
- South West Wales Cancer Centre, Swansea, United Kingdom
| | - Andrew Rea Bateman
- University of Southampton School of Medicine, Southampton, United Kingdom
| | - Simon Gollins
- North Wales Cancer Treatment Centre, Rhyl, United Kingdom
| | - Maria A. Hawkins
- CRUK/MRC Oxford Institute for Radiation Oncology, Oxford, United Kingdom
| | - Jo Canham
- Cardiff University, Cardiff, United Kingdom
| | | | - Stephen Falk
- Bristol Haematology and Oncology Centre, Bristol, United Kingdom
| | | | - Ruby Ray
- Centre for Trials Research, Cardiff University, Cardiff, United Kingdom
| | | | - Wendy Wade
- NISCHR CRC South East Wales Research Network, Cardiff, United Kingdom
| | | | | | - Tim Maughan
- University of Oxford, Oxford, United Kingdom
| | - Gareth Owen Griffiths
- Southampton Clinical Trials Unit, University of Southampton, Southampton, United Kingdom
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23
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Wolstenholme J, Fusco F, Gray AM, Moschandreas J, Virdee PS, Love S, Van Hazel G, Gibbs P, Wasan HS, Sharma RA. Quality of life in the FOXFIRE, SIRFLOX and FOXFIRE-global randomised trials of selective internal radiotherapy for metastatic colorectal cancer. Int J Cancer 2020; 147:1078-1085. [PMID: 31840815 DOI: 10.1002/ijc.32828] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 10/28/2019] [Accepted: 11/08/2019] [Indexed: 11/09/2022]
Abstract
Selective internal radiotherapy (SIRT) is a liver-directed treatment involving the injection of yttrium-90 microspheres into the blood supply of liver tumours. There are very few studies assessing health-related quality of life (HRQOL) in patients treated with SIRT. Patients with liver metastases from colorectal cancer (CRC) were randomised in the FOXFIRE (FFr; ISRCTN83867919), SIRFLOX (SF; NCT00724503) and FOXFIRE-Global (FFrG; NCT01721954) trials of first-line oxaliplatin-fluorouracil (FOLFOX) chemotherapy combined with SIRT versus FOLFOX alone. HRQOL was assessed using the three-level EQ-5D, European Organisation for Research and Treatment of Cancer Quality of Life (EORTC QLQ-C30) and EORTC Colorectal Liver Metastases cancer module (EORTC QLQ-LMC21) at baseline, ≤3 months, 6 months, 12 months and annually thereafter from randomisation, and at disease progression. Analyses were conducted on an intention-to-treat basis. In total, 554 patients were randomised to SIRT + FOLFOX and 549 patients to FOLFOX alone. HRQOL was statistically significant lower in SIRT + FOLFOX patients ≤3 months after SIRT administration in all three instruments, particularly global health, physical and role functioning and symptoms of fatigue, nausea/vomiting and appetite loss. By accepted thresholds, these differences were deemed not clinically important. Differences between SIRT + FOLFOX and FOLFOX alone over the 2-year follow up and at disease progression were also not clinically important. Although there is some decrease in HRQOL for up to 3 months following SIRT, the addition of SIRT to FOLFOX chemotherapy does not change HRQOL to a clinically important degree in metastatic CRC patients.
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Affiliation(s)
- Jane Wolstenholme
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Francesco Fusco
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom.,Centre for Health Economics, University of York, York, United Kingdom
| | - Alastair M Gray
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Joanna Moschandreas
- Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom.,Centre for the Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Pradeep S Virdee
- Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom
| | - Sharon Love
- Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom
| | - Guy Van Hazel
- University of Western Australia, Perth, WA, Australia
| | | | - Harpreet S Wasan
- Department of Oncology and Cancer Medicine, Imperial College Healthcare NHS Trust & Imperial College, London, United Kingdom
| | - Ricky A Sharma
- University College London Hospitals Biomedical Research Centre, NIHR, UCL Cancer Institute, University College London, London, United Kingdom
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24
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Winter H, Kaisaki PJ, Harvey J, Giacopuzzi E, Ferla MP, Pentony MM, Knight SJ, Sharma RA, Taylor JC, McCullagh JS. Identification of Circulating Genomic and Metabolic Biomarkers in Intrahepatic Cholangiocarcinoma. Cancers (Basel) 2019; 11:E1895. [PMID: 31795195 PMCID: PMC6966597 DOI: 10.3390/cancers11121895] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 11/19/2019] [Accepted: 11/22/2019] [Indexed: 02/06/2023] Open
Abstract
Intrahepatic cholangiocarcinoma (ICC) is an aggressive cancer arising from the bile ducts with a need for earlier diagnosis and a greater range of treatment options. KRAS/NRAS mutations are common in ICC tumours and 6-32% of patients also have isocitrate dehydrogenase 1 and 2 (IDH1 and IDH2) gene mutations associated with metabolic changes. This feasibility study investigated sequencing circulating tumour DNA (ctDNA) combined with metabolite profiling of plasma as a method for biomarker discovery in ICC patients. Plasma was collected from four ICC patients receiving radio-embolisation and healthy controls at multiple time points. ctDNA was sequenced using Ampliseq cancer hotspot panel-v2 on Ion Torrent PGM for single nucleotide variants (SNV) detection and with Illumina whole genome sequencing for copy number variants (CNV) and further targeted examination for SNVs. Untargeted analysis of metabolites from patient and control plasma was performed using liquid chromatography coupled with high-resolution tandem mass spectrometry (LC-MS/MS). Metabolite identification was performed using multi-parameter comparisons with analysis of authentic standards, and univariate statistical analysis was performed to identify differences in metabolite abundance between patient and control samples. Recurrent somatic SNVs and CNVs were identified in ctDNA from three out of four patients that included both NRAS and IDH1 mutations linked to ICC. Plasma metabolite analysis revealed biomarker metabolites associated with ICC and in particular 2-hydroxyglutarate (2-HG) levels were elevated in both samples from the only patient showing a variant allele in IDH1. A reduction in the number of CNVs was observed with treatment. This study demonstrates that ctDNA and metabolite levels can be identified and correlated in ICC patient blood samples and differentiated from healthy controls. We conclude that combining genomic and metabolic analysis of plasma offers an effective approach to biomarker identification with potential for disease stratification and early detection studies.
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Affiliation(s)
- Helen Winter
- National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Wellcome Centre for Human Genetics, University of Oxford, Oxford OX3 7BN, UK; (H.W.); (P.J.K.); (E.G.); (M.P.F.); (M.M.P.); (J.C.T.)
- NIHR Oxford Biomedical Research Centre, Department of Oncology, University of Oxford, Oxford OX3 7DQ, UK;
- Bristol Cancer Institute, Horfield Rd, Bristol BS2 8ED, UK
| | - Pamela J. Kaisaki
- National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Wellcome Centre for Human Genetics, University of Oxford, Oxford OX3 7BN, UK; (H.W.); (P.J.K.); (E.G.); (M.P.F.); (M.M.P.); (J.C.T.)
| | - Joe Harvey
- Chemistry Research Laboratory, Department of Chemistry, University of Oxford, Oxford OX1 3TA, UK;
| | - Edoardo Giacopuzzi
- National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Wellcome Centre for Human Genetics, University of Oxford, Oxford OX3 7BN, UK; (H.W.); (P.J.K.); (E.G.); (M.P.F.); (M.M.P.); (J.C.T.)
| | - Matteo P. Ferla
- National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Wellcome Centre for Human Genetics, University of Oxford, Oxford OX3 7BN, UK; (H.W.); (P.J.K.); (E.G.); (M.P.F.); (M.M.P.); (J.C.T.)
| | - Melissa M. Pentony
- National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Wellcome Centre for Human Genetics, University of Oxford, Oxford OX3 7BN, UK; (H.W.); (P.J.K.); (E.G.); (M.P.F.); (M.M.P.); (J.C.T.)
| | - Samantha J.L. Knight
- National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Wellcome Centre for Human Genetics, University of Oxford, Oxford OX3 7BN, UK; (H.W.); (P.J.K.); (E.G.); (M.P.F.); (M.M.P.); (J.C.T.)
| | - Ricky A. Sharma
- NIHR Oxford Biomedical Research Centre, Department of Oncology, University of Oxford, Oxford OX3 7DQ, UK;
- NIHR University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, University College London, London WC1E 6DD, UK
| | - Jenny C. Taylor
- National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Wellcome Centre for Human Genetics, University of Oxford, Oxford OX3 7BN, UK; (H.W.); (P.J.K.); (E.G.); (M.P.F.); (M.M.P.); (J.C.T.)
