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Hotca A, Sindhu KK, Lehrer EJ, Hartsell WF, Vargas C, Tsai HK, Chang JH, Apisarnthanarax S, Nichols RC, Chhabra AM, Hasan S, Press RH, Lazarev S, Hajj C, Kabarriti R, Rule WG, Simone CB, Choi JI. Reirradiation With Proton Therapy for Recurrent Malignancies of the Esophagus and Gastroesophageal Junction: Results of the Proton Collaborative Group Multi-Institutional Prospective Registry Trial. Adv Radiat Oncol 2024; 9:101459. [PMID: 38596455 PMCID: PMC11002543 DOI: 10.1016/j.adro.2024.101459] [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] [Received: 07/12/2023] [Accepted: 01/21/2024] [Indexed: 04/11/2024] Open
Abstract
Purpose Treatment options for recurrent esophageal cancer (EC) previously treated with radiation therapy (RT) are limited. Reirradiation (reRT) with proton beam therapy (PBT) can offer lower toxicities by limiting doses to surrounding tissues. In this study, we present the first multi-institutional series reporting on toxicities and outcomes after reRT for locoregionally recurrent EC with PBT. Methods and Materials Analysis of the prospective, multicenter, Proton Collaborative Group registry of patients with recurrent EC who had previously received photon-based RT and underwent PBT reRT was performed. Patient/tumor characteristics, treatment details, outcomes, and toxicities were collected. Local control (LC), distant metastasis-free survival (DMFS), and overall survival (OS) were estimated using the Kaplan-Meier method. Event time was determined from reRT start. Results Between 2012 and 2020, 31 patients received reRT via uniform scanning/passive scattering (61.3%) or pencil beam scanning (38.7%) PBT at 7 institutions. Median prior RT, PBT reRT, and cumulative doses were 50.4 Gy (range, 37.5-110.4), 48.6 Gy (relative biological effectiveness) (25.2-72.1), and 99.9 Gy (79.1-182.5), respectively. Of these patients, 12.9% had 2 prior RT courses, and 67.7% received PBT with concurrent chemotherapy. Median follow-up was 7.2 months (0.9-64.7). Post-PBT, there were 16.7% locoregional only, 11.1% distant only, and 16.7% locoregional and distant recurrences. Six-month LC, DMFS, and OS were 80.5%, 83.4%, and 69.1%, respectively. One-year LC, DMFS, and OS were 67.1%, 83.4%, and 27%, respectively. Acute grade ≥3 toxicities occurred in 23% of patients, with 1 acute grade 5 toxicity secondary to esophageal hemorrhage, unclear if related to reRT or disease progression. No grade ≥3 late toxicities were reported. Conclusions In the largest report to date of PBT for reRT in patients with recurrent EC, we observed acceptable acute toxicities and encouraging rates of disease control. However, these findings are limited by the poor prognoses of these patients, who are at high risk of mortality. Further research is needed to better assess the long-term benefits and toxicities of PBT in this specific patient population.
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Affiliation(s)
| | - Kunal K. Sindhu
- Icahn School of Medicine at Mount Sinai, New York, New York
- New York Proton Center, New York, New York
| | - Eric J. Lehrer
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | | | | | - Smith Apisarnthanarax
- University of Washington, Fred Hutchinson Cancer Center Proton Therapy, Seattle, Washington
| | - Romaine C. Nichols
- University of Florida Health Proton Therapy Institute, Jacksonville, Florida
| | - Arpit M. Chhabra
- Icahn School of Medicine at Mount Sinai, New York, New York
- New York Proton Center, New York, New York
| | - Shaakir Hasan
- New York Proton Center, New York, New York
- Montefiore Medical Center, Bronx, New York
| | | | - Stanislav Lazarev
- Icahn School of Medicine at Mount Sinai, New York, New York
- New York Proton Center, New York, New York
| | - Carla Hajj
- New York Proton Center, New York, New York
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Rafi Kabarriti
- New York Proton Center, New York, New York
- Montefiore Medical Center, Bronx, New York
| | | | - Charles B. Simone
- New York Proton Center, New York, New York
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - J. Isabelle Choi
- New York Proton Center, New York, New York
- Memorial Sloan Kettering Cancer Center, New York, New York
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Yanagihara TK, Tepper JE, Moon AM, Barry A, Molla M, Seong J, Torres F, Apisarnthanarax S, Buckstein M, Cardenes H, Chang DT, Feng M, Guha C, Hallemeier CL, Hawkins MA, Hoyer M, Iwata H, Jabbour SK, Kachnic L, Kharofa J, Kim TH, Kirichenko A, Koay EJ, Makishima H, Mases J, Meyer JJ, Munoz-Schuffenegger P, Owen D, Park HC, Saez J, Sanford NN, Scorsetti M, Smith GL, Wo JY, Yoon SM, Lawrence TS, Reig M, Dawson LA. Defining Minimum Treatment Parameters of Ablative Radiation Therapy in Patients With Hepatocellular Carcinoma: An Expert Consensus. Pract Radiat Oncol 2024; 14:134-145. [PMID: 38244026 DOI: 10.1016/j.prro.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 08/29/2023] [Accepted: 08/29/2023] [Indexed: 01/22/2024]
Abstract
PURPOSE External beam radiation therapy (EBRT) is a highly effective treatment in select patients with hepatocellular carcinoma (HCC). However, the Barcelona Clinic Liver Cancer system does not recommend the use of EBRT in HCC due to a lack of sufficient evidence and intends to perform an individual patient level meta-analysis of ablative EBRT in this population. However, there are many types of EBRT described in the literature with no formal definition of what constitutes "ablative." Thus, we convened a group of international experts to provide consensus on the parameters that define ablative EBRT in HCC. METHODS AND MATERIALS Fundamental parameters related to dose, fractionation, radiobiology, target identification, and delivery technique were identified by a steering committee to generate 7 Key Criteria (KC) that would define ablative EBRT for HCC. Using a modified Delphi (mDelphi) method, experts in the use of EBRT in the treatment of HCC were surveyed. Respondents were given 30 days to respond in round 1 of the mDelphi and 14 days to respond in round 2. A threshold of ≥70% was used to define consensus for answers to each KC. RESULTS Of 40 invitations extended, 35 (88%) returned responses. In the first round, 3 of 7 KC reached consensus. In the second round, 100% returned responses and consensus was reached in 3 of the remaining 4 KC. The distribution of answers for one KC, which queried the a/b ratio of HCC, was such that consensus was not achieved. Based on this analysis, ablative EBRT for HCC was defined as a BED10 ≥80 Gy with daily imaging and multiphasic contrast used for target delineation. Treatment breaks (eg, for adaptive EBRT) are allowed, but the total treatment time should be ≤6 weeks. Equivalent dose when treating with protons should use a conversion factor of 1.1, but there is no single conversion factor for carbon ions. CONCLUSIONS Using a mDelphi method assessing expert opinion, we provide the first consensus definition of ablative EBRT for HCC. Empirical data are required to define the a/b of HCC.
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Affiliation(s)
- Ted K Yanagihara
- Ablative Radiotherapy Modified Delphi Steering Committee; Department of Radiation Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina.
| | - Joel E Tepper
- Ablative Radiotherapy Modified Delphi Steering Committee; Department of Radiation Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Andrew M Moon
- Ablative Radiotherapy Modified Delphi Steering Committee; Division of Gastroenterology and Hepatology, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Aisling Barry
- Ablative Radiotherapy Modified Delphi Steering Committee; Department of Radiation Oncology, Cork University Hospital, Cork, Ireland
| | - Meritxell Molla
- Ablative Radiotherapy Modified Delphi Steering Committee; Radiation Oncology Department, Hospital Clínic Barcelona, Barcelona, Spain
| | - Jinsil Seong
- Ablative Radiotherapy Modified Delphi Steering Committee; Department of Radiation Oncology, Yonsei University Medical College, Seoul, Republic of Korea
| | - Ferran Torres
- Ablative Radiotherapy Modified Delphi Steering Committee; Biostatistics Unit, Medical School, Universitat Auntònoma de Barcelona, Barcelona, Spain
| | | | - Michael Buckstein
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Higinia Cardenes
- Department of Radiation Oncology, Weill Cornell Medicine, New York, New York
| | - Daniel T Chang
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Mary Feng
- Department of Radiation Oncology, University of California, San Francisco, California
| | - Chandan Guha
- Department of Radiation Oncology, Montefiore Hospital, New York, New York
| | | | - Maria A Hawkins
- Department of Radiation Oncology, University College London, London, England
| | - Morten Hoyer
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Hiromitsu Iwata
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya, Japan
| | - Salma K Jabbour
- Department of Radiation Oncology, Robert Wood Johnson Medical School, Rutgers Cancer Institute, New Brunswick, New Jersey
| | - Lisa Kachnic
- Department of Radiation Oncology, Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York
| | - Jordan Kharofa
- Department of Radiation Oncology, University of Cincinnati Cancer Center, Cincinnati, Ohio
| | - Tae Hyun Kim
- Department of Radiation Oncology, Proton Therapy Center, National Cancer Center, Seoul, Republic of Korea
| | - Alexander Kirichenko
- Department of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, Pennsylvania
| | - Eugene J Koay
- Department of GI Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hirokazu Makishima
- Department of Radiation Oncology, Proton Medical Research Center, University of Tsukuba, Tsukuba, Japan
| | - Joel Mases
- Radiation Oncology Department, Hospital Clínic Barcelona, Barcelona, Spain
| | - Jeffrey J Meyer
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Dawn Owen
- Department of Radiation Oncology, Mayo College of Medicine, Rochester, Minnesota
| | - Hee Chul Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jordi Saez
- Radiation Oncology Department, Hospital Clínic Barcelona, Barcelona, Spain
| | - Nina N Sanford
- Department of Radiation Oncology, University of Texas, Southwestern, Dallas, Texas
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Milan, Italy
| | - Grace L Smith
- Department of GI Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Sang Min Yoon
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Theodore S Lawrence
- Ablative Radiotherapy Modified Delphi Steering Committee; Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Maria Reig
- Ablative Radiotherapy Modified Delphi Steering Committee; Radiation Oncology Department, Hospital Clínic Barcelona, Barcelona, Spain; Liver Cancer Unit, Barcelona Clinic Liver Cancer Group, Barcelona University, Barcelona, Spain.
