Support Through Remote Observation and Nutrition Guidance (STRONG), a digital health intervention to reduce malnutrition among pancreatic cancer patients: A study protocol for a pilot randomized controlled trial

Background

Malnutrition is a common and distressing condition among pancreatic cancer patients. Fewer than a quarter of pancreatic cancer patients receive medical nutrition therapy (MNT), important for improving nutritional status, weight maintenance, quality of life and survival. System, provider, and patient level barriers limit access to MNT. We propose to examine the feasibility of a 12-week multi-level, digital health intervention designed to expand MNT access among pancreatic cancer patients.

Methods

Individuals with advanced pancreatic cancer starting chemotherapy (N = 80) will be 1:1 randomized to the intervention or usual care. The Support Through Remote Observation and Nutrition Guidance (STRONG) intervention includes system-level (e.g., routine malnutrition and screening), provider-level (e.g., dietitian training and web-based dashboard), and patient-level strategies (e.g., individualized nutrition plan, self-monitoring of dietary intake via Fitbit, ongoing goal monitoring and feedback). Individuals receiving usual care will be referred to dietitians based on their oncologists' discretion. Study assessments will be completed at baseline, 4-, 8-, 12-, and 16-weeks.

Results

Primary outcomes will be feasibility (e.g., recruitment, retention, assessment completion) and acceptability. We will collect additional implementation outcomes, such as intervention adherence, perceived usability, and feedback on intervention quality via an exit interview. We will collect preliminary data on outcomes that may be associated with the intervention including malnutrition, quality of life, treatment outcomes, and survival.

Conclusion

This study will advance our knowledge on the feasibility of a digital health intervention to reduce malnutrition among individuals with advanced pancreatic cancer. Trial registration: NCT05675059, registered on December 9, 2022.

Multi-institutional experience of MR-guided stereotactic body radiation therapy for adrenal gland metastases

Purpose

While dose escalation is associated with improved local control (LC) for adrenal gland metastases (AGMs), the proximity of gastrointestinal (GI) organs-at-risk (OARs) limits the dose that can be safely prescribed via CT-based stereotactic body radiation therapy (SBRT). The advantages of magnetic resonance-guided SBRT (MRgSBRT), including tumor tracking and online plan adaptation, facilitate safe dose escalation.

Methods

This is a multi-institutional review of 57 consecutive patients who received MRgSBRT on a 0.35-T MR linac to 61 AGMs from 2019 to 2021. The Kaplan-Meier method was used to estimate overall survival (OS), progression-free survival (PFS), and LC, and the Cox proportional hazards model was utilized for univariate analysis (UVA).

Results

Median follow up from MRgSBRT was 16.4 months (range [R]: 1.1-39 months). Median age was 67 years (R: 28-84 years). Primary histologies included non-small cell lung cancer (N = 38), renal cell carcinoma (N = 6), and melanoma (N = 5), amongst others. The median maximum diameter was 2.7 cm (R: 0.6-7.6 cm), and most AGMs were left-sided (N = 32). The median dose was 50 Gy (R: 30-60 Gy) in 5-10 fractions with a median BED10 of 100 Gy (R: 48-132 Gy). 45 cases (74 %) required adaptation for at least 1 fraction (median: 4 fractions, R: 0-10). Left-sided AGMs required adaptation in at least 1 fraction more frequently than right-sided AGMs (88 % vs 59 %, p = 0.018). There were 3 cases of reirradiation, including 60 Gy in 10 fractions (N = 1) and 40 Gy in 5 fractions (N = 2). One-year LC, PFS, and OS were 92 %, 52 %, and 78 %, respectively. On UVA, melanoma histology predicted for inferior 1-year LC (80 % vs 93 %, p = 0.012). There were no instances of grade 3+ toxicity.

Conclusions

We demonstrate that MRgSBRT achieves favorable early LC and no grade 3 + toxicity despite prescribing a median BED10 of 100 Gy to targets near GI OARs.

Outcomes of Cytoreductive Stereotactic Body Radiotherapy (SBRT) in Patients with Oligometastatic or Oligoprogressive Dominant Lung Metastases from Colorectal Primary

PURPOSE/OBJECTIVE(S)

Oxaliplatin based systemic therapy regimens have improved the prognosis of patients with colorectal cancer (CRC) and with this, there has been increased interest in the integration of local therapies to oligometastatic and oligoprogressive sites. There is a vast body of literature exploring the benefits of cytoreduction with surgery and stereotactic body radiation therapy (SBRT) approaches. We report our rates of local control (LC) and overall survival (OS) for patients with oligometastatic/progressive CRC with lung metastases treated with SBRT.

MATERIALS/METHODS

Single institution retrospective review of patients diagnosed with oligometastatic or oligoprogressive CRC with dominant metastases to the lungs who were treated with SBRT between September 2009 and December 2022. Oligometastatic disease was defined as newly diagnosed, untreated CRC with up to 5 metastases, up to 3 in one organ. Oligoprogressive disease was defined as CRC with 1 - 2 distant sites that continued to progress on active treatment while the primary site was controlled. Survival was estimated using Kaplan-Meier. Association between local control and patient factors was analyzed using log-rank test.

RESULTS

A total of 84 patients with oligometastatic or oligoprogressive CRC were treated with SBRT to 124 lung lesions. Colon cancer was the primary site for 54 patients with a median age at time of SBRT of 66 years (IQR 57 - 73) and a median tumor diameter of 1.20 cm (IQR 0.93 - 1.90). Rectal cancer was the primary site for 30 patients, median age was 60 years (IQR 49 - 70) and median tumor diameter was 1.10 cm (IQR 0.80 - 1.48). Median dose for the entire cohort was 6000 cGy (range 5000 - 6000) with median number of fractions 5 (range 3 - 5). Median follow-up after SBRT was 24 months. Overall, there were 9 local failures at last follow-up. Almost half (n = 42) of the patients experienced distant recurrence. Median local control (LC) for the entire cohort was not reached, 2-yr LC and 5-yr LC were 94.6% and 85.7% respectively. There were no differences in LC between colon and rectal cancer (p = 0.29). Actuarial median overall survival was 71 months (95% CI 44.3 - 97.7) and 5-yr OS was 50.2%. Due to the small number of events, we were unable to identify patient factors associated with local failure on univariate or multivariate analysis.