| | - James S.O. McCullagh
- Chemistry Research Laboratory, Department of Chemistry, University of Oxford, Oxford OX1 3TA, UK;
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25
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Beaton L, Tregidgo HFJ, Znati SA, Forsyth S, Clarkson MJ, Bandula S, Chouhan M, Lowe HL, Zaw Thin M, Hague J, Sharma D, Pollok JM, Davidson BR, Raja J, Munneke G, Stuckey DJ, Bascal ZA, Wilde PE, Cooper S, Ryan S, Czuczman P, Boucher E, Hartley JA, Lewis AL, Jansen M, Meyer T, Sharma RA. VEROnA Protocol: A Pilot, Open-Label, Single-Arm, Phase 0, Window-of-Opportunity Study of Vandetanib-Eluting Radiopaque Embolic Beads (BTG-002814) in Patients With Resectable Liver Malignancies. JMIR Res Protoc 2019; 8:e13696. [PMID: 31579027 PMCID: PMC6777276 DOI: 10.2196/13696] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 07/08/2019] [Accepted: 07/16/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Transarterial chemoembolization (TACE) is the current standard of care for patients with intermediate-stage hepatocellular carcinoma (HCC) and is also a treatment option for patients with liver metastases from colorectal cancer. However, TACE is not a curative treatment, and tumor progression occurs in more than half of the patients treated. Despite advances and technical refinements of TACE, including the introduction of drug-eluting beads-TACE, the clinical efficacy of TACE has not been optimized, and improved arterial therapies are required. OBJECTIVE The primary objectives of the VEROnA study are to evaluate the safety and tolerability of vandetanib-eluting radiopaque embolic beads (BTG-002814) in patients with resectable liver malignancies and to determine concentrations of vandetanib and the N-desmethyl metabolite in plasma and resected liver following treatment with BTG-002814. METHODS The VEROnA study is a first-in-human, open-label, single-arm, phase 0, window-of-opportunity study of BTG-002814 (containing 100 mg vandetanib) delivered transarterially, 7 to 21 days before surgery in patients with resectable liver malignancies. Eligible patients have a diagnosis of colorectal liver metastases, or HCC (Childs Pugh A), diagnosed histologically or radiologically, and are candidates for liver surgery. All patients are followed up for 28 days following surgery. Secondary objectives of this study are to evaluate the anatomical distribution of BTG-002814 on noncontrast-enhanced imaging, to evaluate histopathological features in the surgical specimen, and to assess changes in blood flow on dynamic contrast-enhanced magnetic resonance imaging following treatment with BTG-002814. Exploratory objectives of this study are to study blood biomarkers with the potential to identify patients likely to respond to treatment and to correlate the distribution of BTG-002814 on imaging with pathology by 3-dimensional modeling. RESULTS Enrollment for the study was completed in February 2019. Results of a planned interim analysis were reviewed by a safety committee after the first 3 patients completed follow-up. The recommendation of the committee was to continue the study without any changes to the dose or trial design, as there were no significant unexpected toxicities related to BTG-002814. CONCLUSIONS The VEROnA study is studying the feasibility of administering BTG-002814 to optimize the use of this novel technology as liver-directed therapy for patients with primary and secondary liver cancer. TRIAL REGISTRATION ClinicalTrial.gov NCT03291379; https://clinicaltrials.gov/ct2/show/NCT03291379. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/13696.
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Affiliation(s)
- Laura Beaton
- University College London Cancer Institute, University College London, London, United Kingdom
| | - Henry F J Tregidgo
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Sami A Znati
- University College London Cancer Institute, University College London, London, United Kingdom
| | - Sharon Forsyth
- Cancer Research UK University College London Cancer Trials Centre, London, United Kingdom
| | - Matthew J Clarkson
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Steven Bandula
- University College London Centre for Medical Imaging, University College London, London, United Kingdom
| | - Manil Chouhan
- University College London Centre for Medical Imaging, University College London, London, United Kingdom
| | - Helen L Lowe
- University College London Experimental Cancer Medicine Centre Good Clinical Laboratory Practice Facility, University College London, London, United Kingdom
| | - May Zaw Thin
- Centre for Advanced Biomedical Imaging, University College London, London, United Kingdom
| | - Julian Hague
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Dinesh Sharma
- Division of Transplantation and Immunology, Royal Free Hospital NHS Foundation Trust, London, United Kingdom
| | - Joerg-Matthias Pollok
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
- Hepatopancreatobiliary Surgery and Liver Transplantation, Royal Free Hospital NHS Foundation Trust, London, United Kingdom
| | - Brian R Davidson
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
- Hepatopancreatobiliary Surgery and Liver Transplantation, Royal Free Hospital NHS Foundation Trust, London, United Kingdom
| | - Jowad Raja
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Graham Munneke
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Daniel J Stuckey
- Centre for Advanced Biomedical Imaging, University College London, London, United Kingdom
| | | | | | | | | | | | | | - John A Hartley
- University College London Cancer Institute, University College London, London, United Kingdom
| | | | - Marnix Jansen
- University College London Cancer Institute, University College London, London, United Kingdom
| | - Tim Meyer
- University College London Cancer Institute, University College London, London, United Kingdom
- Department of Oncology, Royal Free Hospital NHS Foundation Trust, London, United Kingdom
| | - Ricky A Sharma
- National Institute for Health Research University College London Hospitals Biomedical Centre, University College London Cancer Institute, London, United Kingdom
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26
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Carter R, Cheraghchi-Bashi A, Westhorpe A, Yu S, Shanneik Y, Seraia E, Ouaret D, Inoue Y, Koch C, Wilding J, Ebner D, Ryan AJ, Buffa FM, Sharma RA. Identification of anticancer drugs to radiosensitise BRAF-wild-type and mutant colorectal cancer. Cancer Biol Med 2019; 16:234-246. [PMID: 31516745 PMCID: PMC6713640 DOI: 10.20892/j.issn.2095-3941.2018.0284] [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] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 12/21/2018] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Patients with BRAF-mutant colorectal cancer (CRC) have a poor prognosis. Molecular status is not currently used to select which drug to use in combination with radiotherapy. Our aim was to identify drugs that radiosensitise CRC cells with known BRAF status. METHODS We screened 298 oncological drugs with and without ionising radiation in colorectal cancer cells isogenic for BRAF. Hits from rank product analysis were validated in a 16-cell line panel of human CRC cell lines, using clonogenic survival assays and xenograft models in vivo. RESULTS Most consistently identified hits were drugs targeting cell growth/proliferation or DNA damage repair. The most effective class of drugs that radiosensitised wild-type and mutant cell lines was PARP inhibitors. In clonogenic survival assays, talazoparib produced a radiation enhancement ratio of 1.9 in DLD1 (BRAF-wildtype) cells and 1.8 in RKO (BRAF V600E) cells. In DLD1 xenografts, talazoparib significantly increased the inhibitory effect of radiation on tumour growth (P ≤ 0.01). CONCLUSIONS Our method for screening large drug libraries for radiosensitisation has identified PARP inhibitors as promising radiosensitisers of colorectal cancer cells with wild-type and mutant BRAF backgrounds.
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Affiliation(s)
- Rebecca Carter
- NIHR University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, University College London, London WC1E 6DD, UK
- NIHR Oxford Biomedical Research Centre, Department of Oncology, University of Oxford, Oxford OX1 2JD, UK
| | - Azadeh Cheraghchi-Bashi
- NIHR Oxford Biomedical Research Centre, Department of Oncology, University of Oxford, Oxford OX1 2JD, UK
| | - Adam Westhorpe
- NIHR University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, University College London, London WC1E 6DD, UK
- NIHR Oxford Biomedical Research Centre, Department of Oncology, University of Oxford, Oxford OX1 2JD, UK
| | - Sheng Yu
- Computational Biology and Integrative Genomics, University of Oxford, Oxford OX1 2JD, UK
| | - Yasmin Shanneik
- NIHR Oxford Biomedical Research Centre, Department of Oncology, University of Oxford, Oxford OX1 2JD, UK
| | - Elena Seraia
- NDM Research Building, Nuffield Department of Medicine, University of Oxford, Oxford OX1 2JD, UK
| | - Djamila Ouaret
- Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford OX1 2JD, UK
| | - Yasuhiro Inoue
- Mie University, Graduate School of Medicine, Department of Gastrointestinal and Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Edobashi 2-174, Tsu, Japan
| | - Catherine Koch
- Department of Biology, Massachusetts Institute of Technology, Cambridge, Massachusetts 02142, USA
| | - Jenny Wilding
- Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford OX1 2JD, UK
| | - Daniel Ebner
- Target Discovery Institute, National Phenotypic Screening Centre, Nuffield Department of Medicine, University of Oxford, Oxford OX1 2JD, UK
| | - Anderson J. Ryan
- CRUK & MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford OX1 2JD, UK
| | - Francesca M. Buffa
- CRUK & MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford OX1 2JD, UK
| | - Ricky A. Sharma
- NIHR University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, University College London, London WC1E 6DD, UK
- NIHR Oxford Biomedical Research Centre, Department of Oncology, University of Oxford, Oxford OX1 2JD, UK
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27
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Beaton L, Bandula S, Gaze MN, Sharma RA. How rapid advances in imaging are defining the future of precision radiation oncology. Br J Cancer 2019; 120:779-790. [PMID: 30911090 PMCID: PMC6474267 DOI: 10.1038/s41416-019-0412-y] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [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: 06/06/2018] [Revised: 01/23/2019] [Accepted: 02/05/2019] [Indexed: 12/13/2022] Open
Abstract
Imaging has an essential role in the planning and delivery of radiotherapy. Recent advances in imaging have led to the development of advanced radiotherapy techniques—including image-guided radiotherapy, intensity-modulated radiotherapy, stereotactic body radiotherapy and proton beam therapy. The optimal use of imaging might enable higher doses of radiation to be delivered to the tumour, while sparing normal surrounding tissues. In this article, we review how the integration of existing and novel forms of computed tomography, magnetic resonance imaging and positron emission tomography have transformed tumour delineation in the radiotherapy planning process, and how these advances have the potential to allow a more individualised approach to the cancer therapy. Recent data suggest that imaging biomarkers that assess underlying tumour heterogeneity can identify areas within a tumour that are at higher risk of radio-resistance, and therefore potentially allow for biologically focussed dose escalation. The rapidly evolving concept of adaptive radiotherapy, including artificial intelligence, requires imaging during treatment to be used to modify radiotherapy on a daily basis. These advances have the potential to improve clinical outcomes and reduce radiation-related long-term toxicities. We outline how recent technological advances in both imaging and radiotherapy delivery can be combined to shape the future of precision radiation oncology.
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Affiliation(s)
- Laura Beaton
- Cancer Institute, University College London, London, UK
| | - Steve Bandula
- Cancer Institute, University College London, London, UK.,NIHR University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, University College London, London, UK
| | - Mark N Gaze
- NIHR University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, University College London, London, UK
| | - Ricky A Sharma
- Cancer Institute, University College London, London, UK. .,NIHR University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, University College London, London, UK.