| | - Laura A Dawson
- Ablative Radiotherapy Modified Delphi Steering Committee; Department of Radiation Oncology, Radiation Medicine Program/University Health Network, University of Toronto, Toronto, Canada
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Alexander NA, Schaub SK, Goff PH, Hippe DS, Park SY, Lachance K, Bierma M, Liao JJ, Apisarnthanarax S, Bhatia S, Tseng YD, Nghiem PT, Parvathaneni U. Increased risk of recurrence and disease-specific death following delayed postoperative radiation for Merkel cell carcinoma. J Am Acad Dermatol 2024; 90:261-268. [PMID: 37778663 DOI: 10.1016/j.jaad.2023.07.1047] [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: 01/13/2023] [Revised: 06/09/2023] [Accepted: 07/27/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Merkel cell carcinoma (MCC) is often treated with surgery and postoperative radiation therapy (PORT). The optimal time to initiate PORT (Time-to-PORT [ttPORT]) is unknown. PURPOSE We assessed if delays in ttPORT were associated with inferior outcomes. METHODS Competing risk regression was used to evaluate associations between ttPORT and locoregional recurrence (LRR) for patients with stage I/II MCC in a prospective registry and adjust for covariates. Distant metastasis and death were competing risks. RESULTS The cohort included 124 patients with median ttPORT of 41 days (range: 8-125 days). Median follow-up was 55 months. 17 (14%) patients experienced a LRR, 14 (82%) of which arose outside the radiation field. LRR at 5 years was increased for ttPORT >8 weeks vs ≤ 8 weeks, 28.0% vs 9.2%, P = .006. There was an increase in the cumulative incidence of MCC-specific death with increasing ttPORT (HR = 1.14 per 1-week increase, P = .016). LIMITATIONS The relatively low number of LRRs limited the extent of our multivariable analyses. CONCLUSIONS Delay of PORT was associated with increased LRR, usually beyond the radiation field. This is consistent with the tendency of MCC to spread quickly via lymphatics. Initiation of PORT within 8 weeks was associated with improved locoregional control and MCC-specific survival.
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Affiliation(s)
- Nora A Alexander
- Department of Dermatology, University of Washington, Seattle, Washington; Division of Dermatology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Stephanie K Schaub
- Department of Radiation Oncology, University of Washington, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington.
| | - Peter H Goff
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Daniel S Hippe
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Song Y Park
- Department of Dermatology, University of Washington, Seattle, Washington
| | - Kristina Lachance
- Department of Dermatology, University of Washington, Seattle, Washington
| | - Marika Bierma
- Department of Dermatology, University of Washington, Seattle, Washington
| | - Jay J Liao
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | | | - Shailender Bhatia
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington
| | - Yolanda D Tseng
- Department of Radiation Oncology, University of Washington, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Paul T Nghiem
- Department of Dermatology, University of Washington, Seattle, Washington
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Bierma MM, Goff PH, Hippe DS, Lachance K, Schaub SK, Wallner K, Tseng YD, Liao JJ, Apisarnthanarax S, Nghiem P, Parvathaneni U. Postoperative Radiation Therapy Is Indicated for "Low-Risk" Pathologic Stage I Merkel Cell Carcinoma of the Head and Neck Region but Not for Other Locations. Adv Radiat Oncol 2024; 9:101364. [PMID: 38189056 PMCID: PMC10767274 DOI: 10.1016/j.adro.2023.101364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 08/17/2023] [Indexed: 01/09/2024] Open
Abstract
Purpose The role of postoperative radiation therapy (PORT) in early stage Merkel cell carcinoma (MCC) is controversial. We analyzed the role of PORT in preventing local recurrences (LR) among patients with low-risk, pathologic stage I MCC based on the location of the primary tumors: head/neck (HN) versus non-HN sites. Methods and Materials One hundred forty-seven patients with MCC were identified that had "low risk" disease (pathologic T1 primary tumor, negative microscopic margins, negative pathologic node status, no immunosuppression or prior systemic therapy). LR was defined as tumor recurrence within 2 cm of the primary surgical bed, and its frequency was estimated with the cumulative incidence method. Results Seventy-nine patients received PORT (30 HN, 49 non-HN) with a median dose of 50 Gy (range, 8-64 Gy) and 68 patients were treated with surgery alone (30 HN, 38 non-HN). Overall, PORT was associated with a decreased risk of LR (5-year rate: 0% vs 9.5%; P = .004) with 6 LRs observed in the surgery alone group. Although the addition of PORT significantly reduced LR rates among patients with HN MCC (0% vs. 21%; P = .034), no LRs were observed in patients with non-HN MCC managed with surgery alone. There was no significant difference in MCC-specific survival comparing HN versus non-HN groups, with or without PORT. Conclusions For low-risk, pathologic stage I MCC of the extremities and trunk, excellent local control rates were achieved with surgery, and PORT is not indicated. However, PORT was associated with a significant reduction in LRs among low-risk MCC of the HN.
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Affiliation(s)
- Marika M. Bierma
- Department of Dermatology, University of Washington, Seattle, Washington
| | - Peter H. Goff
- Department of Dermatology, University of Washington, Seattle, Washington
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Daniel S. Hippe
- Fred Hutchinson Cancer Center, Biostatistics, Seattle, Washington
| | - Kristina Lachance
- Department of Dermatology, University of Washington, Seattle, Washington
| | - Stephanie K. Schaub
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Kent Wallner
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Yolanda D. Tseng
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Jay J. Liao
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | | | - Paul Nghiem
- Department of Dermatology, University of Washington, Seattle, Washington
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Anderson AC, Menon M, Cohen SA, Hannan L, Safyan R, Chiorean EG, Schouten J, Apisarnthanarax S, Kim EY. Clinical Outcomes and Immunotoxicity in People with HIV (PWH) after Definitive Chemoradiation (CRT) for Anal Squamous Cell Carcinoma. Int J Radiat Oncol Biol Phys 2023; 117:e282-e283. [PMID: 37785053 DOI: 10.1016/j.ijrobp.2023.06.1266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Anal cancer disproportionately affects PWH despite antiretroviral therapy. Data on CRT outcomes are limited. Modern IMRT CRT decreases acute toxicity but may exacerbate immune dysregulation from chronic HIV. Although historical CRT has been associated with prolonged CD4 count suppression, little is known about late immunotoxicity in PWH after contemporary CRT. We report clinical outcomes and long term immunotoxicity. MATERIALS/METHODS Single-center retrospective review of all PWH confirmed on chart review with anal squamous cell carcinoma without prior pelvic irradiation treated with definitive IMRT CRT. Patient and CRT factors including HIV suppression (<200 copies/mL), mean CD4 count (cells/µL), and receipt of capecitabine (C) or 5-fluorouracil (F) +/- mitomycin (M) were summarized with n (%) or median (interquartile range). Progression-free and overall survival (PFS; OS) were estimated per Kaplan-Meier with 95% confidence intervals and compared with log-rank tests. Mean CD4 count and CD4:CD8 were compared by HIV suppression status (Welch's t-test); longitudinal changes in median CD4 count and CD4:CD8 were compared between baseline vs. nadir (within 6 months of CRT start) and 1-year follow-up for patients with complete data (Wilcoxon signed-rank test). RESULTS A total of 23 PWH were treated between 2010-2022, median age 52, median 16 (13 - 19) years after HIV diagnosis; 4 had unsuppressed HIV; AJCC 8th stage I/II/III/IV 5/5/12/1. Radiation dose was median 54 Gy in 30 fractions over 42 (40 - 44) days. Most had C+M (57%); only 43% had 2×M with either C or F. One had neoadjuvant carboplatin/paclitaxel/pembrolizumab. With 2.9 (1.03 - 3.3) years follow-up, median OS was 6.6 (6.2 - unreached [UR]) years. With 2.2 (0.67 - 2.7) years follow-up, median PFS was UR. OS and PFS were similar regardless of HIV suppression status (both P ≥ 0.09). Overall baseline CD4 count was 458 (226 - 484), and CD4:CD8 was 0.54 (0.2 - 0.7). Nadir CD4 was 100 (59 - 126) and CD4:CD8 was 0.3 (0.2 - 0.4). Baseline and nadir CD4 count and CD4:CD8 were lower if HIV-unsuppressed (each P ≤ 0.04). One year after CRT, CD4 count was 252 (102 - 276), while CD4:CD8 was 0.5 (0.2 - 0.7). For 7 patients with repeated values the change in median from baseline to nadir, 6-, and 12-months post-CRT was -282, -549 (both P = 0.02), -480 (P = 0.9) for CD4 counts, and -0.7, -0.5, -0.4 (each P > 0.5) for CD4:CD8 ratios; none had unsuppressed HIV. CONCLUSION Definitive IMRT CRT with guideline-concordant doublet chemotherapy for anal cancer in PWH is effective despite unsuppressed HIV. Treatment leads to prolonged immunological changes that may increase the risk of HIV-related morbidity and mortality. Modifiable treatment-related causes of hematoimmunologic toxicity should be investigated further, and immune surveillance after CRT should be considered to better understand impact on quality of life.