CONCLUSION

Cytoreductive SBRT is an effective treatment option for patients with oligometastatic or oligoprogressive CRC with dominant lung metastases offering excellent rates of LC. Most patients failed distantly highlighting the importance of additional systemic therapies.

Adrenal Stereotactic Body Radiation Therapy: Do Dosimetric Factors Predict for Grade 2+ Lymphopenia?

PURPOSE/OBJECTIVE(S)

Recent studies suggest improvement in outcomes in multiple oligometastatic tumor sites with immunotherapy (IO) and radiation therapy (RT). However, RT may induce lymphopenia that can be immunosuppressive and dosimetric consensus is lacking on parameters predicting grade ≥2 lymphopenia. In this study, we evaluated lymphopenia post receipt of stereotactic body RT (SBRT) for adrenal metastases to see if we could identify any modifiable treatment planning factors.

MATERIALS/METHODS

Patients with adrenal oligometastases who were treated with conventional SBRT or MRI-guided (MRgSBRT), had absolute lymphocyte count (ALC) and white blood cell count (WBC) data available within 6 weeks before and after their radiation treatment, and had contouring data available for review were included in this IRB approved retrospective study. Lymphopenia was graded for ALC as: Grade 1 (1.0-0.8 no/ul), Grade 2 (<0.8 - 0.5 no/ul), Grade 3 (<0.5-0.2 no/ul), Grade 4 (<0.2 no/ul). The vertebral bodies (VB), at the level of the planning treatment volume (PTV) and one above and below, and the spleen were contoured. Dosimetric variables of interest included spleen and VB mean dose (Gy) as well as V2.5-20 Gy in 2.5 Gy increments. Regression analyses were used to identify dosimetric variables associated with absolute and relative difference in ALC post-SBRT.

RESULTS

A total of 30 patients were identified with a slight male predominance (N = 17, 57%) and most commonly left adrenal (N = 17) versus right adrenal (N = 10, 33%) or bilateral metastases (N = 3, 10%). Grade 2+ lymphopenia was observed in N = 7 patients pre-SBRT (23%) and N = 17 patients post-SBRT (57%). N = 26 (87%) of the patients had previous chemotherapies and N = 17 (57%) had previous immunotherapy. Multiple primary tumor types were represented with the most common non-small cell lung cancer (N = 14, 47%), followed by melanoma (N = 4, 13%) and small cell lung cancer (N = 3, 10%). Most patients were treated with non-MRgSBRT (N = 19, 63%) vs MRgRT (N = 11, 37%) and all received SBRT in 5 fractions with median dose 50 Gy (Range: 25 - 60 Gy). The median pre-SBRT ALC was 1.13 (Range: 0.39 - 2.96) and median post-SBRT ALC was 0.72 (Range: 0.11 - 4.15). On linear regression analysis, there was no significant association between post SBRT ALC nor lymphopenia grade with splenic or vertebral body dose, treatment laterality, or SBRT dose.

CONCLUSION

In this retrospective series of predominately metastatic lung cancer patients treated with adrenal SBRT, we observed high rates of post SBRT grade 2+ lymphopenia, yet no dosimetric parameter was predictive, not even for left-sided lesions. Future work includes clinical validation of these findings in a larger population, likely with multi-institutional collaboration, and further study of the investigation of the IO/RT sequencing issues in such heavily pre-treated patients.

Borderline Resectable Pancreatic Cancer: Impact on Neoadjuvant Response Post Integration of MRI Guided Adaptive Radiation Therapy

PURPOSE/OBJECTIVE(S)

The optimal neoadjuvant therapy regimen for patients with borderline resectable pancreas cancer (BRPC) remains to be defined, with a recent ALLIANCE study reporting that chemotherapy alone prior to resection is an acceptable standard of care. However, pathologic differences in response between patients receiving chemotherapy alone and chemotherapy with radiation with stereotactic technique is not clear. In this study, we sought to compare differences in pathologic outcomes between patients undergoing surgery in 2018 compared with 2021 at our comprehensive cancer center, after the new data of chemotherapy alone had been reported and after our center integrated stereotactic MRI guided online adaptive radiotherapy (SMART).

MATERIALS/METHODS

Newly diagnosed BRPC patients were included on this IRB approved study if they were treated on our institutional clinical pathway with initial chemotherapy (FOLFIRINOX or Gemcitabine based) followed by 5 fraction stereotactic body radiation therapy (SBRT) with the intention of primary tumor resection. After surgical resection, tumor response was classified by the Tumor Regression Grading (TRG) System of the College of American Pathology on a scale from 0 (complete response) to 3 (poor response).

RESULTS

In 2018 when patients were treated on a conventional Linac, the median SBRT dose was 40.5 Gy compared with 46.1 Gy in 2021 after SMART integration. In 2018, 54 BRPC patients were treated and 52% were explored. Of those, 72% were resected with a 95% (19/20) rate of R0 resection. In 2021, 66 BRPC patients were treated and 45% were explored. Of those, 74% were resected with a 100% (22/22) rate of R0 resection. In 2018, pathological results showed that 55% (11/20) had lymphovascular invasion (LVI) and 90% (18/20) had perineural invasion (PNI) with a median tumor size of 2.5 cm. The average lymph node ratio in 2018 was 0.06 in 2018 and 0.05 in 2021. In 2021, pathological results showed that 36% (8/22) had LVI and 64% (14/22) had PNI with a median tumor size of 2.2 cm. In 2018, 43% of surgeries required portal vein (PV) resection compared with 27% in 2021. In 2018, of those patients who underwent surgery, 65% (13/20) received both chemotherapy and SBRT compared to 10% (2/20) with chemotherapy alone. In 2021, 73% (16/22) received chemotherapy and SBRT prior to surgery compared with 27% (6/22) who received chemotherapy only. Patients who received chemotherapy only (n = 8) had an average TRG of 2.1 compared to the patients receiving combination therapy (29) with an average TRG of 1.8.