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28
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Ahmad SS, Crittenden MR, Tran PT, Kluetz PG, Blumenthal GM, Bulbeck H, Baird RD, Williams KJ, Illidge T, Hahn SM, Lawrence TS, Spears PA, Walker AJ, Sharma RA. Clinical Development of Novel Drug-Radiotherapy Combinations. Clin Cancer Res 2019; 25:1455-1461. [PMID: 30498095 PMCID: PMC6397668 DOI: 10.1158/1078-0432.ccr-18-2466] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 10/16/2018] [Accepted: 11/26/2018] [Indexed: 12/25/2022]
Abstract
Radiotherapy is a fundamental component of treatment for the majority of patients with cancer. In recent decades, technological advances have enabled patients to receive more targeted doses of radiation to the tumor, with sparing of adjacent normal tissues. There had been hope that the era of precision medicine would enhance the combination of radiotherapy with targeted anticancer drugs; however, this ambition remains to be realized. In view of this lack of progress, the FDA-AACR-ASTRO Clinical Development of Drug-Radiotherapy Combinations Workshop was held in February 2018 to bring together stakeholders and opinion leaders from academia, clinical radiation oncology, industry, patient advocacy groups, and the FDA to discuss challenges to introducing new drug-radiotherapy combinations to the clinic. This Perspectives in Regulatory Science and Policy article summarizes the themes and action points that were discussed. Intelligent trial design is required to increase the number of studies that efficiently meet their primary outcomes; endpoints to be considered include local control, organ preservation, and patient-reported outcomes. Novel approaches including immune-oncology or DNA-repair inhibitor agents combined with radiotherapy should be prioritized. In this article, we focus on how the regulatory challenges associated with defining a new drug-radiotherapy combination can be overcome to improve clinical outcomes for patients with cancer.
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Affiliation(s)
- Saif S Ahmad
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom
| | - Marka R Crittenden
- Translational Radiation Research, Earle A. Chiles Research Institute, Providence Cancer Center, Portland, Oregon; The Oregon Clinic, Portland, Oregon
| | - Phuoc T Tran
- Department of Radiation Oncology and Molecular Radiation Sciences, Oncology and Urology, Johns Hopkins University, Baltimore, Maryland
| | - Paul G Kluetz
- FDA Oncology Center of Excellence, Silver Spring, Maryland
| | | | - Helen Bulbeck
- CTRad, National Cancer Research Institute, London, United Kingdom
| | - Richard D Baird
- Cambridge Breast Cancer Research Unit, University of Cambridge, Cambridge, United Kingdom
| | - Kaye J Williams
- Division of Pharmacy and Optometry, Manchester Cancer Research Centre, The University of Manchester, Manchester, United Kingdom
| | - Tim Illidge
- Division of Cancer Sciences, The University of Manchester, Manchester Academic Health Science Centre, NIHR Biomedical Research Centre, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Stephen M Hahn
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Theodore S Lawrence
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Patricia A Spears
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| | - Amanda J Walker
- Department of Radiation Oncology, Wentworth Douglass Hospital and Seacoast Cancer Center, Dover, New Hampshire.
| | - Ricky A Sharma
- Radiation Oncology, NIHR University College London Hospitals Biomedical Research Centre, University College London Cancer Institute, University College London, London, United Kingdom.
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29
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Chauhan N, Mulcahy MF, Salem R, Benson Iii AB, Boucher E, Bukovcan J, Cosgrove D, Laframboise C, Lewandowski RJ, Master F, El-Rayes B, Strosberg JR, Sze DY, Sharma RA. TheraSphere Yttrium-90 Glass Microspheres Combined With Chemotherapy Versus Chemotherapy Alone in Second-Line Treatment of Patients With Metastatic Colorectal Carcinoma of the Liver: Protocol for the EPOCH Phase 3 Randomized Clinical Trial. JMIR Res Protoc 2019; 8:e11545. [PMID: 30664496 PMCID: PMC6354199 DOI: 10.2196/11545] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 11/09/2018] [Accepted: 11/09/2018] [Indexed: 12/21/2022] Open
Abstract
Background Colorectal cancer is one of the most common cancers and causes of cancer-related death. Up to approximately 70% of patients with metastatic colorectal cancer (mCRC) have metastases to the liver at initial diagnosis. Second-line systemic treatment in mCRC can prolong survival after development of disease progression during or after first-line treatment and in those who are intolerant to first-line treatment. Objective The objective of this study is to evaluate the efficacy and safety of transarterial radioembolization (TARE) with TheraSphere yttrium-90 (90Y) glass microspheres combined with second-line therapy in patients with mCRC of the liver who had disease progression during or after first-line chemotherapy. Methods EPOCH is an open-label, prospective, multicenter, randomized, phase 3 trial being conducted at up to 100 sites in the United States, Canada, Europe, and Asia. Eligible patients have mCRC of the liver and disease progression after first-line chemotherapy with either an oxaliplatin-based or irinotecan-based regimen and are eligible for second-line chemotherapy with the alternate regimen. Patients were randomized 1:1 to the TARE group (chemotherapy with TARE in place of the second chemotherapy infusion and subsequent resumption of chemotherapy) or the control group (chemotherapy alone). The addition of targeted agents is permitted. The primary end points are progression-free survival and hepatic progression-free survival. The study objective will be considered achieved if at least one primary end point is statistically significant. Secondary end points are overall survival, time to symptomatic progression defined as Eastern Cooperative Oncology Group Performance Status score of 2 or higher, objective response rate, disease control rate, quality-of-life assessment by the Functional Assessment of Cancer Therapy-Colorectal Cancer questionnaire, and adverse events. The study is an adaptive trial, comprising a group sequential design with 2 interim analyses with a planned maximum of 420 patients. The study is designed to detect a 2.5-month increase in median progression-free survival, from 6 months in the control group to 8.5 months in the TARE group (hazard ratio [HR] 0.71), and a 3.5-month increase in median hepatic progression-free survival time, from 6.5 months in the control group to 10 months in the TARE group (HR 0.65). On the basis of simulations, the power to detect the target difference in either progression-free survival or hepatic progression-free survival is >90%, and the power to detect the target difference in each end point alone is >80%. Results Patient enrollment ended in October 2018. The first interim analysis in June 2018 resulted in continuation of the study without any changes. Conclusions The EPOCH study may contribute toward the establishment of the role of combination therapy with TARE and oxaliplatin- or irinotecan-based chemotherapy in the second-line treatment of mCRC of the liver. Trial Registration ClinicalTrials.gov NCT01483027; https://clinicaltrials.gov/ct2/show/NCT01483027 (Archived by WebCite at http://www.webcitation.org/734A6PAYW) International Registered Report Identifier (IRRID) RR1-10.2196/11545
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Affiliation(s)
- Nikhil Chauhan
- Research and Development, BTG International group companies, London, United Kingdom
| | - Mary F Mulcahy
- Division of Hematology and Oncology, Department of Medicine, Robert H Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, United States
| | - Riad Salem
- Division of Hematology and Oncology, Department of Medicine, Robert H Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, United States.,Section of Interventional Radiology, Department of Radiology, Robert H Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, United States.,Division of Transplant Surgery, Department of Surgery, Robert H Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, United States
| | - Al B Benson Iii
- Division of Hematology and Oncology, Department of Medicine, Robert H Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, United States.,Northwestern Medical Group, Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, IL, United States
| | - Eveline Boucher
- Research and Development, BTG International group companies, London, United Kingdom
| | - Janet Bukovcan
- Research and Development, BTG International group companies, London, United Kingdom
| | - David Cosgrove
- Division of Medical Oncology, Vancouver Cancer Center, Compass Oncology, Vancouver, WA, United States
| | - Chantal Laframboise
- Research and Development, BTG International group companies, London, United Kingdom
| | - Robert J Lewandowski
- Division of Hematology and Oncology, Department of Medicine, Robert H Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, United States.,Section of Interventional Radiology, Department of Radiology, Robert H Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, United States.,Division of Transplant Surgery, Department of Surgery, Robert H Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, United States
| | - Fayaz Master
- Research and Development, BTG International group companies, London, United Kingdom
| | - Bassel El-Rayes
- Winship Cancer Institute, Emory University, Atlanta, GA, United States.,Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, United States
| | | | - Daniel Y Sze
- Interventional Radiology, Stanford University Medical Center, Stanford, CA, United States
| | - Ricky A Sharma
- National Institute for Health Research University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, London, United Kingdom
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30
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Ricketts K, Ahmad R, Beaton L, Cousins B, Critchley K, Davies M, Evans S, Fenuyi I, Gavriilidis A, Harmer QJ, Jayne D, Jefford M, Loizidou M, Macrobert A, Moorcroft S, Naasani I, Ong ZY, Prise KM, Rannard S, Richards T, Schettino G, Sharma RA, Tillement O, Wakefield G, Williams NR, Yaghini E, Royle G. Recommendations for clinical translation of nanoparticle-enhanced radiotherapy. Br J Radiol 2018; 91:20180325. [PMID: 30179039 PMCID: PMC6319829 DOI: 10.1259/bjr.20180325] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 08/23/2018] [Accepted: 08/29/2018] [Indexed: 01/06/2023] Open
Abstract
A multi-disciplinary cooperative for nanoparticle-enhanced radiotherapy (NERT) has been formed to review the current status of the field and identify key stages towards translation. Supported by the Colorectal Cancer Healthcare Technologies Cooperative, the cooperative comprises a diverse cohort of key contributors along the translation pathway including academics of physics, cancer and radio-biology, chemistry, nanotechnology and clinical trials, clinicians, manufacturers, industry, standards laboratories, policy makers and patients. Our aim was to leverage our combined expertise to devise solutions towards a roadmap for translation and commercialisation of NERT, in order to focus research in the direction of clinical implementation, and streamline the critical pathway from basic science to the clinic. A recent meeting of the group identified barriers to and strategies for accelerated clinical translation. This commentary reports the cooperative's recommendations. Particular emphasis was given to more standardised and cohesive research methods, models and outputs, and reprioritised research drivers including patient quality of life following treatment. Nanoparticle design criteria were outlined to incorporate scalability of manufacture, understanding and optimisation of biological mechanisms of enhancement and in vivo fate of nanoparticles, as well as existing design criteria for physical and chemical enhancement. In addition, the group aims to establish a long-term and widespread international community to disseminate key findings and create a much-needed cohesive body of evidence necessary for commercial and clinical translation.