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Affiliation(s)
- A C Anderson
- Department of Radiation Oncology, University of Washington/ Fred Hutchinson Cancer Center, Seattle, WA
| | - M Menon
- Division of Hematology, Department of Medicine, University of Washington/ Fred Hutchinson Cancer Center, Seattle, WA
| | - S A Cohen
- Division of Oncology, Department of Medicine, University of Washington/ Fred Hutchinson Cancer Center, Seattle, WA
| | - L Hannan
- Division of Oncology, Department of Medicine, University of Washington/ Fred Hutchinson Cancer Center, Seattle, WA
| | - R Safyan
- Division of Oncology, Department of Medicine, University of Washington/ Fred Hutchinson Cancer Center, Seattle, WA
| | - E G Chiorean
- Division of Oncology, Department of Medicine, University of Washington/ Fred Hutchinson Cancer Center, Seattle, WA
| | - J Schouten
- Division of Allergy & Infectious Diseases, Department of Medicine, University of Washington/ Fred Hutchinson Cancer Center, Seattle, WA
| | - S Apisarnthanarax
- Department of Radiation Oncology, University of Washington/ Fred Hutchinson Cancer Center, Seattle, WA
| | - E Y Kim
- Department of Radiation Oncology, University of Washington/ Fred Hutchinson Cancer Center, Seattle, WA
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6
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Zaki P, Apisarnthanarax S, Bowen SR, Grassberger C, Tsai J, Nguyen MH, Ibrahim P, Nyflot M. Liver Regeneration Following Radiation Therapy in Hepatocellular Carcinoma Patients: Insights from Functional Liver Imaging. Int J Radiat Oncol Biol Phys 2023; 117:e743. [PMID: 37786157 DOI: 10.1016/j.ijrobp.2023.06.2279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) A critical need for hepatocellular carcinoma (HCC) patients is understanding how the liver recovers following radiation therapy (RT). While liver regeneration after hepatic resection has been well-studied, liver recovery following RT is less understood. We have previously studied 99mTc-sulphur colloid (SC) single photon emission tomography (SPECT)/CT to spatially and quantitatively analyze liver function. The purpose of this study was to assess both volumetric and functional liver changes following RT. MATERIALS/METHODS Patients with HCC had liver function assessed with SC SPECT/CT before and after definitive RT. Patients received 30-67.5 Gy in 4-15 fractions. Anatomic and functional liver metrics were assessed before and after treatment. The anatomic liver volume (ALV) was drawn on CT imaging. Liver function was measured as the functional volume encompassing 30% of maximum uptake (FLV) and mean liver-to-spleen uptake ratio (L/S). Changes in liver size and function were compared to clinical characteristics, including Child-Pugh (CP) score. Parametric t-tests were used to analyze the data. RESULTS Of 23 evaluable patients (proton RT, n = 16 or photon RT, n = 7), 15 patients had CP-A5/6, 7 had CP-B7/8, and 1 had CP-C10 scores. The mean interval of SC SPECT was 67 days following RT (range, 44 to 113 days). The mean PTV was 272 cc (range 22-802 cc). Regarding baseline liver status, mean pre-treatment ALV was 1584 cc (range 810-2749 cc) with no significant difference in ALV between CP-A and B/C patients (p = 0.285). Pre-treatment mean liver function as assessed with L/S was 1.06 ± 0.43 with significantly greater function in CP-A compared to CP-B/C patients (1.27 vs 0.66, respectively, p<0.001). Mean pre-treatment FLV was 1351 ± 430.8 cc with no significant difference in FLV between CP-A and B/C patients (1422 ± 441 cc vs 1220 ± 436 cc, respectively, p = 0.31). When evaluating change following RT, the mean change in ALV was 0.9% (range, -29% to 23%) with no significant difference between CP-A and CP-B/C patients (-1.5% vs 5.4%, respectively, p = 0.19). In contrast, change in liver function following RT was larger; mean change in FLV was -20% (range, -55% to 33%) and mean change in L/S was -16% (range, -66% to 105%). While change in FLV was not significantly different between CP-A and CP-B/C patients, CP-B/C patients had significantly greater decline in mean liver function (L/S) than CP-A patients (-40 ± 18% vs -3.6 ± 36%, respectively, p = 0.018). There was no association between change in liver volume and change in L/S, p = 0.543. CONCLUSION Functional liver imaging metrics reveal different information about the potential functional reserve of irradiated livers compared to anatomic measurements. These data imply that functional liver imaging may more accurately assess the regenerative potential of irradiated and non-irradiated volumes of liver, which may be useful in clinical scenarios where assessment of the function of future liver remnants become critical.
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Affiliation(s)
- P Zaki
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - S Apisarnthanarax
- Department of Radiation Oncology, University of Washington/ Fred Hutchinson Cancer Center, Seattle, WA
| | - S R Bowen
- University of Washington, Department of Radiation Oncology & Radiology, Seattle, WA
| | - C Grassberger
- Department of Radiation Oncology, University of Washington/ Fred Hutchinson Cancer Center, Seattle, WA
| | - J Tsai
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - M H Nguyen
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - P Ibrahim
- University of Detroit Mercy, Detroit, MI
| | - M Nyflot
- University of Washington, Department of Radiation Oncology & Radiology, Seattle, WA
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7
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Goff PH, Huynh ET, Lachance K, Harikrishnan N, Cook M, Schaub SK, Tseng YD, Liao JJ, Apisarnthanarax S, Wallner K, Nghiem P, Parvathaneni U. Efficacy of Single-Fraction Postoperative Radiotherapy in Resected, Early-Stage Merkel Cell Carcinoma with High-Risk Features. Int J Radiat Oncol Biol Phys 2023; 117:e298. [PMID: 37785091 DOI: 10.1016/j.ijrobp.2023.06.2310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Merkel cell carcinoma (MCC) is an aggressive skin cancer with a high recurrence risk. Postoperative radiotherapy (PORT) improves the local recurrence rate (LRR) in early-stage MCC with risk factors per NCCN guidelines: primary tumor size > 1cm, head/neck (HN) location, immunosuppression, lymphovascular invasion (LVI), and positive/narrow surgical margins. Conventionally fractionated PORT (C-PORT, ∼50 Gy in 25 fractions) is often recommended for localized MCC with these risk factors; however, some institutions elect observation. Prior studies suggest LRR of ∼20% for stage I/II MCC with high-risk features managed with surgery alone. C-PORT significantly decreases LRR but may cause significant morbidity and financial toxicity. We have previously reported that single fraction (SF)-PORT with 8 Gy achieves high rates of in-field control both in the metastatic and adjuvant settings with minimal morbidity. Here, we present updated long-term outcomes of SF-PORT, offered as an alternative to C-PORT with the hypothesis that it improves LRR relative to observation while minimizing toxicity, for resected stage I/II MCC. MATERIALS/METHODS A retrospective, single-institution analysis was completed for stage I/II MCC patients receiving SF-PORT following surgical management. The primary objective was estimating the LRR, defined as recurrence within 2 cm of the primary tumor. Patients with resected, stage I/II MCC with at least one high-risk feature were offered C-PORT as standard of care or SF-PORT as an alternative. RESULTS Forty-six patients (median age: 74.5; range 50-96 years) received SF-PORT to the primary tumor site at a median 44 days after wide local excision (85%), shave/excisional biopsy (13%), or Mohs (2%). Fifty-four percent of patients had 1 high-risk feature, 35% had 2, and 11% had 3 or more. HN (74%) was the most common primary site, 26% of tumors were > 1cm, 26% were LVI+, and 15% of patients were immunosuppressed (pathological margin status was often not available). There were no local recurrences (LRR = 0%) at a median follow-up time of 2.3 years. In-field locoregional control was 96% (44/46 patients) with 2 in-field, regional recurrences observed in draining nodal basins of HN primary lesions. There were 2 out-of-field regional nodal recurrences (1 patient with IMS; neither received elective nodal SFRT). Of 9 patients who received elective nodal SF-PORT, 8 did not have a successful sentinel lymph node biopsy. No MCC-specific deaths were observed. The most common side effect was in-field, grade 1 erythema (13%); no side effects > grade 1 (CTCAE v5) were noted. CONCLUSION SF-PORT is associated with a very low LRR which has proven durable with long-term follow-up. The LRR for SF-PORT appears lower than historical controls treated with surgery alone for patients with resected, stage I/II MCC with high-risk features.