CONCLUSION

This data suggests that higher ablative dose delivery with SMART following systemic therapy may be associated with improved pathologic outcomes, with less LVI, PNI, portal vein resection and improved TRG scores. Further prospective study is needed to confirm improved pathologic outcomes with SMART and to optimize patient selection regarding which patients benefit the most from the combination of chemotherapy and SBRT.

Pancreas Cancer Learning Health Network Established to Share Best Practice Across 14 Centers and Improve Patient Outcomes

PURPOSE/OBJECTIVE(S)

Pancreas cancer (PC) survival is among the lowest of all malignancies. Clinical trials have failed to significantly improve outcomes. Individual and institutional biases in care result in significant variation in practice, further hindering progress. Learning health networks (LHNs) prospectively collect real world data across centers and test improvements that can rapidly be expanded across centers if deemed successful. Herein, we report preliminary progress from the Pancreas Cancer Canopy Cancer Collective (PC-CCC), the first oncology LHN, established to improve duration and quality of survival in PC.

MATERIALS/METHODS

In 2019, we established the PC-CCC with six care centers who engaged in a collaborative design process to create a set of improvement aims, change ideas, and outcome measures. Center team members receive training and coaching in collaborative quality improvement methods, applied to local improvement efforts. Eight more centers joined in 2021, and a shared Canopy outcomes database was built and implemented to inform center-specific and network-wide improvement efforts and allow the LHN to undertake research using real-world data. Current improvement efforts are focused on proactively screening new PC patients for: (1) Clinical trials, (2) pancreas enzymes, (3) palliative care needs, and (4) goals of care conversations.

RESULTS

Currently, 14 care centers are active participants in the PC-CCC LHN. Data on a total of 2,002 PC patients are available to date. At presentation to the care center, most patients are female (51%) and have biopsy proven PC (83.9%). Average age is 68 years, and presenting disease status is metastatic (14.5%), resectable (11.4%), locally advanced (10.9%), borderline resectable (8.1%), or not yet staged (40%). For those who received radiation, 75.8% received stereotactic body radiation therapy. Among patients whose chemotherapy regimen was documented, most received 5-fluorouracilbased treatment (52%). Descriptive follow up data (including treatment and outcomes) are being actively updated, to be reported at time of presentation.

CONCLUSION

Creation of a cancer LHN for PC is feasible and has set the stage for improving patient and provider outcomes through iterative community-building, continuous improvement, and sharing of data and multidisciplinary best practices. Additionally, the data obtained from the CCC database can rapidly inform the network how variation in clinical practice across centers can influence outcomes.

Toward Burnout Prevention: Can One Short Virtual Reality Relaxation and Mindfulness Training Session for Staff and Patients Decrease Stress and Improve Subjective Sense of Wellbeing?

PURPOSE/OBJECTIVE(S)

Mental wellness of healthcare workers has deteriorated recently, increasing burnout rates. Cancer patients are also often highly distressed, reporting fear, pain, and fatigue. Relaxation and mindfulness training have been shown to decrease stress and anxiety. Currently, the use of virtual reality (VR) for relaxation and mindfulness for cancer patients and oncology clinical staff is an ongoing area of research. We aimed to test the preliminary efficacy of incorporating an innovative digital therapeutic (DTx) we developed at our center in this population.

MATERIALS/METHODS

Cancer patients and clinic staff from one institution's Gastrointestinal and Radiation Oncology departments participated in the immersive VR-enhanced relaxation and mindfulness experience for this IRB-exempt study. Users completed a pre-VR survey via iPad assessing baseline knowledge and practice of stress reduction techniques, baseline stress, and familiarity with VR. In the VR app deployed on an Oculus Quest 2, users chose a relaxing water scene (e.g., stream, beach) and optional soothing background music. Users could also choose a relaxation or mindfulness training audio track. A post-VR survey assessed whether the experience affected their subjective stress and sense of wellbeing ("Yes" or "No") as well as the feasibility of using the app. A binomial test on a single proportion was used to test whether more participants (>50%) indicated their stress was reduced following the VR training than did not. Post-VR qualitative verbal feedback was also collected to identify future changes to the VR app.

RESULTS

Six patients, a patient's son, and forty-three employees used the VR app. Users were aged ≤ 30 years old (18%), 30-50 years (60%), and 50-70 years (22%). Users completed the VR experience in a median of 14 min (IQR: 11-19 min). In the pre-survey, most (78%) reported they felt stress at this point in their lives. In the post-survey, significantly more than the expected proportion of participants (>50%) reported feeling less stressed after using the VR app (88%, n = 44, p <0.001). Most (90%) reported that the VR app improved their subjective sense of wellbeing. All (100%) users reported it was easy to learn the VR controls. Nearly all (96%) reported they would be interested in using this VR app again, including 30% and 38% who reported they would be "extremely likely" and "very likely," respectively, to use the app again.

CONCLUSION

These findings suggest our VR relaxation and mindfulness training was well accepted and could be integrated into the hospital setting in short sessions. Further work should be done based on participant feedback to expand the offerings of this VR app to offer a wider range of relaxation experiences and gamified psychological interventions that can help de-stress, recharge, and build resiliency.