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Affiliation(s)
- Kate Ricketts
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Reem Ahmad
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Laura Beaton
- NIHR University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, University College London, London, UK
| | - Brian Cousins
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Kevin Critchley
- School of Physics and Astronomy, University of Leeds, Leeds, UK
| | | | - Stephen Evans
- School of Physics and Astronomy, University of Leeds, Leeds, UK
| | - Ifeyemi Fenuyi
- Division of Surgery and Interventional Science, University College London, London, UK
| | | | | | - David Jayne
- Leeds Institute of Clinical Sciences, St James’s University Hospital, Leeds, UK
| | | | - Marilena Loizidou
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Alexander Macrobert
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Sam Moorcroft
- School of Physics and Astronomy, University of Leeds, Leeds, UK
| | | | | | - Kevin M Prise
- Centre for Cancer Research & Cell Biology, Queens University Belfast, Belfast, UK
| | - Steve Rannard
- Department of Chemistry and Materials Innovation Factory, University of Liverpool, Liverpool, UK
| | - Thomas Richards
- Department of Oncology, University College London Hospital NHS Foundation Trust, London, UK
| | - Giuseppe Schettino
- Medical Radiation Science Group, National Physical Laboratory, Teddington, UK
| | - Ricky A Sharma
- NIHR University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, University College London, London, UK
| | | | | | - Norman R Williams
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Elnaz Yaghini
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Gary Royle
- Department of Medical Physics and Bioengineering, University College London, London, UK
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31
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White J, Carolan-Rees G, Dale M, Morgan HE, Patrick HE, See TC, Beeton EL, Swinson DEB, Bell JK, Manas DM, Crellin A, Slevin NJ, Sharma RA. Analysis of a National Programme for Selective Internal Radiation Therapy for Colorectal Cancer Liver Metastases. Clin Oncol (R Coll Radiol) 2018; 31:58-66. [PMID: 30297164 DOI: 10.1016/j.clon.2018.09.002] [Citation(s) in RCA: 15] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 07/31/2018] [Accepted: 08/01/2018] [Indexed: 12/20/2022]
Abstract
AIMS Patients with chemotherapy-refractory colorectal cancer liver metastases have limited therapeutic options. Selective internal radiation therapy (SIRT) delivers yttrium 90 microspheres as a minimally invasive procedure. This prospective, single-arm, observational, service-evaluation study was part of National Health Service England Commissioning through Evaluation. METHODS Patients eligible for treatment had histologically confirmed carcinoma with liver-only/liver-dominant metastases with clinical progression during or following oxaliplatin-based and irinotecan-based chemotherapy. All patients received SIRT plus standard of care. The primary outcome was overall survival; secondary outcomes included safety, progression-free survival (PFS) and liver-specific PFS (LPFS). RESULTS Between December 2013 and March 2017, 399 patients were treated in 10 centres with a median follow-up of 14.3 months (95% confidence interval 9.2-19.4). The median overall survival was 7.6 months (95% confidence interval 6.9-8.3). The median PFS and LPFS were 3.0 months (95% confidence interval 2.8-3.1) and 3.7 months (95% confidence interval 3.2-4.3), respectively. During the follow-up period, 143 patients experienced an adverse event and 8% of the events were grade 3. CONCLUSION Survival estimates from this pragmatic study show clinical outcomes attainable in the National Health Service comparable with previously published data. This study shows the value of a registry-based commissioning model to aid national commissioning decisions for highly specialist cancer treatments.
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Affiliation(s)
- J White
- Cedar, Cardiff & Vale University Health Board, Cardiff Medicentre, Cardiff, UK
| | - G Carolan-Rees
- Cedar, Cardiff & Vale University Health Board, Cardiff Medicentre, Cardiff, UK
| | - M Dale
- Cedar, Cardiff & Vale University Health Board, Cardiff Medicentre, Cardiff, UK
| | - H E Morgan
- Cedar, Cardiff University, Cardiff Medicentre, Cardiff, UK
| | - H E Patrick
- Centre for Health Technology Evaluation, National Institute for Health and Care Excellence, London, UK
| | - T C See
- Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - E L Beeton
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - D E B Swinson
- Leeds Teaching Hospitals NHS Trust, St James's Hospital, Leeds, UK
| | - J K Bell
- Department of Radiology, The Christie NHS Foundation Trust, Manchester, UK
| | - D M Manas
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Newcastle upon Tyne, UK
| | - A Crellin
- NHS England, Institute of Oncology, St James's University Hospital, Leeds, UK
| | - N J Slevin
- The Christie NHS Foundation Trust, Withington, Manchester, UK
| | - R A Sharma
- NIHR University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, University College London, London, UK.
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Kannan P, Kretzschmar WW, Winter H, Warren D, Bates R, Allen PD, Syed N, Irving B, Papiez BW, Kaeppler J, Markelc B, Kinchesh P, Gilchrist S, Smart S, Schnabel JA, Maughan T, Harris AL, Muschel RJ, Partridge M, Sharma RA, Kersemans V. Functional Parameters Derived from Magnetic Resonance Imaging Reflect Vascular Morphology in Preclinical Tumors and in Human Liver Metastases. Clin Cancer Res 2018; 24:4694-4704. [PMID: 29959141 PMCID: PMC6171743 DOI: 10.1158/1078-0432.ccr-18-0033] [Citation(s) in RCA: 12] [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] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 05/11/2018] [Accepted: 06/25/2018] [Indexed: 12/13/2022]
Abstract
Purpose: Tumor vessels influence the growth and response of tumors to therapy. Imaging vascular changes in vivo using dynamic contrast-enhanced MRI (DCE-MRI) has shown potential to guide clinical decision making for treatment. However, quantitative MR imaging biomarkers of vascular function have not been widely adopted, partly because their relationship to structural changes in vessels remains unclear. We aimed to elucidate the relationships between vessel function and morphology in vivo Experimental Design: Untreated preclinical tumors with different levels of vascularization were imaged sequentially using DCE-MRI and CT. Relationships between functional parameters from MR (iAUC, K trans, and BATfrac) and structural parameters from CT (vessel volume, radius, and tortuosity) were assessed using linear models. Tumors treated with anti-VEGFR2 antibody were then imaged to determine whether antiangiogenic therapy altered these relationships. Finally, functional-structural relationships were measured in 10 patients with liver metastases from colorectal cancer.Results: Functional parameters iAUC and K trans primarily reflected vessel volume in untreated preclinical tumors. The relationships varied spatially and with tumor vascularity, and were altered by antiangiogenic treatment. In human liver metastases, all three structural parameters were linearly correlated with iAUC and K trans For iAUC, structural parameters also modified each other's effect.Conclusions: Our findings suggest that MR imaging biomarkers of vascular function are linked to structural changes in tumor vessels and that antiangiogenic therapy can affect this link. Our work also demonstrates the feasibility of three-dimensional functional-structural validation of MR biomarkers in vivo to improve their biological interpretation and clinical utility. Clin Cancer Res; 24(19); 4694-704. ©2018 AACR.
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Affiliation(s)
- Pavitra Kannan
- CRUK and MRC Oxford Institute for Radiation Oncology Department of Oncology, University of Oxford, Oxford, United Kingdom.
| | - Warren W Kretzschmar
- School of Engineering Sciences in Chemistry, Biotechnology and Health, Department of Gene Technology, Science for Life Laboratory, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Helen Winter
- CRUK and MRC Oxford Institute for Radiation Oncology Department of Oncology, University of Oxford, Oxford, United Kingdom
| | - Daniel Warren
- CRUK and MRC Oxford Institute for Radiation Oncology Department of Oncology, University of Oxford, Oxford, United Kingdom
| | - Russell Bates
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, United Kingdom
| | - Philip D Allen
- CRUK and MRC Oxford Institute for Radiation Oncology Department of Oncology, University of Oxford, Oxford, United Kingdom
| | - Nigar Syed
- CRUK and MRC Oxford Institute for Radiation Oncology Department of Oncology, University of Oxford, Oxford, United Kingdom
- NHS, Department of Radiology, Churchill Hospital, Oxford, United Kingdom
| | - Benjamin Irving
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, United Kingdom
| | - Bartlomiej W Papiez
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, United Kingdom
| | - Jakob Kaeppler
- CRUK and MRC Oxford Institute for Radiation Oncology Department of Oncology, University of Oxford, Oxford, United Kingdom
| | - Bosjtan Markelc
- CRUK and MRC Oxford Institute for Radiation Oncology Department of Oncology, University of Oxford, Oxford, United Kingdom
| | - Paul Kinchesh
- CRUK and MRC Oxford Institute for Radiation Oncology Department of Oncology, University of Oxford, Oxford, United Kingdom
| | - Stuart Gilchrist
- CRUK and MRC Oxford Institute for Radiation Oncology Department of Oncology, University of Oxford, Oxford, United Kingdom
| | - Sean Smart
- CRUK and MRC Oxford Institute for Radiation Oncology Department of Oncology, University of Oxford, Oxford, United Kingdom
| | - Julia A Schnabel
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, United Kingdom
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Tim Maughan
- CRUK and MRC Oxford Institute for Radiation Oncology Department of Oncology, University of Oxford, Oxford, United Kingdom
| | - Adrian L Harris
- CRUK and MRC Oxford Institute for Radiation Oncology Department of Oncology, University of Oxford, Oxford, United Kingdom
| | - Ruth J Muschel
- CRUK and MRC Oxford Institute for Radiation Oncology Department of Oncology, University of Oxford, Oxford, United Kingdom
| | - Mike Partridge
- CRUK and MRC Oxford Institute for Radiation Oncology Department of Oncology, University of Oxford, Oxford, United Kingdom
| | - Ricky A Sharma
- CRUK and MRC Oxford Institute for Radiation Oncology Department of Oncology, University of Oxford, Oxford, United Kingdom
- NIHR University College London Hospitals Biomedical Research Centre, University College London, London, United Kingdom
| | - Veerle Kersemans
- CRUK and MRC Oxford Institute for Radiation Oncology Department of Oncology, University of Oxford, Oxford, United Kingdom
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Falls KC, Sharma RA, Lawrence YR, Amos RA, Advani SJ, Ahmed MM, Vikram B, Coleman CN, Prasanna PG. Radiation-Drug Combinations to Improve Clinical Outcomes and Reduce Normal Tissue Toxicities: Current Challenges and New Approaches: Report of the Symposium Held at the 63rd Annual Meeting of the Radiation Research Society, 15-18 October 2017; Cancun, Mexico. Radiat Res 2018; 190:350-360. [PMID: 30280985 PMCID: PMC6322391 DOI: 10.1667/rr15121.1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The National Cancer Institute's (NCI) Radiation Research Program (RRP) is endeavoring to increase the relevance of preclinical research to improve outcomes of radiation therapy for cancer patients. These efforts include conducting symposia, workshops and educational sessions at annual meetings of professional societies, including the American Association of Physicists in Medicine, American Society of Radiation Oncology, Radiation Research Society (RRS), Radiosurgery Society, Society of Nuclear Medicine and Molecular Imaging, Society for Immunotherapy of Cancer and the American Association of Immunology. A symposium entitled "Radiation-Drug Combinations to Improve Clinical Outcomes and Reduce Normal Tissue Toxicities" was conducted by the NCI's RRP during the 63rd Annual Meeting of the RRS on October 16, 2017 in Cancun, Mexico. In this symposium, discussions were held to address the challenges in developing radiation-drug combinations, optimal approaches with scientific evidence to replace standard-of-care, approaches to reduce normal tissue toxicities and enhance post-treatment quality-of-life and recent advances in antibody-drug conjugates. The symposium included two broad overview talks followed by two talks illustrating examples of radiation-drug combinations under development. The overview talks identified the essential preclinical infrastructure necessary to accelerate progress in the development of evidence and important challenges in the translation of drug combinations to the clinic from the laboratory. Also addressed, in the example talks (in light of the suggested guidelines and identified challenges), were the development and translation of novel antibody drug conjugates as well as repurposing of drugs to improve efficacy and reduce normal tissue toxicities. Participation among a cross section of clinicians, scientists and scholars-in-training alike who work in this focused area highlighted the importance of continued discussions to identify and address complex challenges in this emerging area in radiation oncology.