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Affiliation(s)
- P H Goff
- Department of Radiation Oncology, University of Washington / Fred Hutchinson Cancer Center, Seattle, WA
| | - E T Huynh
- University of Washington, Division of Dermatology, Seattle, WA
| | - K Lachance
- University of Washington, Division of Dermatology, Seattle, WA
| | - N Harikrishnan
- University of Washington, Division of Dermatology, Seattle, WA
| | - M Cook
- University of Washington, Division of Dermatology, Seattle, WA
| | - S K Schaub
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Y D Tseng
- Department of Radiation Oncology, University of Washington/ Fred Hutchinson Cancer Center, Seattle, WA
| | - J J Liao
- Department of Radiation Oncology, University of Washington - Fred Hutchinson Cancer Center, Seattle, WA
| | - S Apisarnthanarax
- Department of Radiation Oncology, University of Washington/ Fred Hutchinson Cancer Center, Seattle, WA
| | - K Wallner
- University of Washington, Seattle, WA
| | - P Nghiem
- University of Washington, Division of Dermatology, Seattle, WA
| | - U Parvathaneni
- Department of Radiation Oncology, University of Washington/ Fred Hutchinson Cancer Center, Seattle, WA
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8
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Eckstein J, Choi JI, Lozano A, Ohri N, Press R, Hasan S, Kabarriti R, Chang J, Urbanic J, Durci M, Mohammed N, Stevens C, Tsai H, Apisarnthanarax S, Regine W, Vargas C, Nichols R, Herman J, Simone CB, Chhabra A. Proton Therapy for Unresectable and Medically Inoperable Locally Advanced Pancreatic Cancer: Results From a Multi-Institutional Prospective Registry. Adv Radiat Oncol 2023; 8:101250. [PMID: 37408677 PMCID: PMC10318270 DOI: 10.1016/j.adro.2023.101250] [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] [Received: 11/22/2022] [Accepted: 04/11/2023] [Indexed: 07/07/2023] Open
Abstract
Purpose Compared with photon-based techniques, proton beam radiation therapy (PBT) may improve the therapeutic ratio of radiation therapy (RT) for locally advanced pancreatic cancer (LAPC), but available data have been limited to single-institutional experiences. This study examined the toxicity, survival, and disease control rates among patients enrolled in a multi-institutional prospective registry study and treated with PBT for LAPC. Methods and Materials Between March 2013 and November 2019, 19 patients with inoperable disease across 7 institutions underwent PBT with definitive intent for LAPC. Patients received a median radiation dose/fractionation of 54 Gy/30 fractions (range, 50.4-60.0 Gy/19-33 fractions). Most received prior (68.4%) or concurrent (78.9%) chemotherapy. Patients were assessed prospectively for toxicities using National Cancer Institute Common Terminology Criteria for Adverse Events, version 4.0. Kaplan-Meier analysis was used to analyze overall survival, locoregional recurrence-free survival, time to locoregional recurrence, distant metastasis-free survival, and time to new progression or metastasis for the adenocarcinoma cohort (17 patients). Results No patients experienced grade ≥3 acute or chronic treatment-related adverse events. Grade 1 and 2 adverse events occurred in 78.7% and 21.3% of patients, respectively. Median overall survival, locoregional recurrence-free survival, distant metastasis-free survival, and time to new progression or metastasis were 14.6, 11.0, 11.0, and 13.9 months, respectively. Freedom from locoregional recurrence at 2 years was 81.7%. All patients completed treatment with one requiring a RT break for stent placement. Conclusions Proton beam RT for LAPC offered excellent tolerability while still maintaining disease control and survival rates comparable with dose-escalated photon-based RT. These findings are consistent with the known physical and dosimetric advantages offered by proton therapy, but the conclusions are limited owing to the patient sample size. Further clinical studies incorporating dose-escalated PBT are warranted to evaluate whether these dosimetric advantages translate into clinically meaningful benefits.
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Affiliation(s)
- Jacob Eckstein
- Northwell Health, Department of Radiation Medicine, New Hyde Park, New York
| | | | | | - Nitin Ohri
- Montefiore Einstein Cancer Center, Department of Radiation Oncology, Bronx, New York
| | | | | | - Rafi Kabarriti
- Montefiore Einstein Cancer Center, Department of Radiation Oncology, Bronx, New York
| | - John Chang
- Oklahoma Proton Center, Oklahoma City, Oklahoma
| | - James Urbanic
- University of California, Department of Radiation Medicine and Applied Sciences, San Diego, California
| | - Michael Durci
- Willis Knighton Cancer Center, Shreveport, Louisiana
| | | | - Craig Stevens
- Oakland University William Beaumont School of Medicine, Department of Radiation Oncology, Royal Oak, Michigan
| | - Henry Tsai
- Princeton Radiation Oncology, Somerset, New Jersey
| | - Smith Apisarnthanarax
- University of Washington Medicine, Department of Radiation Oncology, Seattle, Washington
| | - William Regine
- University of Maryland School of Medicine, Department of Radiation Oncology, Baltimore, Maryland
| | - Carlos Vargas
- Mayo Clinic, Department of Radiation Oncology, Rochester, Minnesota
| | - Romaine Nichols
- University of Florida Protons, Department of Radiation Oncology, Gainesville, Florida
| | - Joseph Herman
- Northwell Health, Department of Radiation Medicine, New Hyde Park, New York
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9
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Grassberger C, King G, Apisarnthanarax S. Combining immunotherapy and radiotherapy in hepatocellular carcinoma: the importance of irradiated tumor burden and the possible role of a low dose radiotherapy induction strategy. Transl Cancer Res 2023; 12:701-704. [PMID: 37180671 PMCID: PMC10174792 DOI: 10.21037/tcr-23-192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 03/16/2023] [Indexed: 05/16/2023]
Affiliation(s)
- Clemens Grassberger
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Gentry King
- Fred Hutchinson Cancer Research Center, University of Washington School of Medicine, Seattle, WA, USA
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10
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Zaki P, Chuong MD, Schaub SK, Lo SS, Ibrahim M, Apisarnthanarax S. Proton Beam Therapy and Photon-Based Magnetic Resonance Image-Guided Radiation Therapy: The Next Frontiers of Radiation Therapy for Hepatocellular Carcinoma. Technol Cancer Res Treat 2023; 22:15330338231206335. [PMID: 37908130 PMCID: PMC10621304 DOI: 10.1177/15330338231206335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 08/21/2023] [Accepted: 09/21/2023] [Indexed: 11/02/2023] Open
Abstract
External beam radiation therapy (EBRT) has increasingly been utilized in the treatment of hepatocellular carcinoma (HCC) due to technological advances with positive clinical outcomes. Innovations in EBRT include improved image guidance, motion management, treatment planning, and highly conformal techniques such as intensity-modulated radiation therapy (IMRT) and stereotactic body radiation therapy (SBRT). Moreover, proton beam therapy (PBT) and magnetic resonance image-guided radiation therapy (MRgRT) have expanded the capabilities of EBRT. PBT offers the advantage of minimizing low- and moderate-dose radiation to the surrounding normal tissue, thereby preserving uninvolved liver and allowing for dose escalation. MRgRT provides the advantage of improved soft tissue delineation compared to computerized tomography (CT) guidance. Additionally, MRgRT with online adaptive therapy is particularly useful for addressing motion not otherwise managed and reducing high-dose radiation to the normal tissue such as the stomach and bowel. PBT and online adaptive MRgRT are emerging technological advancements in EBRT that may provide a significant clinical benefit for patients with HCC.
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Affiliation(s)
- Peter Zaki
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Michael D. Chuong
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL, USA
| | - Stephanie K. Schaub
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Simon S. Lo
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Mariam Ibrahim
- School of Medicine, St. George's University, St. George's, Grenada
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11
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Akaike T, Cahill K, Akaike G, Huynh ET, Hippe DS, Shinohara MM, Liao J, Apisarnthanarax S, Parvathaneni U, Hall E, Bhatia S, Cheng RK, Nghiem P, Tseng YD. Management and Prognosis of Cardiac Metastatic Merkel Cell Carcinoma: A Case-Control Study and Literature Review. Cancers (Basel) 2022; 14:cancers14235914. [PMID: 36497395 PMCID: PMC9741306 DOI: 10.3390/cancers14235914] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/18/2022] [Accepted: 11/23/2022] [Indexed: 12/03/2022] Open
Abstract
Merkel cell carcinoma (MCC), an aggressive neuroendocrine skin cancer, has a high rate (20%) of distant metastasis. Within a prospective registry of 582 patients with metastatic MCC (mMCC) diagnosed between 2003-2021, we identified 9 (1.5%) patients who developed cardiac metastatic MCC (mMCC). We compared overall survival (OS) between patients with cardiac and non-cardiac metastases in a matched case-control study. Cardiac metastasis was a late event (median 925 days from initial MCC diagnosis). The right heart was predominantly involved (8 of 9; 89%). Among 7 patients treated with immunotherapy, 6 achieved a complete or partial response of the cardiac lesion. Among these 6 responders, 5 received concurrent cardiac radiotherapy (median 20 Gray) with immunotherapy; 4 of 5 did not have local disease progression or recurrence in the treated cardiac lesion. One-year OS was 44%, which was not significantly different from non-cardiac mMCC patients (45%, p = 0.96). Though it occurs relatively late in the disease course, cardiac mMCC responded to immunotherapy and/or radiotherapy and was not associated with worse prognosis compared to mMCC at other anatomic sites. These results are timely as cardiac mMCC may be increasingly encountered in the era of immunotherapy as patients with metastatic MCC live longer.