Anal Carcinoma, Version 2.2023, NCCN Clinical Practice Guidelines in Oncology

This discussion summarizes the NCCN Clinical Practice Guidelines for managing squamous cell anal carcinoma, which represents the most common histologic form of the disease. A multidisciplinary approach including physicians from gastroenterology, medical oncology, surgical oncology, radiation oncology, and radiology is necessary. Primary treatment of perianal cancer and anal canal cancer are similar and include chemoradiation in most cases. Follow-up clinical evaluations are recommended for all patients with anal carcinoma because additional curative-intent treatment is possible. Biopsy-proven evidence of locally recurrent or persistent disease after primary treatment may require surgical treatment. Systemic therapy is generally recommended for extrapelvic metastatic disease. Recent updates to the NCCN Guidelines for Anal Carcinoma include staging classification updates based on the 9th edition of the AJCC Staging System and updates to the systemic therapy recommendations based on new data that better define optimal treatment of patients with metastatic anal carcinoma.

Rectal tumor fragmentation as a response pattern following chemoradiation

Background

Tumor response to neoadjuvant therapy is heterogenous and prognostically important for locally advanced rectal adenocarcinoma (LARC) patients. Commonly applied response classification approaches including tumor regression grading (TRG) and TN downstaging can be discordant. The aim of this study is to compare the prognostic value of discordant tumor response measurement categorized according to the AJCC/CAP TRG schema and ypTN stage.

Methods

This is a single-center retrospective review of 90 consecutive patients with stage II-III rectal cancer receiving neoadjuvant chemoradiation (nCRT), total mesorectal excision (TME) and adjuvant chemotherapy (ACT) between 2007 and 2018. Two pathologists re-examined each case to assign a consensus AJCC TRG. A Cox proportional hazards ratio model assessed the effect of patient, tumor, and treatment factors on disease-free survival (DFS).

Results

Median follow-up after surgery was 46 months (95% CI: 41-50 months). Median age at diagnosis was 55 years (range: 27-80). Most patients were male (58%) and Caucasian (92%) with clinical stage III disease (68%). Seventy-three patients (81%) underwent low anterior resection (LAR), 17 (19%) underwent abdominoperineal resection (APR). The median interval from completion of nCRT to surgery was 62 days (IQR: 56-70 days). The 4-year OS, DFS, and LC was 92.4%, 74.4%, and 90.2%, respectively. In the multivariate analysis, ypTN downstaging was not prognostically significant; however, AJCC TRG score 3 (minimal tumor response to treatment) was strongly predictive for inferior DFS (3-year DFS 79% vs. 25%, P<0.001). Patients with TRG 3 had a significantly higher risk of both local (75% vs. 5%) and distant failure (75% vs. 19%).

Conclusions

Minimal tumor response to neoadjuvant therapy, AJCC TRG 3, irrespective of ypTN downstaging, is a pattern of residual disease that is at highest risk for recurrence. Response categorization discrepancies may be partly explained by alternative patterns of residual disease, including tumor fragmentation, and may be best reflected by TRG. The optimal tumor response categorization method requires further study to best stratify patient risk and management.

Rectal Cancer, Version 2.2022, NCCN Clinical Practice Guidelines in Oncology

This selection from the NCCN Guidelines for Rectal Cancer focuses on management of malignant polyps and resectable nonmetastatic rectal cancer because important updates have been made to these guidelines. These recent updates include redrawing the algorithms for stage II and III disease to reflect new data supporting the increasingly prominent role of total neoadjuvant therapy, expanded recommendations for short-course radiation therapy techniques, and new recommendations for a “watch-and-wait” nonoperative management technique for patients with cancer that shows a complete response to neoadjuvant therapy. The complete version of the NCCN Guidelines for Rectal Cancer, available online at NCCN.org, covers additional topics including risk assessment, pathology and staging, management of metastatic disease, posttreatment surveillance, treatment of recurrent disease, and survivorship.

Unresectable Intrahepatic Cholangiocarcinoma Treated with Radiation Segmentectomy/Lobectomy Using Yttrium 90-labeled Glass Microspheres

Background

There is no curative treatment option for patients with unresectable intrahepatic, cholangiocarcinoma (IHC). The aim of this study was to evaluate the efficacy of; radiation segmentectomy/lobectomy using Y90-labeled glass microspheres in patients with; unresectable IHC.

Methods

This IRB-approved, single-center study included, 16 patients (age: 67 ± 7.7 years) with IHC who received radiation segmentectomy or lobectomy, treatment using Y90-labeled glass microspheres between May 2009 and October 2019. Radiation, segmentectomy/lobectomy was defined as at least 190 Gy dose delivered into treated liver; volume.

Results

The median OS from IHC diagnosis was 22.7 months (95% CI: 13.9-66.1) and from, radioembolization it was 7 months (95% CI: 4.33-54.17). Patients who did not receive, chemotherapy before the radioembolization had significantly longer median OS (26.8 vs. 5.9, months, P = 0.03). Four patients had >20 months survival after radioembolization, including 2, patients with survival of 42 and 54 months. There was no 30-day mortality and no severe, complications.

Conclusion

Radiation segmentectomy/lobectomy is safe with minimal side effects. The median, OS of the study group is modest; however, 4 patients (25%) showed excellent survival. These results suggest a need for a larger study to define the IHC patient group who could, most benefit from this procedure.

Yttrium-90 Radioembolization for Liver-Dominant Metastatic Prostate Cancer: A Case Series

Transarterial radioembolization (TARE) with yttrium-90 glass microspheres is widely used to treat primary and secondary malignancies in the liver. However, the safety and efficacy of TARE in patients with liver-dominant metastatic castration-resistant prostate cancer (mCRPC) is unknown. A proof-of-concept, retrospective analysis of 7 consecutive patients with liver-dominant mCRPC who were treated with TARE was performed. The median overall survival was 27.2, 32.1, and 108.1 months from the time of TARE, the diagnosis of liver metastases, and initial cancer diagnosis, respectively. The median liver progression-free survival was 7.3 months. No grade 3 or higher adverse effects were noted. TARE was found to be a safe and effective tool for treating patients with liver-dominant mCRPC in this limited cohort.