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Affiliation(s)
- Kelly C. Falls
- Free Radical and Radiation Biology Program, Department of Radiation Oncology, Carver College of Medicine, Holden Comprehensive Cancer Center, The University of Iowa, Iowa City, Iowa 52242
- Scholar-in-Training, Radiation Research Society
| | - Ricky A. Sharma
- NHR University College of London Hospitals Biomedical Research Center, UCL Cancer Institute, University College London, United Kingdom
| | - Yaacov R. Lawrence
- Center for Translational Research in Radiation Oncology, Department of Radiation Oncology, Sheba Medical Center affiliated with Tel Aviv University, Tel HaShomer 5265601, Israel
| | - Richard A. Amos
- Proton and Advanced Radiotherapy Group, Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Sunil J. Advani
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, Moores Cancer Center, La Jolla, California 92093
| | - Mansoor M. Ahmed
- National Cancer Institute, Division of Cancer Treatment and Diagnosis, Radiation Research Program, Bethesda, Maryland 20892
| | - Bhadrasain Vikram
- National Cancer Institute, Division of Cancer Treatment and Diagnosis, Radiation Research Program, Bethesda, Maryland 20892
| | - C. Norman Coleman
- National Cancer Institute, Division of Cancer Treatment and Diagnosis, Radiation Research Program, Bethesda, Maryland 20892
| | - Pataje G. Prasanna
- National Cancer Institute, Division of Cancer Treatment and Diagnosis, Radiation Research Program, Bethesda, Maryland 20892
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Lyon PC, Winter H, Herbschleb K, Campo L, Carlisle R, Wu F, Goldin R, Coussios CC, Middleton MR, Gleeson FV, Boardman P, Sharma RA. Long-term radiological and histological outcomes following selective internal radiation therapy to liver metastases from breast cancer. Radiol Case Rep 2018; 13:1259-1266. [PMID: 30258519 PMCID: PMC6153140 DOI: 10.1016/j.radcr.2018.08.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 05/23/2018] [Revised: 08/19/2018] [Accepted: 08/26/2018] [Indexed: 11/29/2022] Open
Abstract
Liver metastasis from breast cancer is associated with poor prognosis and is a major cause of early morbidity and mortality. When liver resection is not feasible, minimally invasive directed therapies are considered to attempt to prolong survival. Selective internal radiation therapy (SIRT) with yttrium-90 microspheres is a liver-directed therapy that can improve local control of liver metastases from colorectal cancer. We present a case of a patient with a ductal breast adenocarcinoma, who developed liver and bone metastasis despite extensive treatment with systemic chemotherapies. Following SIRT to the liver, after an initial response, the patient ultimately progressed in the liver after 7 months. Liver tumor histology obtained 20 months after the SIRT intervention demonstrated the presence of the resin microspheres in situ. This case report demonstrates the long-term control that may be achieved with SIRT to treat liver metastases from breast cancer that is refractory to previous chemotherapies, and the presence of microspheres in situ long-term.
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Affiliation(s)
- Paul C Lyon
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Old Road, Headington, Oxford OX3 7LE, United Kingdom.,Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom.,Institute of Biomedical Engineering, University of Oxford, Old Road Campus Research Building, Oxford OX3 7DQ, United Kingdom
| | - Helen Winter
- Department of Oncology, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 7LE, United Kingdom
| | - Karin Herbschleb
- Department of Oncology, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 7LE, United Kingdom
| | - Leticia Campo
- Good Clinical Practice Laboratories, Oxford Institute for Radiation Oncology, University of Oxford, Old Road Campus Research Building, Oxford OX3 7DQ, United Kingdom
| | - Robert Carlisle
- Institute of Biomedical Engineering, University of Oxford, Old Road Campus Research Building, Oxford OX3 7DQ, United Kingdom
| | - Feng Wu
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom
| | - Robert Goldin
- Centre for Pathology, Imperial College at St Mary's Hospital, London W2 1NY, United Kingdom
| | - Constantin C Coussios
- Institute of Biomedical Engineering, University of Oxford, Old Road Campus Research Building, Oxford OX3 7DQ, United Kingdom
| | - Mark R Middleton
- Department of Oncology, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 7LE, United Kingdom
| | - Fergus V Gleeson
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Old Road, Headington, Oxford OX3 7LE, United Kingdom
| | - Philip Boardman
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Old Road, Headington, Oxford OX3 7LE, United Kingdom
| | - Ricky A Sharma
- Department of Oncology, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 7LE, United Kingdom.,NIHR University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, University College London, 72 Huntley Street, London WC1E 6DD, United Kingdom
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Abstract
In patients with liver-limited oligometastatic disease, the goal of treatment can be curative intent. Historically, this was accomplished in patients presenting with upfront resectable disease. The availability of increasingly efficacious chemotherapy and biologic combinations with encouraging response rates led to the potential to convert unresectable disease to resectability. Beyond the backbone of surgery, we now have a portfolio of locoregional strategies to consider.From an interventional radiology perspective, the use of portal vein embolization can facilitate hypertrophy of the liver in anticipation of resection, thus converting unresectable disease to one amenable to a surgical approach with curative intent. Technological advances in liver-directed ablative therapies have afforded the possibility of eliminate radiographically evident disease with the hope for long-term disease control. Advanced radiotherapy techniques are further increasing the therapeutic options for patients with metastatic colorectal cancer. Improvements in external-beam radiotherapy over the past 2 decades include image-guided radiotherapy, intensity-modulated radiotherapy, stereotactic body radiotherapy, and proton-beam therapy. Finally, selective internal radiation therapy (SIRT) with microspheres labeled with the β-emitter 90Y enable targeted delivery of radiation to hepatic tumors. A coordinated multidisciplinary approach is required to integrate these nonsurgical adjuncts in an evidence-based manner to optimize outcomes for patients with potentially resectable metastatic disease. In this article, we summarize recent developments in systemic therapy, radiotherapy, and interventional liver-directed therapies that have changed the treatment landscape for patients with oligometastatic colorectal cancer.
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Affiliation(s)
- Sharlene Gill
- From the BC Cancer-Vancouver and Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada; National Institute for Health Research University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, University College, London, United Kingdom
| | - David M Liu
- From the BC Cancer-Vancouver and Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada; National Institute for Health Research University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, University College, London, United Kingdom
| | - Harshani M Green
- From the BC Cancer-Vancouver and Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada; National Institute for Health Research University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, University College, London, United Kingdom
| | - Ricky A Sharma
- From the BC Cancer-Vancouver and Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada; National Institute for Health Research University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, University College, London, United Kingdom
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36
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MacGregor TP, Carter R, Gillies RS, Findlay JM, Kartsonaki C, Castro-Giner F, Sahgal N, Wang LM, Chetty R, Maynard ND, Cazier JB, Buffa F, McHugh PJ, Tomlinson I, Middleton MR, Sharma RA. Translational study identifies XPF and MUS81 as predictive biomarkers for oxaliplatin-based peri-operative chemotherapy in patients with esophageal adenocarcinoma. Sci Rep 2018; 8:7265. [PMID: 29739952 PMCID: PMC5940885 DOI: 10.1038/s41598-018-24232-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 02/09/2018] [Indexed: 02/06/2023] Open
Abstract
Oxaliplatin-based chemotherapy is used to treat patients with esophageal adenocarcinoma (EAC), but no biomarkers are currently available for patient selection. We performed a prospective, clinical trial to identify potential biomarkers associated with clinical outcomes. Tumor tissue was obtained from 38 patients with resectable EAC before and after 2 cycles of oxaliplatin-fluorouracil chemotherapy. Pre-treatment mRNA expression of 280 DNA repair (DNAR) genes was tested for association with histopathological regression at surgery, disease-free survival (DFS) and overall survival (OS). High expression of 13 DNA damage repair genes was associated with DFS less than one year (P < 0.05); expression of 11 DNAR genes were associated with worse OS (P < 0.05). From clinical associations with outcomes, two genes, ERCC1 and EME1, were identified as candidate biomarkers. In cell lines in vitro, we showed the mechanism of action related to repair of oxaliplatin-induced DNA damage by depletion and knockout of protein binding partners of the candidate biomarkers, XPF and MUS81 respectively. In clinical samples from the clinical trial, pre-treatment XPF protein levels were associated with pathological response, and MUS81 protein was associated with 1-year DFS. XPF and MUS81 merit further validation in prospective clinical trials as biomarkers that may predict clinical response of EAC to oxaliplatin-based chemotherapy.