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Affiliation(s)
- Tomoko Akaike
- Division of Dermatology, Department of Medicine, University of Washington, Seattle, WA 98195, USA
- Correspondence: ; Tel.: +1-206-221-4594
| | - Kelsey Cahill
- Division of Dermatology, Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Gensuke Akaike
- Department of Radiology, University of Washington, Seattle, WA 98195, USA
- TRA Medical Imaging, Tacoma, WA 98402, USA
| | - Emily T. Huynh
- Division of Dermatology, Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Daniel S. Hippe
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA 98109, USA
| | - Michi M. Shinohara
- Division of Dermatology, Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Jay Liao
- Department of Radiation Oncology, University of Washington, Seattle, WA 91895, USA
| | | | - Upendra Parvathaneni
- Department of Radiation Oncology, University of Washington, Seattle, WA 91895, USA
| | - Evan Hall
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Shailender Bhatia
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Richard K. Cheng
- Division of Cardiology, University of Washington Medical Center, Seattle, WA 98195, USA
| | - Paul Nghiem
- Division of Dermatology, Department of Medicine, University of Washington, Seattle, WA 98195, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA 98109, USA
| | - Yolanda D. Tseng
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA 98109, USA
- Department of Radiation Oncology, University of Washington, Seattle, WA 91895, USA
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12
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Hotca A, Sindhu K, Lehrer E, Hartsell W, Vargas C, Chon B, Chang J, Apisarnthanarax S, Ashman J, Nichols R, Chhabra A, Hasan S, Press R, Lazarev S, Hajj C, Kabarriti R, Simone C, Choi I. Reirradiation with Proton Therapy for Recurrent Malignancies of the Esophagus and Gastroesophageal Junction: Results of the Proton Collaborative Group Multi-Institutional Prospective Registry Trial. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.1030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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13
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Narang A, Hill C, Ghaly M, Korah B, Miller E, Malik N, Raldow A, Anwar M, Sanford N, Aguilera T, Kim E, Apisarnthanarax S, Murphy J, Frakes J, Hoffe S, Schefter T, Chang D, Hong T, Herman J, Goodman K. Current Practice Patterns among Radiation Oncologists at High-Volume Pancreatic Cancer Centers Participating in the Canopy Cancer Collective Learning Health Network. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.1111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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14
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Gutschenritter T, Post A, Bowen S, Nguyen B, Shankaran V, Zhen D, Farjah F, Oelschlager B, Zeng J, Apisarnthanarax S. Utilizing Intensity Modulated Proton Therapy with a Single Posterior-Anterior Beam for Esophageal Chemoradiation: Dosimetry and Long-Term Clinical Outcomes. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.1029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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15
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Kosydar S, Woodfin MW, Halasz LM, Apisarnthanarax S, Rengan R, Lo SS. The Impact of COVID-19 on US Radiation Oncology Residents. J Cancer Educ 2022; 37:1525-1531. [PMID: 33694133 PMCID: PMC7946574 DOI: 10.1007/s13187-021-01993-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/07/2021] [Indexed: 06/12/2023]
Abstract
The purpose of our study is to assess the impact of COVID-19 on the clinical responsibilities, training, and wellness of US radiation oncology residents. An anonymous cross-sectional survey was sent to all 91 radiation oncology residency programs in the USA. The survey included questions related to demographics, changes in clinical duties and training, job prospects, and wellness indicators. Univariate and multivariate logistic regression analyses were used to evaluate factors associated with residents endorsing high satisfaction with their departments' response to COVID-19. A total of 96 residents completed the survey from 67 US radiation oncology programs. In the multivariate logistic regression model, remote contouring (OR: 3.91 (95% CI: 1.11, 13.80), p = 0.03) and belief that one will be adequately trained to independently practice after completing residency (OR: 4.68 (1.12, 19.47), p = 0.03) were significantly associated with high resident satisfaction with their department's response to COVID-19. Most residents indicated that hypofractionation was encouraged to a greater extent (n = 79, 82.3%), patients were triaged by disease risk (n = 67, 69.8%), and most agreed/strongly agreed that they have been provided with adequate personal protective equipment (PPE) (n = 85, 88.5%). The COVID-19 pandemic has affected the training and wellness of radiation oncology residents. Our analysis suggests that radiation oncology programs might increase resident satisfaction with their department's response to COVID-19 by enabling remote contouring and working with residents to identity and remedy possible concerns regarding their ability to independently practice post residency.
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Affiliation(s)
- Samuel Kosydar
- School of Medicine, University of Washington, Seattle, WA, USA
| | | | - Lia M Halasz
- School of Medicine, University of Washington, Seattle, WA, USA
- Department of Radiation Oncology, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Smith Apisarnthanarax
- School of Medicine, University of Washington, Seattle, WA, USA
- Department of Radiation Oncology, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Ramesh Rengan
- School of Medicine, University of Washington, Seattle, WA, USA
- Department of Radiation Oncology, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Simon S Lo
- School of Medicine, University of Washington, Seattle, WA, USA.
- Department of Radiation Oncology, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA.
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16
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Apisarnthanarax S, Cardenes H. In Reply to Nguyen et al. Pract Radiat Oncol 2022; 12:e240. [PMID: 35512992 DOI: 10.1016/j.prro.2022.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 01/26/2022] [Indexed: 11/25/2022]
Affiliation(s)
| | - Higinia Cardenes
- Department of Radiation Oncology, Weill Cornell Medicine, New York, New York
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17
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Hallemeier CL, Apisarnthanarax S, Dawson LA. BCLC 2022 update: Important advances, but missing external beam radiotherapy. J Hepatol 2022; 76:1237-1239. [PMID: 34990748 DOI: 10.1016/j.jhep.2021.12.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 12/27/2021] [Indexed: 12/15/2022]
Affiliation(s)
| | | | - Laura Ann Dawson
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
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18
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Apisarnthanarax S, Barry A, Cao M, Czito B, DeMatteo R, Drinane M, Hallemeier CL, Koay EJ, Lasley F, Meyer J, Owen D, Pursley J, Schaub SK, Smith G, Venepalli NK, Zibari G, Cardenes H. External Beam Radiation Therapy for Primary Liver Cancers: An ASTRO Clinical Practice Guideline. Pract Radiat Oncol 2022; 12:28-51. [PMID: 34688956 DOI: 10.1016/j.prro.2021.09.004] [Citation(s) in RCA: 80] [Impact Index Per Article: 40.0] [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: 09/01/2021] [Accepted: 09/07/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE This guideline provides evidence-based recommendations for the indications and technique-dose of external beam radiation therapy (EBRT) in hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (IHC). METHODS The American Society for Radiation Oncology convened a task force to address 5 key questions focused on the indications, techniques, and outcomes of EBRT in HCC and IHC. This guideline is intended to cover the definitive, consolidative, salvage, preoperative (including bridge to transplant), and adjuvant settings as well as palliative EBRT for symptomatic primary lesions. Recommendations were based on a systematic literature review and created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength. RESULTS Strong recommendations are made for using EBRT as a potential first-line treatment in patients with liver-confined HCC who are not candidates for curative therapy, as consolidative therapy after incomplete response to liver-directed therapies, and as a salvage option for local recurrences. The guideline conditionally recommends EBRT for patients with liver-confined multifocal or unresectable HCC or those with macrovascular invasion, sequenced with systemic or catheter-based therapies. Palliative EBRT is conditionally recommended for symptomatic primary HCC and/or macrovascular tumor thrombi. EBRT is conditionally recommended as a bridge to transplant or before surgery in carefully selected patients. For patients with unresectable IHC, consolidative EBRT with or without chemotherapy should be considered, typically after systemic therapy. Adjuvant EBRT is conditionally recommended for resected IHC with high-risk features. Selection of dose-fractionation regimen and technique should be based on disease extent, disease location, underlying liver function, and available technologies. CONCLUSIONS The task force has proposed recommendations to inform best clinical practices on the use of EBRT for HCC and IHC with strong emphasis on multidisciplinary care. Future studies should focus on further defining the role of EBRT in the context of liver-directed and systemic therapies and refining optimal regimens and techniques.