Neoadjuvant rectal score is prognostic for survival: A population-based propensity-matched analysis

INTRODUCTION

Neoadjuvant rectal (NAR) score may serve as a surrogate short-term endpoint for overall survival (OS) in clinical trials. This study aims to test the NAR score using a large, national cancer registry.

METHODS

National Cancer Database patients with clinical stage II/III rectal adenocarcinoma (RAC) treated with neoadjuvant chemoradiation (CRT) followed by surgery were selected and divided into low-, intermediate-, and high-NAR subgroups. OS outcomes were analyzed using Kaplan-Meier and logistic regression models.

RESULTS

A total of 12 452 patients were selected, of which 5071 (40.7%) were in clinical stage II and 7381 (59.3%) were in clinical stage III; 15.2% had pathologic complete response. The mean NAR score was 10.01 ± 10.61. Six thousand nine hundred and forty-one (55.7%) did not receive adjuvant chemotherapy (AC) and were propensity-matched across NAR subgroups (966 in each group). A significant difference in 5-year OS between low-, intermediate-, and high-NAR groups was observed (85% vs. 76% vs. 68%; p < 0.001). Five thousand five hundred and eleven (44.3%) received AC and 1045 triplets were propensity-matched per NAR groups. A significant difference was again observed for 5-year OS (93% vs. 88% vs. 75%; p < 0.001). Logistic regression confirmed NAR strata as a significant predictor of 5-year OS.

CONCLUSION

NAR score, as a neoadjuvant response measure, is a strong predictor of 5-year OS, regardless of AC receipt in a heterogenous population of locally advanced RAC patients.

Pathological and surgical outcomes of pancreatic adenocarcinoma (PA) after pre-operative ablative stereotactic magnetic resonance image-guided adaptive radiotherapy (A-SMART)

Purpose

Preoperative radiation therapy (RT) for pancreatic adenocarcinoma reduces positive surgical margin rates, and when delivered to an ablative dose range it may improve local control and overall survival for patients with unresectable disease. Use of stereotactic body RT to achieve a higher biologically effective dose has been limited by toxicity to adjacent radiosensitive structures, but this can be mitigated by stereotactic magnetic resonance image guided adaptive radiation therapy (SMART).

Methods and Materials

We describe our single-institution experience of high biologically effective dose SMART before resection of localized pancreatic adenocarcinoma. Toxicity was evaluated according to Common Terminology Criteria for Adverse Events (V 5.0). Tumor response was evaluated according to the College of American Pathologists tumor regression grading criteria.

Results

We analyzed 26 patients with borderline resectable (80.8%), locally advanced (11.5%), and resectable (7.7%) tumors who received ablative dose SMART (A-SMART) followed by surgical resection. Median age at diagnosis was 68 years (range, 34-86). Most patients received chemotherapy (80.8%) before RT. All patients received A-SMART to a median dose of 50 (range, 40-50) Gy in 5 fractions. Toxicity data were collected prospectively and there were no acute grade 2+ toxicities associated with RT. The median time to resection was 50 days (range, 37-115), and the procedure types included Whipple (69%), distal (23%), or total pancreatectomy (8%). The R0 resection rate was 96% and no perioperative deaths occurred within 90 days. Pathologic response was observed in 88% of cases. The time from RT to surgery was associated with tumor regression grade (P = .0003). The median follow-up after RT was 16.5 months (range, 3.9-26.2). The derived median progression-free survival from RT was 13.2 months.

Conclusions

The initial surgical and pathologic outcomes after A-SMART are encouraging. Preoperative A-SMART was associated with low toxicity rates and no surgical or RT-associated mortality. The surgical morbidity was comparable to historic rates after upfront resection. These data also suggest that the time from stereotactic body RT to surgical resection is associated with pathologic response.

Phase I Study of Lenvatinib and Capecitabine with External Radiation Therapy in Locally Advanced Rectal Adenocarcinoma

Background

Neoadjuvant chemoradiation with fluoropyrimidine followed by surgery and adjuvant chemotherapy has been the standard treatment of locally advanced stages II and III rectal cancer for many years. There is a high risk for disease recurrence; therefore, optimizing chemoradiation strategies remains an unmet need. Based on a few studies, there is evidence of the synergistic effect of VEGF/PDGFR blockade with radiation.

Methods

In this phase I, dose-escalation and dose-expansion study, we studied 3 different dose levels of lenvatinib in combination with capecitabine-based chemoradiation for locally advanced rectal cancer.

Results

A total of 20 patients were enrolled, and 19 were eligible for assessment of efficacy. The combination was well tolerated, with an MTD of 24 mg lenvatinib. The downstaging rate for the cohort and the pCR was 84.2% and 37.8%, respectively. Blood-based protein biomarkers TSP-2, VEGF-R3, and VEGF correlated with NAR score and were also differentially expressed between response categories. The NAR, or neoadjuvant rectal score, encompasses cT clinical tumor stage, pT pathological tumor stage, and pN pathological nodal stage and provides a continuous variable for evaluating clinical trial outcomes.

Conclusion

The combination of lenvatinib with capecitabine and radiation in locally advanced rectal cancer was found to be safe and tolerable, and potential blood-based biomarkers were identified.

Clinical Trial Registration

NCT02935309

Role of Radioembolization in the Management of Liver-Dominant Metastatic Renal Cell Carcinoma: A Single-Center, Retrospective Study

PURPOSE

The management of Renal cell carcinoma (RCC) patients with liver metastases is challenging. Liver-directed therapy, such as Transarterial radioembolization (TARE), is a reasonable option for these patients; however, its safety and efficacy are not well characterized. This study evaluated the safety and efficacy of TARE in patients with liver-dominant metastatic RCC.