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Affiliation(s)
- T P MacGregor
- NIHR Oxford Biomedical Research Centre, Department of Oncology, University of Oxford, Oxford, UK
| | - R Carter
- NIHR Oxford Biomedical Research Centre, Department of Oncology, University of Oxford, Oxford, UK
| | - R S Gillies
- NIHR Oxford Biomedical Research Centre, Department of Oncology, University of Oxford, Oxford, UK
- Department of Upper GI Surgery, Churchill Hospital, Oxford, UK
| | - J M Findlay
- Department of Upper GI Surgery, Churchill Hospital, Oxford, UK
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK
| | - C Kartsonaki
- NIHR Oxford Biomedical Research Centre, Department of Oncology, University of Oxford, Oxford, UK
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Medical Research Council Population Health Research Unit (MRC PHRU) at the University of Oxford, Oxford, UK
| | - F Castro-Giner
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK
| | - N Sahgal
- Ludwig Institute for Cancer Research, University of Oxford, Nuffield Department of Medicine, Oxford, UK
| | - L M Wang
- NIHR Oxford Biomedical Research Centre/Department of Cellular Pathology/Radcliffe Department of Medicine, Oxford University Hospitals and University of Oxford, Oxford, UK
- Department of Laboratory Medicine, Changi General Hospital, Singapore, Singapore
| | - R Chetty
- Laboratory Medicine Programme, University Health Network, Toronto, Canada
| | - N D Maynard
- Department of Upper GI Surgery, Churchill Hospital, Oxford, UK
| | - J B Cazier
- NIHR Oxford Biomedical Research Centre, Department of Oncology, University of Oxford, Oxford, UK
- Centre for Computational Biology, Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - F Buffa
- NIHR Oxford Biomedical Research Centre, Department of Oncology, University of Oxford, Oxford, UK
| | - P J McHugh
- Department of Oncology, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
| | - I Tomlinson
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK
| | - M R Middleton
- NIHR Oxford Biomedical Research Centre, Department of Oncology, University of Oxford, Oxford, UK
| | - R A Sharma
- NIHR Oxford Biomedical Research Centre, Department of Oncology, University of Oxford, Oxford, UK.
- NIHR University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, University College London, London, UK.
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Abstract
4D reconstruction of dynamic positron emission tomography (dPET) data can improve the signal-to-noise ratio in reconstructed image sequences by fitting smooth temporal functions to the voxel time-activity-curves (TACs) during the reconstruction, though the optimal choice of function remains an open question. We propose a spline-residue model, which describes TACs as weighted sums of convolutions of the arterial input function with cubic B-spline basis functions. Convolution with the input function constrains the spline-residue model at early time-points, potentially enhancing noise suppression in early time-frames, while still allowing a wide range of TAC descriptions over the entire imaged time-course, thus limiting bias. Spline-residue based 4D-reconstruction is compared to that of a conventional (non-4D) maximum a posteriori (MAP) algorithm, and to 4D-reconstructions based on adaptive-knot cubic B-splines, the spectral model and an irreversible two-tissue compartment ('2C3K') model. 4D reconstructions were carried out using a nested-MAP algorithm including spatial and temporal roughness penalties. The algorithms were tested using Monte-Carlo simulated scanner data, generated for a digital thoracic phantom with uptake kinetics based on a dynamic [18F]-Fluromisonidazole scan of a non-small cell lung cancer patient. For every algorithm, parametric maps were calculated by fitting each voxel TAC within a sub-region of the reconstructed images with the 2C3K model. Compared to conventional MAP reconstruction, spline-residue-based 4D reconstruction achieved >50% improvements for five of the eight combinations of the four kinetics parameters for which parametric maps were created with the bias and noise measures used to analyse them, and produced better results for 5/8 combinations than any of the other reconstruction algorithms studied, while spectral model-based 4D reconstruction produced the best results for 2/8. 2C3K model-based 4D reconstruction generated the most biased parametric maps. Inclusion of a temporal roughness penalty function improved the performance of 4D reconstruction based on the cubic B-spline, spectral and spline-residue models.
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Affiliation(s)
- George P Ralli
- Department of Oncology, University of Oxford, Old Road Campus Research Building, Roosevelt Drive, Oxford OX3 7DQ, United Kingdom
| | - Michael A Chappell
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Old Road Campus Research Building, Roosevelt Drive, Oxford OX3 7DQ, United Kingdom
| | - Daniel R McGowan
- Department of Oncology, University of Oxford, Old Road Campus Research Building, Roosevelt Drive, Oxford OX3 7DQ, United Kingdom
- Radiation Physics and Protection, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford OX3 7LE, United Kingdom
| | - Ricky A Sharma
- NIHR University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, University College London, 72 Huntley Street, London WC1E 6DD, United Kingdom
| | - Geoff S Higgins
- Department of Oncology, University of Oxford, Old Road Campus Research Building, Roosevelt Drive, Oxford OX3 7DQ, United Kingdom
| | - John D Fenwick
- Institute of Translational Medicine, University of Liverpool, UCD Block, Royal Liverpool University Hospital, Daulby Street, Liverpool L69 3GA, United Kingdom
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38
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Miller MD, Sharma RA, Rivas J, Robbins R, Seixas A, Giardin J, de Leon MJ, Varga AW, Ayappa I, Rapoport D, Osorio RS, Godinho A. 0281 Decreased Objective Total Sleep Time in APOE Ɛ4 Positive Cognitively Normal Elderly. Sleep 2018. [DOI: 10.1093/sleep/zsy061.280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | | | - J Rivas
- New York University, New York, NY
| | | | - A Seixas
- New York University, New York, NY
| | | | - M J de Leon
- Mount Sinai School of Medicine, New York, NY
| | - A W Varga
- Mount Sinai School of Medicine, New York, NY
| | - I Ayappa
- Mount Sinai School of Medicine, New York, NY
| | - D Rapoport
- Mount Sinai School of Medicine, New York, NY
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Varga AW, Kam K, Parekh A, Sharma RA, Castillo B, Miller MD, Bagchi N, Rapoport DM, Ayappa I, Osorio RS. 0292 Sleep Spindle Characteristics and Their Association with Cerebrospinal Fluid Biomarkers of Alzheimer’s Disease in Cognitively Normal Older Adults. Sleep 2018. [DOI: 10.1093/sleep/zsy061.291] [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] [Indexed: 11/13/2022] Open
Affiliation(s)
- A W Varga
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - K Kam
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - A Parekh
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - R A Sharma
- NYU Center for Brain Health, New York, NY
| | - B Castillo
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - M D Miller
- NYU Center for Brain Health, New York, NY
| | - N Bagchi
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - D M Rapoport
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - I Ayappa
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - R S Osorio
- NYU Center for Brain Health, New York, NY
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40
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Sharma RA, Miller MD, Kam K, Parekh A, Rivas J, Bubu OM, Varga AW, Iosifescu DV, Osorio RS. 0970 Sleep Spindle Count In Subsyndromal Depressed vs Normal Elderly: A Protective Effect Of Sleep Spindles? Sleep 2018. [DOI: 10.1093/sleep/zsy061.969] [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] [Indexed: 11/14/2022] Open
Affiliation(s)
- R A Sharma
- New York University School of Medicine, New York, NY
| | | | - K Kam
- Icahn School of Medicine, Mount Sinai, New York, NY
| | - A Parekh
- Icahn School of Medicine, Mount Sinai, New York, NY
| | - J Rivas
- New York University, New York, NY
| | - O M Bubu
- University of South Florida, Tampa, FL
| | - A W Varga
- Icahn School of Medicine, Mount Sinai, New York, NY
| | - D V Iosifescu
- New York University School of Medicine, New York, NY
| | - R S Osorio
- New York University School of Medicine, New York, NY
- New York University School of Medicine, New York, NY
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41
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BUBU OM, Andrade A, Hogan MM, Umasabor-Bubu OQ, Mukhtar F, Sharma RA, Miller M, Mbah A, Borenstein A, Mortimer J, Kip K, Morgan D, Jean-Louis G, Osorio R. 0737 Obstructive Sleep Apnea: A Distinct Physiological Phenotypic Risk Factor in older adults with Cognitive decline and Alzheimer’s disease. Sleep 2018. [DOI: 10.1093/sleep/zsy061.736] [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] [Indexed: 11/13/2022] Open
Affiliation(s)
- O M BUBU
- University of South Florida, Tampa, FL
- Wheaton College, Wheaton, IL
| | | | | | | | - F Mukhtar
- University of South Florida, Tampa, FL
| | | | - M Miller
- New York University, New York, NY
| | - A Mbah
- University of South Florida, Tampa, FL
| | | | | | - K Kip
- University of South Florida, Tampa, FL
| | - D Morgan
- University of South Florida, Tampa, FL
- Byrd Alzheimer’s Institute, Tampa, FL
- Michigan State University, East Lansing, MI
| | | | - R Osorio
- New York University, New York, NY
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Sharma RA, Miller MD, Kam K, Parekh A, Bubu OM, Rivas J, Ayappa I, Rapoport DM, Varga AW, Osorio RS. 0695 Objectively Measured Total Sleep Time as a Tool to Detect Longitudinal Changes In Alzheimer’s Disease Neuroimaging Biomarker (FDG PET). Sleep 2018. [DOI: 10.1093/sleep/zsy061.694] [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] [Indexed: 11/12/2022] Open