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Affiliation(s)
| | - Aisling Barry
- Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - Minsong Cao
- Department of Radiation Oncology, University of California, Los Angeles, California
| | - Brian Czito
- Department of Radiation Oncology, Duke University, Durham, North Carolina
| | - Ronald DeMatteo
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mary Drinane
- Department of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Eugene J Koay
- Department of Radiation Oncology, UT-MD Anderson Cancer Center, Houston, Texas
| | - Foster Lasley
- Department of Radiation Oncology, GenesisCare, Rogers, Arkansas
| | - Jeffrey Meyer
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Dawn Owen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Jennifer Pursley
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Stephanie K Schaub
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Grace Smith
- Department of Radiation Oncology, UT-MD Anderson Cancer Center, Houston, Texas
| | - Neeta K Venepalli
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Gazi Zibari
- Department of Transplantation Services, Willis-Knighton Medical Center, Shreveport, Louisiana
| | - Higinia Cardenes
- Department of Radiation Oncology, Weill Cornell, New York, New York
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19
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Chuong MD, Hallemeier CL, Li H, Zhu XR, Zhang X, Tryggestad EJ, Yu J, Yang M, Choi JI, Kang M, Liu W, Knopf A, Meijers A, Molitoris JK, Apisarnthanarax S, Giap H, Hoppe BS, Lee P, Chang JY, Simone CB, Lin SH. Executive Summary of Clinical and Technical Guidelines for Esophageal Cancer Proton Beam Therapy From the Particle Therapy Co-Operative Group Thoracic and Gastrointestinal Subcommittees. Front Oncol 2021; 11:748331. [PMID: 34737959 PMCID: PMC8560961 DOI: 10.3389/fonc.2021.748331] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 09/28/2021] [Indexed: 02/02/2023] Open
Abstract
Radiation therapy (RT) is an integral component of potentially curative management of esophageal cancer (EC). However, RT can cause significant acute and late morbidity due to excess radiation exposure to nearby critical organs, especially the heart and lungs. Sparing these organs from both low and high radiation dose has been demonstrated to achieve clinically meaningful reductions in toxicity and may improve long-term survival. Accruing dosimetry and clinical evidence support the consideration of proton beam therapy (PBT) for the management of EC. There are critical treatment planning and delivery uncertainties that should be considered when treating EC with PBT, especially as there may be substantial motion-related interplay effects. The Particle Therapy Co-operative Group Thoracic and Gastrointestinal Subcommittees jointly developed guidelines regarding patient selection, treatment planning, clinical trials, and future directions of PBT for EC.
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Affiliation(s)
- Michael D Chuong
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL, United States
| | | | - Heng Li
- Department of Radiation Oncology, Johns Hopkins University, Baltimore, MD, United States
| | - Xiaorong Ronald Zhu
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX, United States
| | - Xiaodong Zhang
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX, United States
| | - Erik J Tryggestad
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Jen Yu
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL, United States
| | - Ming Yang
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX, United States
| | - J Isabelle Choi
- Department of Radiation Oncology, New York Proton Center, New York, NY, United States
| | - Minglei Kang
- Department of Radiation Oncology, New York Proton Center, New York, NY, United States
| | - Wei Liu
- Department of Radiation Oncology, Mayo Clinic, Scottsdale, AZ, United States
| | - Antje Knopf
- Department of Radiation Oncology, University of Groningen, Groningen, Netherlands
| | - Arturs Meijers
- Department of Radiation Oncology, University of Groningen, Groningen, Netherlands
| | - Jason K Molitoris
- Department of Radiation Oncology, University of Maryland, Baltimore, Baltimore, MD, United States
| | - Smith Apisarnthanarax
- Department of Radiation Oncology, University of Washington, Seattle, WA, United States
| | - Huan Giap
- Department of Radiation Oncology, University of Miami, Miami, FL, United States
| | - Bradford S Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, United States
| | - Percy Lee
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX, United States
| | - Joe Y Chang
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX, United States
| | - Charles B Simone
- Department of Radiation Oncology, New York Proton Center, New York, NY, United States
| | - Steven H Lin
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX, United States
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Zaki P, Greer M, Blau M, Kim E, Apisarnthanarax S, Zeng J, Kim J, Ford E. Perceptions of Disease-Site Specific Chart Rounds at an Academic Institution. Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.1390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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21
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Bierma M, Goff P, Hippe D, Lachance K, Schaub S, Tseng Y, Apisarnthanarax S, Liao J, Parvathaneni U, Nghiem P. LB759 Post-operative radiation therapy to prevent local recurrence of low-risk Merkel cell carcinomas of the head and neck versus other sites. J Invest Dermatol 2021. [DOI: 10.1016/j.jid.2021.07.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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22
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Parzen JS, Hartsell W, Chang J, Apisarnthanarax S, Molitoris J, Durci M, Tsai H, Urbanic J, Ashman J, Vargas C, Stevens C, Kabolizadeh P. Hypofractionated proton beam radiotherapy in patients with unresectable liver tumors: multi-institutional prospective results from the Proton Collaborative Group. Radiat Oncol 2020; 15:255. [PMID: 33148296 PMCID: PMC7643436 DOI: 10.1186/s13014-020-01703-3] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 10/29/2020] [Indexed: 01/07/2023] Open
Abstract
Background Recent advances in radiotherapy techniques have allowed ablative doses to be safely delivered to inoperable liver tumors. In this setting, proton beam radiotherapy (PBT) provides the means to escalate radiation dose to the target volume while sparing the uninvolved liver. This study evaluated the safety and efficacy of hypofractionated PBT for liver tumors, predominantly hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC). Methods We evaluated the prospective registry of the Proton Collaborative Group for patients undergoing definitive PBT for liver tumors. Demographic, clinicopathologic, toxicity, and dosimetry information were compiled. Results To date, 63 patients have been treated at 9 institutions between 2013 and 2019. Thirty (48%) had HCC and 25 (40%) had ICC. The median dose and biological equivalent dose (BED) delivered was 58.05 GyE (range 32.5–75) and 80.5 GyE (range 53.6–100), respectively. The median mean liver BED was 13.9 GyE. Three (4.8%) patients experienced at least one grade ≥ 3 toxicity. With median follow-up of 5.1 months (range 0.1–40.8), the local control (LC) rate at 1 year was 91.2% for HCC and 90.9% for ICC. The 1-year LC was significantly higher (95.7%) for patients receiving BED greater than 75.2 GyE than for patients receiving BED of 75.2 GyE or lower (84.6%, p = 0.029). The overall survival rate at 1 year was 65.6% for HCC and 81.8% for ICC. Conclusions Hypofractionated PBT results in excellent LC, sparing of the uninvolved liver, and low toxicity, even in the setting of dose-escalation. Higher dose correlates with improved LC, highlighting the importance of PBT especially in patients with recurrent or bulky disease.
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Affiliation(s)
| | - William Hartsell
- Northwestern Medicine Chicago Proton Center, Warrenville, IL, USA
| | - John Chang
- Oklahoma Proton Center, Oklahoma City, OK, USA
| | | | | | | | - Henry Tsai
- Princeton ProCure Proton Therapy Center, Kendall Park, NJ, USA
| | - James Urbanic
- California Protons Therapy Center, San Diego, CA, USA
| | | | | | | | - Peyman Kabolizadeh
- Beaumont Proton Therapy Center, Royal Oak, MI, USA. .,Department of Radiation Oncology, Oakland University William Beaumont School of Medicine, 3601 W Thirteen Mile Rd, Royal Oak, MI, 48073, USA.