MATERIALS AND METHODS

This is a retrospective, single-center study. Thirty-eight patients' medical records were reviewed who underwent TARE between January 1, 2009, and December 31, 2019, in a tertiary cancer center. Two were excluded from further analysis. Thirty-six patients received 51 TARE treatments. Median follow-up time was 18.2 months. Imaging data were evaluated using mRECIST or RECIST 1.1 criteria. Toxicities, treatment responses, liver progression-free survival (LPFS), and median overall survival (OS) were calculated. Univariate and multivariate analyses were conducted to reveal predictors of OS.

RESULTS

Median OS from TARE was 19.3 months (95% CI, 22.6-47.4) and from diagnosis of liver metastases was 36.5 months (95% CI: 26.4-49.8). Mild, grade 1 or 2, biochemical toxicity developed in 27 patients (75%). Grade 3-4 toxicity was noted in two patients (5.5%). The objective response rate was 89%; the disease control rate was 94% (21 complete response, 11 partial response, two stable disease, and two progressive disease). Univariate and multivariate analyses showed longer survival in patients who had objective response, lower lung shunt fraction, and better baseline liver function.

CONCLUSIONS

TARE is safe and effective and led to promising overall survival in patients with liver-dominant metastatic RCC.

LEVEL OF EVIDENCE

Level 3, retrospective cohort study.

Endoscopic and MRI response evaluation following neoadjuvant treatment for rectal cancer: a pictorial review with matched MRI, endoscopic, and pathologic examples

A nonoperative management strategy, or Watch-and-Wait, following neoadjuvant therapies of locally advanced rectal adenocarcinoma is increasingly considered for select patients. Yet, standardized tumor response assessment to best select and surveil suitable patients remains an unmet clinical challenge. Endoscopic and MRI currently provide the most reliable tumor response estimations. However, resources illustrating variable tumor responses to neoadjuvant therapies remain limited. This pictorial review aims to provide detailed and annotated examples of common endoscopic and MRI findings of rectal cancer treatment response, while also emphasizing their respective diagnostic shortcomings and consequently, the necessity for a multidisciplinary approach to optimally manage these patients.

Gastrointestinal Disease-Specific Survivorship Care: A New Personalized Model Integrating Onco-Wellness

Although the number of gastrointestinal (GI) cancer survivors is projected to increase in the coming years, there are currently no survivorship care models that address the specific and growing needs of this population. Current survivorship care models were evaluated to assess their suitability for GI cancer survivors. A survivorship care model based on foundational wellness principles is under development to address the specific needs of GI cancer survivors. This model delivers a cohesive and collaborative care continuum for survivors of different GI malignancies. Oncology providers in GI departments and internal medicine providers in survivorship programs are positioned to provide a comprehensive approach for the care of patients treated with curative intent. Survivorship care is introduced at the conclusion of active treatment in the form of an Onco-wellness consultation, an in-person or telemedicine comprehensive care plan creation and review by our Survivorship Program. Personalized care plan including long term and late effects of treatment, nutrition, physical activity and rehabilitation recommendations, prevention of secondary malignancies and psychosocial needs are reviewed. As patients transition from active treatment to survivorship within the GI Program, the GI Advance Practice Professionals (APPs) are well-positioned to deliver comprehensive survivorship care specific to the GI patient’s needs while integrating recommendations and principles from the Onco-wellness consultation. With projected shortages of both oncology and primary care physicians, such an APP-based model has the potential to bridge gaps in the survivorship care continuum and mutually benefit patients and physicians.

Management of Long-Term Toxicity From Pelvic Radiation Therapy

Pelvic radiation therapy is an integral component in the treatment of various gastrointestinal, gynecologic, and genitourinary cancers. As survival rates from these malignancies improve, the prevalence of toxicity secondary to pelvic radiation has increased. Gastrointestinal toxicities are the most common complications and greatly impact quality of life. Toxicities can present in acute or late stages; although symptoms may be similar during both, the management may differ. Acute toxicities represent an inflammatory reaction in response to the radiation exposure, whereas late toxicities may arise as a result of small vessel disease, ischemia, and fibrosis. Currently, there are no large clinical trials and only limited guidelines on the management of late gastrointestinal radiation toxicities. Therapy is generally approached in a stepwise manner from medical to endoscopic to surgical methods. Several endoscopic therapies, such as the treatment of radiation proctitis with argon plasma coagulation and dilation of radiation bowel strictures, may prevent the need for surgical intervention, which may be associated with high morbidity and mortality. Given that late toxicities can occur years after radiation therapy, they are often difficult to recognize and diagnose. Successful management of late toxicities requires recognition, an understanding of the underlying pathophysiology, and a multidisciplinary approach. More dedicated research could clarify the prevalence of gastrointestinal pelvic radiation toxicities, permit a better understanding of the efficacy and safety profile of current therapies, and allow for the development of novel therapeutic approaches.

Colon Cancer, Version 2.2021, NCCN Clinical Practice Guidelines in Oncology

This selection from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Colon Cancer focuses on systemic therapy options for the treatment of metastatic colorectal cancer (mCRC), because important updates have recently been made to this section. These updates include recommendations for first-line use of checkpoint inhibitors for mCRC, that is deficient mismatch repair/microsatellite instability-high, recommendations related to the use of biosimilars, and expanded recommendations for biomarker testing. The systemic therapy recommendations now include targeted therapy options for patients with mCRC that is HER2-amplified, or BRAF V600E mutation-positive. Treatment and management of nonmetastatic or resectable/ablatable metastatic disease are discussed in the complete version of the NCCN Guidelines for Colon Cancer available at NCCN.org. Additional topics covered in the complete version include risk assessment, staging, pathology, posttreatment surveillance, and survivorship.