Affiliation(s)
| | | | - K Kam
- Icahn School of Medicine, Mount Sinai, New York, NY
| | - A Parekh
- Icah School of Medicine, Mount Sinai, New York, NY
| | - O M Bubu
- University of South Florida, Tampa, FL
| | - J Rivas
- New York University, New York, NY
| | - I Ayappa
- Icahn School of Medicine, Mount Sinai, New York, NY
| | - D M Rapoport
- Icahn School of Medicine, Mount Sinai, New York, NY
| | - A W Varga
- Icahn School of Medicine, Mount Sinai, New York, NY
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BUBU OM, Umasabor-Bubu OQ, Sharma RA, Mukhtar F, Smith AH, Mbah A, Borenstein A, Mortimer J, Seixas A, Jean-Louis G, Kip K, Morgan D, Varga A, Osorio R. 1007 Obstructive Sleep Apnea (OSA) Is Associated with Longitudinal Increases in Brain Florbetapir PET Imaging, CSF TAU, PTAU, And Decrease in CSF AB42 burden, In Elderly Cognitive Normal (NL) And Mild Cognitive Impairment (MCI) Individuals. Sleep 2018. [DOI: 10.1093/sleep/zsy061.1006] [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] [Indexed: 11/13/2022] Open
Affiliation(s)
- O M BUBU
- University of South Florida, Tampa, FL
- Wheaton College, Wheaton, IL
| | | | | | - F Mukhtar
- University of South Florida, Tampa, FL
| | | | - A Mbah
- University of South Florida, Tampa, FL
| | | | | | - A Seixas
- New York University, New York, NY
| | | | - K Kip
- University of South Florida, Tampa, FL
| | - D Morgan
- University of South Florida, Tampa, FL
- Byrd Alzheimer’s Institute, Tampa, FL
- Michigan State University, East Lansing, MI
| | - A Varga
- New York University, New York, NY
| | - R Osorio
- New York University, New York, NY
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Sharma RA, Fumi L, Audisio RA, Denys A, Wood BJ, Pignatti F. Assessment of medical devices: the Emperor's new clothes: Author reply. Br J Radiol 2018; 91:20180310. [PMID: 29688753 DOI: 10.1259/bjr.20180310] [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] [Indexed: 11/05/2022] Open
Affiliation(s)
- Ricky A Sharma
- 1 Oncology Department, NIHR Oxford Biomedical Research Centre, University of Oxford , Oxford , UK.,2 NIHR University College London Hospitals Biomedical Research Centre, UCL Cancer Institute , London , UK
| | - Lucio Fumi
- 3 Wyfold Medical Consultancy, 2 Wyfold Cottages, Wyfold, Reading , Berkshire , UK
| | - Riccardo A Audisio
- 4 Department of Surgery, Institute of Clinical Sciences, Sahlgrenska University Hospital , Göteborg , Sweden
| | - Alban Denys
- 5 Department of Radiology and Interventional Radiology, CHUV University Hospital , Lausanne , Switzerland
| | - Bradford J Wood
- 6 Center for Interventional Oncology, National Cancer Institute and NIH Clinical Center, National Institutes of Health , Bethesda, MD , USA
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Kennedy A, Brown DB, Feilchenfeldt J, Marshall J, Wasan H, Fakih M, Gibbs P, Knuth A, Sangro B, Soulen MC, Pittari G, Sharma RA. Safety of selective internal radiation therapy (SIRT) with yttrium-90 microspheres combined with systemic anticancer agents: expert consensus. J Gastrointest Oncol 2017; 8:1079-1099. [PMID: 29299370 PMCID: PMC5750172 DOI: 10.21037/jgo.2017.09.10] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 09/20/2017] [Indexed: 12/12/2022] Open
Abstract
Selective internal radiation therapy (SIRT) with microspheres labelled with the β-emitter yttrium-90 (Y-90) enables targeted delivery of radiation to hepatic tumors. SIRT is primarily used to treat inoperable primary or metastatic liver tumors. Eligible patients have usually been exposed to a variety of systemic anticancer therapies, including cytotoxic agents, targeted biologics, immunotherapy and peptide receptor radionuclide therapy (PRRT). All these treatments have potential interactions with SIRT; however, robust evidence on the safety of these potential combinations is lacking. This paper provides current clinical experiences and expert consensus guidelines for the use of SIRT in combination with the anticancer treatment agents likely to be encountered in clinical practice. It was agreed by the expert panel that precautions need to be taken with certain drugs, but that, in general, systemic therapies do not necessarily have to be stopped to perform SIRT. The authors recommend stopping vascular endothelial growth factor inhibitors 4-6 weeks before SIRT, and restart after the patient has recovered from the procedure. It may also be prudent to stop potent radiosensitizers such as gemcitabine therapy 4 weeks before SIRT, and restart treatment at least 2‒4 weeks later. Data from phase III studies combining SIRT with fluorouracil (5FU) or folinic acid/5FU/oxaliplatin (FOLFOX) suggest that hematological toxicity is more common from the combination than it is from chemotherapy without SIRT. There is no evidence to suggest that chemotherapy increases SIRT-specific gastro-intestinal or liver toxicities.
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Affiliation(s)
- Andrew Kennedy
- Radiation Oncology Research, Sarah Cannon Research Institute, Nashville, Tennessee, USA
| | - Daniel B. Brown
- Department of Radiology and Radiologic Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - John Marshall
- Hematology and Oncology Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington DC, USA
| | - Harpreet Wasan
- Imperial College, Division of Cancer, Hammersmith Hospital, London, UK
| | - Marwan Fakih
- Department of Medical Oncology & Therapeutics Research, City of Hope, Duarte, California, USA
| | - Peter Gibbs
- Western Hospital, Footscray, Victoria, Australia
| | - Alexander Knuth
- National Center for Cancer Care and Research, HMC, Doha, Qatar
| | - Bruno Sangro
- Liver Unit, Clinica Universidad de Navarra, IDISNA, CIBEREHD, Pamplona, Navarra, Spain
| | - Michael C. Soulen
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Ricky A. Sharma
- NIHR University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, University College London, London, UK
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Sharma RA, Fumi L, Audisio RA, Denys A, Wood BJ, Pignatti F. Commentary: how will interventional oncology navigate the "valleys of death" for new medical devices? Br J Radiol 2017; 91:20170643. [PMID: 29172678 PMCID: PMC5965466 DOI: 10.1259/bjr.20170643] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Whereas clinical trials of cancer drugs have methodological standards and conventional primary endpoints, these are not necessarily applicable to the clinical development of loco-regional treatments and new medical devices. The current challenge is to generate high-level clinical evidence for loco-regional treatments to define the benefits for patients. In this article, we argue that, to generate convincing evidence of clinical efficacy and safety, the collective coherence of the entire data package is often more important than the primary endpoint of one clinical trial. We also propose that, when a comprehensive clinical data package is not feasible, limited clinical data can be supplemented with other types of evidence. Emerging life science companies often define the "valley of death" after securing initial investment to translate an early medical device concept to a development stage that is attractive to funders. Unfortunately for this industry, there is a second "valley of death" if the focus and goal is only regulatory approval, to the neglect of clinical acceptance and reimbursement. For the emerging specialism of interventional oncology, it is critical to plan a clear line of sight for each new medical device to avoid the valleys of death and to demonstrate the clinical benefit. Increased international guidance to establish realistic yet convincing standards in this area may avoid attrition of potentially beneficial devices and therapeutic procedures in the valleys of death.
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Affiliation(s)
- Ricky A Sharma
- 1 Department of Oncology, NIHR Oxford Biomedical Research Centre, University of Oxford , Oxford , UK.,2 NIHR University College London Hospitals Biomedical Research Centre, UCL Cancer Institute , London , UK
| | - Lucio Fumi
- 3 Wyfold Medical Consultancy , Wyfold , UK
| | - Riccardo A Audisio
- 4 University of Liverpool, St Helens Teaching Hospital , St. Helens , UK
| | - Alban Denys
- 5 Department of Radiology and Interventional Radiology, CHUV University Hospital , Lausanne , Switzerland
| | - Bradford J Wood
- 6 Center for Interventional Oncology, National Cancer Institute and NIH Clinical Center, National Institutes of Health , Bethesda, MD , USA
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Harrington K, Hall E, Hawkins M, Henry A, MacKay R, Maughan T, McDonald A, Nutting C, Oelfke U, Sebag-Montefiore D, Sharma RA, van Herk M, Faivre-Finn C. Introducing the Cancer Research UK Advanced Radiotherapy Technologies Network (ART-NET). Clin Oncol (R Coll Radiol) 2017; 29:707-710. [PMID: 28807360 PMCID: PMC6155492 DOI: 10.1016/j.clon.2017.07.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 06/30/2017] [Accepted: 07/08/2017] [Indexed: 12/25/2022]
Affiliation(s)
| | - E Hall
- Institute of Cancer Research, London, UK
| | - M Hawkins
- Cancer Research UK/MRC Oxford Institute for Radiation Oncology, Oxford, UK
| | - A Henry
- Leeds Teaching Hospitals NHS Trust, Leeds, UK; University of Leeds, Leeds, UK
| | - R MacKay
- University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester, UK
| | | | - A McDonald
- Institute of Cancer Research, London, UK
| | - C Nutting
- The Royal Marsden NHS Foundation Trust, London, UK
| | - U Oelfke
- Institute of Cancer Research, London, UK
| | - D Sebag-Montefiore
- Leeds Teaching Hospitals NHS Trust, Leeds, UK; University of Leeds, Leeds, UK
| | - R A Sharma
- University College London, London, UK; NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - M van Herk
- University of Manchester, Manchester, UK
| | - C Faivre-Finn
- University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester, UK.