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Greer M, Schaub S, O-Ryan-Blair A, Wong T, Apisarnthanarax S. Proton Beam Therapy For Large Hepatocellular Carcinomas In Western Patients. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.1854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Dinh TKT, Lee HJ, Macomber MW, Apisarnthanarax S, Zeng J, Laramore GE, Rengan R, Russell KJ, Chen JJ, Ellis WJ, Schade GR, Liao JJ. Rectal Hydrogel Spacer Improves Late Gastrointestinal Toxicity Compared to Rectal Balloon Immobilization After Proton Beam Radiation Therapy for Localized Prostate Cancer: A Retrospective Observational Study. Int J Radiat Oncol Biol Phys 2020; 108:635-643. [DOI: 10.1016/j.ijrobp.2020.01.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 01/10/2020] [Accepted: 01/21/2020] [Indexed: 12/19/2022]
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25
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Goff P, Bierma M, Lachance K, Schaub S, Tseng Y, Liao J, Apisarnthanarax S, Nghiem P, Parvathaneni U. Primary Tumor Location As a Potential Risk Factor for Local Recurrence in Resected, Low-risk Merkel Cell Carcinoma: Implications for Postoperative Radiotherapy. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Cook MM, Schaub SK, Goff PH, Fu A, Park SY, Hippe DS, Liao JJ, Apisarnthanarax S, Bhatia S, Tseng YD, Nghiem PT, Parvathaneni U. Postoperative, Single-Fraction Radiation Therapy in Merkel Cell Carcinoma of the Head and Neck. Adv Radiat Oncol 2020; 5:1248-1254. [PMID: 32838069 PMCID: PMC7373007 DOI: 10.1016/j.adro.2020.07.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/12/2020] [Accepted: 07/03/2020] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Conventionally fractionated, postoperative radiation therapy (cPORT; 50 Gy in 25 fractions) is considered for patients with Merkel cell carcinoma (MCC) to improve locoregional control. However, cPORT is associated with acute toxicity, especially in the head and neck (H&N) region, and requires daily treatments over several weeks. We previously reported high rates of durable local control with minimal toxicity using 8-Gy single-fraction radiation therapy (SFRT) in the metastatic setting. We report early results on a cohort of patients with localized H&N MCC who received postoperative SFRT if a cPORT regimen was not feasible. METHODS AND MATERIALS Twelve patients with localized MCC of the H&N (clinical/pathologic stages I-II) and no prior radiation therapy to the region were identified from an institutional review board-approved prospective registry who underwent surgical resection followed by postoperative SFRT. Time to event was calculated starting from the date of resection before SFRT. The cumulative incidence of in-field locoregional recurrences and out-of-field recurrences was estimated with death as a competing risk. RESULTS Twelve patients with H&N MCC were identified with clinical/pathologic stages I-II H&N MCC. Median age at diagnosis was 81 years (range, 58-96 years); 25% had immunosuppression. At a median follow-up of 19 months (range, 8-34), there were no in-field locoregional recurrences. A single out-of-field regional recurrence was observed, which was successfully salvaged. There were no MCC-specific deaths. No radiation-associated toxicities greater than grade 1 (Common Terminology Criteria for Adverse Events v5) were observed. CONCLUSIONS Preliminary data suggest that SFRT could offer a potential alternative to cPORT to treat the primary site for localized H&N MCC, particularly in elderly or frail patients, with promising in-field local control and minimal toxicity. Further data with validation in larger cohorts are needed to confirm the sustained safety and efficacy of postoperative SFRT.
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Affiliation(s)
- Maclean M. Cook
- University of Washington School of Medicine, Division of Dermatology, University of Washington, Seattle, Washington
| | - Stephanie K. Schaub
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Peter H. Goff
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Alex Fu
- University of Washington School of Medicine, Division of Dermatology, University of Washington, Seattle, Washington
| | - Song Y. Park
- University of Washington School of Medicine, Division of Dermatology, University of Washington, Seattle, Washington
| | - Daniel S. Hippe
- Department of Radiology, University of Washington, Seattle, Washington
| | - Jay J. Liao
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | | | - Shailender Bhatia
- Division of Medical Oncology, University of Washington, Seattle, Washington
| | - Yolanda D. Tseng
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Paul T. Nghiem
- University of Washington School of Medicine, Division of Dermatology, University of Washington, Seattle, Washington
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Goff P, Cook M, Schaub S, Park S, Hippe D, Liao J, Apisarnthanarax S, Bhatia S, Nghiem P, Tseng Y, Parvathaneni U. Efficacy and Toxicity of Hypofractionated Adjuvant Radiotherapy in Merkel Cell Carcinoma. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.02.577] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Barry A, Apisarnthanarax S, O'Kane GM, Sapisochin G, Beecroft R, Salem R, Yoon SM, Lim YS, Bridgewater J, Davidson B, Scorsetti M, Solbiati L, Diehl A, Schuffenegger PM, Sham JG, Cavallucci D, Galvin Z, Dawson LA, Hawkins MA. Management of primary hepatic malignancies during the COVID-19 pandemic: recommendations for risk mitigation from a multidisciplinary perspective. Lancet Gastroenterol Hepatol 2020; 5:765-775. [PMID: 32511951 PMCID: PMC7274990 DOI: 10.1016/s2468-1253(20)30182-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/01/2020] [Accepted: 05/01/2020] [Indexed: 01/08/2023]
Abstract
Around the world, recommendations for cancer treatment are being adapted in real time in response to the pandemic of COVID-19. We, as a multidisciplinary team, reviewed the standard management options, according to the Barcelona Clinic Liver Cancer classification system, for hepatocellular carcinoma. We propose treatment recommendations related to COVID-19 for the different stages of hepatocellular carcinoma (ie, 0, A, B, and C), specifically in relation to surgery, locoregional therapies, and systemic therapy. We suggest potential strategies to modify risk during the pandemic and aid multidisciplinary treatment decision making. We also review the multidisciplinary management of intrahepatic cholangiocarcinoma as a potentially curable and incurable diagnosis in the setting of COVID-19.
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Affiliation(s)
- Aisling Barry
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada; Radiation Medicine Program, Toronto General Hospital, University Health Network, Toronto, ON, Canada.
| | - Smith Apisarnthanarax
- Seattle Cancer Care Alliance, and Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Grainne M O'Kane
- Department of Medical Oncology and Haematology, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Gonzalo Sapisochin
- Princess Margaret Cancer Centre, and Department of Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Robert Beecroft
- Department of Medical Imaging, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Riad Salem
- Department of Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Sang Min Yoon
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Young-Suk Lim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | | | - Brian Davidson
- Department of Surgical Biotechnology, UCL Division of Surgery and Interventional Science, University College London, London, UK
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, IRCCS Humanitas Research Hospital, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Luigi Solbiati
- Radiology Department, Humanitas Clinical and Research Center, IRCCS Humanitas Research Hospital, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Adam Diehl
- Department of Medical Oncology, University of Washington, Seattle, WA, USA
| | - Pablo Munoz Schuffenegger
- Radiation Oncology Unit, Department of Hematology Oncology, Pontifical Catholic University of Chile, Santiago, Chile
| | - Jonathan G Sham
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - David Cavallucci
- Department of Surgery, Royal Brisbane and Women's Hospital, University of Queensland, Brisbane, QLD, Australia
| | - Zita Galvin
- Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Laura A Dawson
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada; Radiation Medicine Program, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Maria A Hawkins
- UCL Cancer Institute, University College London, London, UK; Department of Medical Physics and Biomedical Engineering, University College London, London, UK
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Schaub SK, Ermoian RP, Wang CL, O'Malley RB, Kim EY, Shuman WP, Hendrickson K, Apisarnthanarax S. Bridging the Radiation Oncology and Diagnostic Radiology Communication Gap: A Survey to Determine Usefulness and Optimal Presentation of Radiotherapy Treatment Plans for Radiologists. Curr Probl Diagn Radiol 2020; 49:161-167. [PMID: 30885420 DOI: 10.1067/j.cpradiol.2019.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 02/13/2019] [Accepted: 02/14/2019] [Indexed: 11/22/2022]
Abstract
RATIONALE AND OBJECTIVES We hypothesized that providing visual-spatial information to radiologists on where radiation has been delivered in an easily accessible way may improve the accuracy of image interpretation and thereby improve quality of patient care. We present a national representation of radiologists' opinions regarding the usefulness and optimal approach for implementing a system to promote access to radiotherapy (RT) plans. METHODS An anonymous survey was sent to the members of the Association of University Radiologists. Descriptive statistics were performed. RESULTS Questionnaires were returned by 95 of 1383 members. Demographics comprised of 76% attendings with 94% practicing within an academic setting. Only 40% of radiologists reported that they knew most of the time whether a patient has received RT in the field scanned. A large majority of respondents (88%) felt that a history of prior radiation in a cancer patient was at least an occasional barrier that affected the ability to interpret imaging findings in a clinically useful way. The following types of information was considered helpful when interpreting a scan: screenshots of the radiation plan (85%), scrollable DICOM data on planning CT showing delivered RT dose lines (54%), and written text RT treatment summary (47%). Nearly all (89%) desired DICOM data within the clinical radiology Picture Archiving and Communication System system. Radiologists expected the ease of accessibility to RT plans to result in increased efficiency (76%) and accuracy (88%). CONCLUSION Diagnostic radiologists desire improved access and integration of radiotherapy plans into the diagnostic radiology clinical workup in the form of visual-spatial data.
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Affiliation(s)
- Stephanie K Schaub
- University of Washington, Department of Radiation Oncology, Seattle, WA.
| | - Ralph P Ermoian
- University of Washington, Department of Radiation Oncology, Seattle, WA
| | - Carolyn L Wang
- University of Washington, Department of Radiology, Seattle, WA
| | - Ryan B O'Malley
- University of Washington, Department of Radiology, Seattle, WA
| | - Edward Y Kim
- University of Washington, Department of Radiation Oncology, Seattle, WA
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Abstract
Proton beam therapy (PBT) delivers less dose to nearby normal organs compared to X-ray therapy (XRT), which is particularly relevant for treating liver cancers given that both mean and low liver dose are among the most significant predictors of radiation induced liver disease (RILD). High-dose PBT has been shown to achieve excellent long-term tumor control with minimal toxicity in hepatocellular carcinoma (HCC) patients. Increasing data support ablative PBT for patients with unresectable cholangiocarcinoma or liver metastases, especially those with larger tumors not suitable for XRT.