Strategies to Minimize Late Effects From Pelvic Radiotherapy

During the past 30 years, radiation treatment techniques have significantly improved, from conventional external-beam radiation therapy, to three-dimensional conformal radiation therapy, to current intensity-modulated radiation therapy, benefiting patients who undergo treatment of pelvic malignancies. Modern treatment options also include proton beam irradiation as well as low and high dose rate brachytherapy. Although the acute adverse effects of these modalities are well documented in clinical trials, less well known are the true incidence and optimal management of those late adverse effects that can occur months to years later. In a population of survivors of cancer that is steadily increasing, with many such patients receiving radiotherapy at some time during their disease course, these late effects can become a considerable management and quality-of-life issue. This review will examine the range of late toxicities that can occur from pelvic radiotherapy and explore strategies to prevent and mitigate them.

Epidemiology, Diagnosis, Staging and Multimodal Therapy of Esophageal and Gastric Tumors

Gastric and esophageal tumors are diverse neoplasms that involve mucosal and submucosal tissue layers and include squamous cell carcinomas, adenocarcinomas, spindle cell neoplasms, neuroendocrine tumors, marginal B cell lymphomas, along with less common tumors. The worldwide burden of esophageal and gastric malignancies is significant, with esophageal and gastric cancer representing the ninth and fifth most common cancers, respectively. The approach to diagnosis and staging of these lesions is multimodal and includes a combination of gastrointestinal endoscopy, endoscopic ultrasound, and cross-sectional imaging. Likewise, therapy is multidisciplinary and combines therapeutic endoscopy, surgery, radiotherapy, and systemic chemotherapeutic tools. Future directions for diagnosis of esophageal and gastric malignancies are evolving rapidly and will involve advances in endoscopic and endosonographic techniques including tethered capsules, optical coherence tomography, along with targeted cytologic and serological analyses.

Abstract 4293: Final result of lenvatinib and capecitabine in combination with external beam radiation in treatment of locally advanced rectal cancer: Phase I clinical trial

Purpose: Targeting dual/multiple angiogenesis receptor has been shown to augment tumor response. Lenvatinib, a multikinase inhibitor aimed towards FGFR/ PDGFR/ KIT/RET has shown potent antitumor activity in preclinical models. This study aims to understand the effectiveness and safety of lenvatinib and capecitabine combined with radiation in patients with locally advanced rectal cancer (LARC).

Methods: Patients with MRI or endoscopic ultrasound confirmed stage II or stage III rectal cancer were enrolled in 3 cohorts. All cohorts received standard dose 850 mg/m2 PO BID of capecitabine and external beam radiation (180 cGY) on day 1-5 weekly for 5 ½ to 6 weeks. Oral lenvatinib was administered in dose escalation manner in 3 cohorts of 3 patients per dose level (DL), with an expansion cohort at the MTD [cohort 1:14 mg daily; cohort 2: 20 mg daily; cohort 3:24 mg daily]. At the MTD dose, 10 additional patients were added to further evaluate safety and efficacy.

Results: Twenty patients were enrolled and received at least 1 dose of study drug. One patient was deemed not eligible due to having stage IV disease at the time of diagnosis and is only reviewed for toxicity. 3/19 patients had stage II and 16/19 had stage III cancer at time of enrollment. 73.6% (14/19) patients enrolled were male and 26.4% (5/19) were female. The median age was 55 years (42,73). There was no noted dose limited toxicity at maximum tolerated dose (24 mg) of lenvatinib. There were no grade 4 adverse events. The most common grade 3 toxicities were hypertension observed in 15% (3/20) and lymphopenia in 15% (3/20) patients. Other grade 3 toxicities included rectal pain, hyponatremia, lymphopenia, leukocytosis and transaminitis, each noted in 5% (1/20) patients respectively. 19 patients underwent surgery in 6-10 weeks following completion of dual-targeted therapy and radiation. Median time to surgery was 62 days. There were no peri-operative adverse events. 14/19 patients underwent low anterior resection and 5 have had abdominoperineal resection. 7/19 (36.8%) showed complete pathological response (cPR), and downstaging were seen in 73.7% of the patients (14/19). The mean neoadjuvant rectal cancer score (NAR) was 10.4 and median NAR was 8.43.

Conclusion: The combination of lenvatinib and capecitabine plus radiation shows encouraging safety and efficacy results. Larger randomized study is warranted to verify our findings.

Citation Format: Ankita Tandon, Jessica M. Frakes, Rutika Mehta, Sarah Hoffe, Iman Imanirad, Maria E. Martinez Jimenez, Julian Sanchez, Mokenge Malafa, Seth Felder, Sophie Dessureault, Richard D. Kim. Final result of lenvatinib and capecitabine in combination with external beam radiation in treatment of locally advanced rectal cancer: Phase I clinical trial [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 4293.

NCCN Guidelines Insights: Rectal Cancer, Version 6.2020

The NCCN Guidelines for Rectal Cancer provide recommendations for the diagnosis, evaluation, treatment, and follow-up of patients with rectal cancer. These NCCN Guidelines Insights summarize the panel discussion behind recent important updates to the guidelines. These updates include clarifying the definition of rectum and differentiating the rectum from the sigmoid colon; the total neoadjuvant therapy approach for localized rectal cancer; and biomarker-targeted therapy for metastatic colorectal cancer, with a focus on new treatment options for patients with BRAF V600E- or HER2 amplification-positive disease.