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Sharma RA, Gibbs P, Sharma NK, Ricke J, Taieb J, Moschandreas J, Virdee PS, Dutton P, van Hazel G, Wasan HS. Adequate SIRT activity dose is as important as adequate chemotherapy dose - Authors' reply. Lancet Oncol 2017; 18:e637. [PMID: 29208391 DOI: 10.1016/s1470-2045(17)30801-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 10/11/2017] [Indexed: 01/05/2023]
Affiliation(s)
- Ricky A Sharma
- CRUK-MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, UK; NIHR University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, London WC1E 6DD, UK.
| | | | - Navesh K Sharma
- Division of Radiation Oncology, Penn State Hershey Cancer Centre and School of Medicine, PA, USA
| | - Jens Ricke
- Department of Radiology and Nuclear Medicine, University of Magdeburg, Magdeburg, Germany
| | - Julien Taieb
- Department of Hepatogastroenterology and GI Oncology, Université Paris Descartes, Paris, France
| | | | - Pradeep S Virdee
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Peter Dutton
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Guy van Hazel
- University of Western Australia, Perth, WA, Australia
| | - Harpreet S Wasan
- Imperial College Healthcare NHS Trust & Imperial College, Hammersmith Hospital, London, UK
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Abstract
Cholangiocarcinoma is a rare and aggressive malignancy of the biliary tract. Complete surgical resection can be curative, but the majority of patients are diagnosed with advanced disease and usually die within a year of diagnosis. Most deaths are attributable to local disease progression rather than distant metastases, supporting the use of locoregional therapies. There is evidence that locoregional therapies can provide local tumor control resulting in increased survival while avoiding some of the side effects of systemic treatments, increasing potential treatment options for patients who may be unsuitable for systemic palliative treatments. This review considers the evidence for locoregional therapies in cholangiocarcinoma, which can be classified into endoscopic, vascular, percutaneous and radiation oncological therapies. Current guidelines do not recommend the routine use of locoregional therapies due to a lack of prospective data, but the results of ongoing trials are likely to increase the evidence base and impact on clinical practice.
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Affiliation(s)
- Peter L Labib
- UCL Institute for Liver & Digestive Health, Royal Free Hospital Campus, Royal Free Hospital, Pond Street, London, NW3 2QG, UK
| | - Brian R Davidson
- UCL Division of Surgery & Interventional Science, Royal Free Hospital, Pond Street, London, NW3 2QG, UK
| | - Ricky A Sharma
- NIHR University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, University College London, 72 Huntley Street, London, UK
| | - Stephen P Pereira
- UCL Institute for Liver & Digestive Health, Royal Free Hospital Campus, Royal Free Hospital, Pond Street, London, NW3 2QG, UK
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50
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Wasan HS, Gibbs P, Sharma NK, Taieb J, Heinemann V, Ricke J, Peeters M, Findlay M, Weaver A, Mills J, Wilson C, Adams R, Francis A, Moschandreas J, Virdee PS, Dutton P, Love S, Gebski V, Gray A, van Hazel G, Sharma RA. First-line selective internal radiotherapy plus chemotherapy versus chemotherapy alone in patients with liver metastases from colorectal cancer (FOXFIRE, SIRFLOX, and FOXFIRE-Global): a combined analysis of three multicentre, randomised, phase 3 trials. Lancet Oncol 2017; 18:1159-1171. [PMID: 28781171 PMCID: PMC5593813 DOI: 10.1016/s1470-2045(17)30457-6] [Citation(s) in RCA: 215] [Impact Index Per Article: 30.7] [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: 05/02/2017] [Revised: 06/04/2017] [Accepted: 06/05/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Data suggest selective internal radiotherapy (SIRT) in third-line or subsequent therapy for metastatic colorectal cancer has clinical benefit in patients with colorectal liver metastases with liver-dominant disease after chemotherapy. The FOXFIRE, SIRFLOX, and FOXFIRE-Global randomised studies evaluated the efficacy of combining first-line chemotherapy with SIRT using yttrium-90 resin microspheres in patients with metastatic colorectal cancer with liver metastases. The studies were designed for combined analysis of overall survival. METHODS FOXFIRE, SIRFLOX, and FOXFIRE-Global were randomised, phase 3 trials done in hospitals and specialist liver centres in 14 countries worldwide (Australia, Belgium, France, Germany, Israel, Italy, New Zealand, Portugal, South Korea, Singapore, Spain, Taiwan, the UK, and the USA). Chemotherapy-naive patients with metastatic colorectal cancer (WHO performance status 0 or 1) with liver metastases not suitable for curative resection or ablation were randomly assigned (1:1) to either oxaliplatin-based chemotherapy (FOLFOX: leucovorin, fluorouracil, and oxaliplatin) or FOLFOX plus single treatment SIRT concurrent with cycle 1 or 2 of chemotherapy. In FOXFIRE, FOLFOX chemotherapy was OxMdG (oxaliplatin modified de Gramont chemotherapy; 85 mg/m2 oxaliplatin infusion over 2 h, L-leucovorin 175 mg or D,L-leucovorin 350 mg infusion over 2 h, and 400 mg/m2 bolus fluorouracil followed by a 2400 mg/m2 continuous fluorouracil infusion over 46 h). In SIRFLOX and FOXFIRE-Global, FOLFOX chemotherapy was modified FOLFOX6 (85 mg/m2 oxaliplatin infusion over 2 h, 200 mg leucovorin, and 400 mg/m2 bolus fluorouracil followed by a 2400 mg/m2 continuous fluorouracil infusion over 46 h). Randomisation was done by central minimisation with four factors: presence of extrahepatic metastases, tumour involvement of the liver, planned use of a biological agent, and investigational centre. Participants and investigators were not masked to treatment. The primary endpoint was overall survival, analysed in the intention-to-treat population, using a two-stage meta-analysis of pooled individual patient data. All three trials have completed 2 years of follow-up. FOXFIRE is registered with the ISRCTN registry, number ISRCTN83867919. SIRFLOX and FOXFIRE-Global are registered with ClinicalTrials.gov, numbers NCT00724503 (SIRFLOX) and NCT01721954 (FOXFIRE-Global). FINDINGS Between Oct 11, 2006, and Dec 23, 2014, 549 patients were randomly assigned to FOLFOX alone and 554 patients were assigned FOLFOX plus SIRT. Median follow-up was 43·3 months (IQR 31·6-58·4). There were 411 (75%) deaths in 549 patients in the FOLFOX alone group and 433 (78%) deaths in 554 patients in the FOLFOX plus SIRT group. There was no difference in overall survival (hazard ratio [HR] 1·04, 95% CI 0·90-1·19; p=0·61). The median survival time in the FOLFOX plus SIRT group was 22·6 months (95% CI 21·0-24·5) compared with 23·3 months (21·8-24·7) in the FOLFOX alone group. In the safety population containing patients who received at least one dose of study treatment, as treated, the most common grade 3-4 adverse event was neutropenia (137 [24%] of 571 patients receiving FOLFOX alone vs 186 (37%) of 507 patients receiving FOLFOX plus SIRT). Serious adverse events of any grade occurred in 244 (43%) of 571 patients receiving FOLFOX alone and 274 (54%) of 507 patients receiving FOLFOX plus SIRT. 10 patients in the FOLFOX plus SIRT group and 11 patients in the FOLFOX alone group died due to an adverse event; eight treatment-related deaths occurred in the FOLFOX plus SIRT group and three treatment-related deaths occurred in the FOLFOX alone group. INTERPRETATION Addition of SIRT to first-line FOLFOX chemotherapy for patients with liver-only and liver-dominant metastatic colorectal cancer did not improve overall survival compared with that for FOLFOX alone. Therefore, early use of SIRT in combination with chemotherapy in unselected patients with metastatic colorectal cancer cannot be recommended. To further define the role of SIRT in metastatic colorectal cancer, careful patient selection and studies investigating the role of SIRT as consolidation therapy after chemotherapy are needed. FUNDING Bobby Moore Fund of Cancer Research UK, Sirtex Medical.
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Affiliation(s)
- Harpreet S Wasan
- Imperial College Healthcare NHS Trust and Imperial College, Hammersmith Hospital, London, UK
| | | | - Navesh K Sharma
- Division of Radiation Oncology, Penn State Hershey Cancer Centre, School of Medicine, Hershey, PA, USA
| | - Julien Taieb
- Sorbonne Paris Cité, Université Paris Descartes, Georges Pompidou European Hospital, Department of Hepatogastroenterology and GI Oncology, Paris, France
| | - Volker Heinemann
- Department of Medical Oncology and Comprehensive Cancer Centre, Klinikum Grosshadern, Ludwig-Maximilian, University of Munich, Munich, Germany
| | - Jens Ricke
- Department of Radiology and Nuclear Medicine, University of Magdeburg, Magdeburg, Germany
| | | | - Michael Findlay
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Andrew Weaver
- Oxford University NHS Foundation Trust, Churchill Hospital, Oxford, UK
| | - Jamie Mills
- Nottingham University Hospitals NHS Trust, Nottingham City Hospital, Nottingham, UK
| | - Charles Wilson
- Cambridge University Hospitals NHS Trust, Addenbrooke's Hospital, Cambridge, UK
| | | | - Anne Francis
- Oncology Clinical Trials Office, Department of Oncology, University of Oxford, Oxford, UK
| | | | - Pradeep S Virdee
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Peter Dutton
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Sharon Love
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Val Gebski
- National Health and Medical Research Council (NHMRC) Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Alastair Gray
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Guy van Hazel
- School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia
| | - Ricky A Sharma
- Cancer Research UK Medical Research Council (CRUK-MRC) Oxford Institute for Radiation Oncology, University of Oxford, Oxford, UK; National Institute for Health Research University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, London, UK.
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