Radiotherapy for Hepatocellular Carcinoma in Russia: a Survey-Based Analysis of Current Practice and the Impact of an Educational Workshop on Clinical Expertise

Radiation therapy (RT) is an effective treatment modality for hepatocellular carcinoma (HCC), but globally, it is underutilized. In Russia, practice patterns with regard to liver-directed radiation are unknown. Under the auspices of Russian Society of Clinical Oncology (RUSSCO), our team conducted an IRB-approved contouring workshop for Russian radiation oncologists. Pre- and post-workshop surveys were analyzed to determine baseline clinical experience and patterns of care for liver-directed RT among Russian providers. The effect of the contouring workshop on participants' knowledge was tested using mixed effects model. Forty pre-workshop and 24 post-workshop questionnaires were analyzable with a 100% response rate. Sixty percent of respondents had never evaluated a patient with HCC and only 8% (3 out of 40) reported treating an HCC patient with liver-directed RT. Nonetheless, 73% of respondents were comfortable offering liver-directed RT prior to the workshop. After the workshop, 85% of respondents felt comfortable treating a patient with HCC with liver-directed RT and 50% were comfortable recommending stereotactic body radiation therapy (SBRT). Measures of knowledge pertaining to evaluation of HCC patients and selection for appropriate liver-directed therapies were dramatically improved after the workshop. Liver-directed RT is not commonly used in Russia in the management of patients with HCC, and few centers are equipped for motion management. Our contouring workshop resulted in dramatically improved understanding of the evaluation and management of HCC patients. We recommend starting with a more protracted fractionated RT and building experience through attendance of additional educational activities, participation in multidisciplinary liver tumor boards, and prospective analysis of treatment toxicity and outcomes.

An open-label, single-arm pilot study of EUS-guided brachytherapy with phosphorus-32 microparticles in combination with gemcitabine +/- nab-paclitaxel in unresectable locally advanced pancreatic cancer (OncoPaC-1): Technical details and study protocol

Current treatment options for patients with unresectable locally advanced pancreatic cancer (LAPC) include chemotherapy alone or followed by chemoradiation or stereotactic body radiotherapy. However, the prognosis for these patients remains poor, with a median overall survival <12 months. Therefore, novel treatment options are needed. Currently, there is no brachytherapy device approved for pancreatic cancer treatment. Hereby, we present the protocol of a prospective, multicenter, interventional, open-label, single-arm pilot study (OncoPac-1, Clinicaltrial.gov-NCT03076216) aiming to determine the safety and efficacy of Phosphorus-32 when implanted directly into pancreatic tumors using EUS guidance, for patients with unresectable LAPC undergoing chemotherapy (gemcitabine ± nab-paclitaxel).

Magnetic Resonance Guided Radiotherapy for Rectal Cancer: Expanding Opportunities for Non-Operative Management

Colorectal cancer is the third most common cancer in men and the second most common in women worldwide, and the incidence is increasing among younger patients. 30% of these malignancies arise in the rectum. Patients with rectal cancer have historically been managed with preoperative radiation, followed by radical surgery, and adjuvant chemotherapy, with permanent colostomies in up to 20% of patients. Beginning in the early 2000s, non-operative management (NOM) of rectal cancer emerged as a viable alternative to radical surgery in select patients. Efforts have been ongoing to optimize neoadjuvant therapy for rectal cancer, thereby increasing the number of patients potentially eligible to forgo radical surgery. Magnetic resonance guided radiotherapy (MRgRT) has recently emerged as a treatment modality capable of intensifying preoperative radiation therapy for rectal cancer patients. This technology may also predict which patients will achieve a complete response to preoperative therapy, thereby allowing for more appropriate selection of patients for NOM. The present work seeks to illustrate the potential role MRgRT could play in personalizing rectal cancer treatment thus expanding the role of NOM in rectal cancer.

Endoscopic Ultrasound Placement of Preloaded Fiducial Markers Shortens Procedure Time Compared to Back-Loaded Markers

BACKGROUND & AIMS

Fiducial markers are inert radiopaque gold or carbon markers implanted in or near pancreatic tumor to demarcate areas for image-guided radiation therapy. Endoscopic ultrasound (EUS) pre-loaded fiducial needles (PLNs) have been developed to circumvent technical issues associated with traditional back-loaded fiducials (BLNs). We performed a randomized controlled trial to compare procedure times in patients with pancreatic adenocarcinoma undergoing EUS-guided placement of BLNs vs PLNs.

METHODS

In a prospective study, 44 patients with pancreatic adenocarcinoma referred for fiducial marker placement at 2 tertiary care centers were assigned to groups that received PLNs (n = 22) or BLNs (n = 22); each group had the same proportion of patients with tumors of different locations (head or neck vs body or tail).The procedure was standardized among all endoscopists and placement of a minimum of 3 markers inside the tumor was defined as technical success. The times for procedure and fiducial placement were recorded, total number of fiducial markers used documented, and grade of procedure difficulty ranked by passing the needle or deploying the fiducials. Other recorded variables included tumor characteristics, fluoroscopy use, and the number of fiducials clearly seen by EUS and fluoroscopy. The primary aim was to compare the duration of EUS-guided fiducial insertion of BLNs vs PLNs.

RESULTS

The median placement time was significantly shorter in the PLN group (9 min) than the BLN group (16 min) (P < .001). However, the 44% reduction in time did not reach pre-specified levels (≥60%). Similar results were found after stratifying by tumor location. Deployment of BLNs was easier than deployment of PLNs (P = .03). There was no significant difference between groups in technical success, number of fiducials placed, EUS or fluoroscopic visualization, or adverse events. During simulation computed tomography and image-guided radiation therapy, there was no difference between groups in visualization of fiducials, migration rate, or accuracy of placement.

CONCLUSIONS

In a randomized controlled trial of 44 patients with pancreatic adenocarcinoma, we found EUS-guided placement of PLNs to require less time and produce similar results compared with BLNs. Further refinements in PLN delivery system are needed to increase the ease of deployment. Clinicaltrials.gov no: NCT02332863.