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Affiliation(s)
- Michael Chuong
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL, USA
| | - Adeel Kaiser
- Department of Radiation Oncology, University of Maryland and Maryland Proton Treatment Center, Baltimore, MD, USA
| | - Jason Molitoris
- Department of Radiation Oncology, University of Maryland and Maryland Proton Treatment Center, Baltimore, MD, USA
| | - Alejandra Mendez Romero
- Department of Radiation Oncology, Erasmus Medical Center and Holland Proton Therapy Center, Rotterdam, The Netherlands
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Post A, Bowen SR, Nguyen BN, Logan W, Zeng J, Apisarnthanarax S. Correlation of heart dose with lymphopenia in esophageal cancer patients treated with chemoradiation. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.4_suppl.346] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
346 Background: Lymphopenia has been associated with survival and disease progression in esophageal cancer patients treated with chemoradiation (cRT). We previously published on our posterior-only proton therapy approach that maximally spares the heart and lungs, but at the cost of increased dose to the bone marrow in the vertebral bodies (VBs). We assessed hematologic toxicity in proton (PT) and IMRT treated patients and studied dosimetric parameters associated with hematologic toxicity. Methods: 35 patients treated with PT and 46 patients treated with IMRT for esophageal cancer between 2011-2018 were analyzed. Most patients were treated concurrently with carboplatin/paclitaxel to a median dose of 50.4 Gy. Lymphocyte, neutrophil and total leukocyte values while under treatment were recorded and graded per the CTCAE v4.03 toxicity scale, and the neutrophil-to-lymphocyte ratio (NLR) was computed. Mean dose and volumes (cc) receiving 5-50 Gy were calculated for the heart and VBs. A receiver-operator characteristic analysis was performed for univariate correlation between incidence of grade ≥3 hematotoxicity and dose-volume parameters. Results: Median follow-up was 36.1 months for all patients and the overall survival at 3 years was 57.5%. The rates of grade 3 or 4 hematologic toxicity in the PT group were 37.1% (leukopenia), 22.9% (neutropenia), and 80.0% (lymphopenia) versus 41.3%, 15.2% and 87.2%, respectively, for IMRT patients. There was a significant correlation between grade 4 lymphopenia and the heart V5, V10 and V20, but no significant correlation between VB doses with any hematotoxicity. Median NLR values and heart dose were higher in the IMRT group (9.17 vs 3.86 with PT, p = 0.0048; 10.5 vs 23.5Gy, p< 0.0001, respectively). There was a correlation between survival and NLR with a hazard ratio of 1.025 (CI 1.006 - 1.044). Conclusions: Low doses to the heart mediate severe lymphopenia in esophageal cancer patients treated with cRT. These data confirm the safety of the posterior-only proton approach without concern for increased hematologic toxicity despite higher vertebral body doses compared to IMRT. They also suggest that the blood pool is more important as a source of severe lymphopenia.
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Affiliation(s)
| | | | | | | | - Jing Zeng
- Johns Hopkins University School of Medicine, Seattle, WA
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Schaub SK, Bowen SR, Nyflot MJ, Apisarnthanarax S. Intensity-modulated proton therapy using dose-painting pencil beam scanning for high-risk hepatocellular carcinoma. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.4_suppl.558] [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: 11/20/2022] Open
Abstract
558 Background: High rates of local control are achievable with hypofractionated proton therapy with passive techniques for hepatocellular carcinoma (HCC), but may have limitations when tumors are adjacent to organs-at-risk (OARs), which may result in tumor underdosage and lead to inferior local control. We present the first reported series of HCC patients treated with pencil beam scanning (PBS) intensity-modulated proton therapy (IMPT) using a simultaneous-integrated boost and protection (SIB/SIP) technique to escalate tumor dose while protecting adjacent OARs. Methods: Twenty-five HCC patients were treated between 2015-2019 with a 15-fraction regimen using IMPT SIB/SIP. SIB/SIP dose levels generally ranged from 36.0-67.5 GyRBE to minimize dose to OARs at their respective dose-limiting thresholds (e.g. luminal gastrointestinal organs, chest wall). Radiation-induced liver disease (RILD) was defined by a Child-Pugh (CP) score increase of 2 or greater and/or any RTOG grade 3 enzyme elevation. Other toxicities were graded by CTCAEv5.0. Overall survival (OS), progression-free survival (PFS), and local control were calculated using the Kaplan-Meier method. Results: Patients most commonly had BCLC stage B or C disease (84%) and CP-A (80%) and ALBI grade 2 (60%) liver function. Median gross tumor volume (GTV) size and volume were 12.3 cm (range 2.17-20.57) and 461 cc (range 4.68-2439), and 32% had gross vascular invasion. Median mean and minimum dose delivered to the gross tumor volume (GTV) was 64.0 GyRBE (EQD2 76.1, BED 91.3, range 54.3-69.6) and 45.1 GyRBE (EQD2 48.9, BED 58.7, range 33.4-67.7), respectively. Median mean dose to liver minus GTV was 15.0 GyRBE (range, 8.2-19.6). 1-year OS, PFS, and local control were 66%, 32%, and 84%, respectively. No isolated local failures occurred. Two patients experienced RILD with no RILD-related deaths. Two grade 3 non-GI toxicities occurred: 1 rib fracture and 1 pneumonitis. No acute or late GI grade ≥2 occurred. Conclusions: In our series of HCC patients with large tumors near OARs, IMPT SIB/SIP allows for tumor dose escalation while sparing of OARs and results in favorable local control and acceptable toxicities.
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Olsen JR, Apisarnthanarax S, Murphy JD, Tait D, Huguet F, Hallemeier CL, Jabbour SK. Gastrointestinal Cancers: Fine-Tuning the Management of Rectal, Esophageal, and Pancreas Cancers. Int J Radiat Oncol Biol Phys 2019; 105:1-10. [PMID: 31422802 PMCID: PMC10949212 DOI: 10.1016/j.ijrobp.2019.04.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 04/25/2019] [Accepted: 04/27/2019] [Indexed: 02/06/2023]
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Havard M, Schaub S, Bowen S, Chapman T, Nyflot M, Apisarnthanarax S. ALBI-RT as a Radiation Therapy Specific Hepatotoxicity Prediction Model for Hepatocellular Carcinoma Patients. Int J Radiat Oncol Biol Phys 2019. [DOI: 10.1016/j.ijrobp.2019.06.1971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Chuong MD, Kaiser A, Khan F, Parikh P, Ben-Josef E, Crane C, Brunner T, Okumura T, Schreuder N, Bentzen SM, Gutierrez A, Mendez Romero A, Yoon SM, Sharma N, Kim TH, Kishi K, Moeslein F, Hoffe S, Schefter T, Hanish S, Scorsetti M, Apisarnthanarax S. Consensus Report From the Miami Liver Proton Therapy Conference. Front Oncol 2019; 9:457. [PMID: 31214502 PMCID: PMC6557299 DOI: 10.3389/fonc.2019.00457] [Citation(s) in RCA: 9] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 05/14/2019] [Indexed: 12/14/2022] Open
Abstract
An international group of 22 liver cancer experts from 18 institutions met in Miami, Florida to discuss the optimal utilization of proton beam therapy (PBT) for primary and metastatic liver cancer. There was consensus that PBT may be preferred for liver cancer patients expected to have a suboptimal therapeutic ratio from XRT, but that PBT should not be preferred for all patients. Various clinical scenarios demonstrating appropriateness of PBT vs. XRT were reviewed.
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Affiliation(s)
- Michael D Chuong
- Baptist Hospital of Miami, Miami Cancer Institute, Miami, FL, United States
| | - Adeel Kaiser
- University of Maryland Medical Center, Baltimore, MD, United States
| | - Fazal Khan
- Baptist Hospital of Miami, Miami Cancer Institute, Miami, FL, United States
| | - Parag Parikh
- Henry Ford Health System, Detroit, MI, United States
| | - Edgar Ben-Josef
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, United States
| | - Christopher Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | | | - Toshiyuki Okumura
- Department of Radiation Oncology, University of Tsukuba, Tsukuba, Japan
| | - Niek Schreuder
- Provision CARES Proton Therapy, Knoxville, TN, United States
| | - Søren M Bentzen
- University of Maryland Medical Center, Baltimore, MD, United States
| | - Alonso Gutierrez
- Baptist Hospital of Miami, Miami Cancer Institute, Miami, FL, United States
| | - Alejandra Mendez Romero
- Erasmus Medical Center, Erasmus University Rotterdam, Rotterdam, Netherlands.,Holland Proton Treatment Center, Rotterdam, Netherlands
| | - Sang Min Yoon
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Navesh Sharma
- Department of Radiation Oncology, Pennsylvania State University, University Park, PA, United States
| | | | | | - Fred Moeslein
- Sarasota Memorial Hospital, Sarasota, FL, United States
| | - Sarah Hoffe
- Moffitt Cancer Center, Tampa, FL, United States
| | - Tracey Schefter
- University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Steven Hanish
- University of Maryland Medical Center, Baltimore, MD, United States
| | - Marta Scorsetti
- Department of Radiation Oncology, Humanitas University, Rozzano, Italy
| | - Smith Apisarnthanarax
- Department of Radiation Oncology, University of Washington, Seattle, WA, United States
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Cook M, Schaub S, Park S, Hippe D, Liao J, Apisarnthanarax S, Bhatia S, Nghiem P, Tseng Y, Parvathaneni U. 550 Efficacy and toxicity of hypofractionated adjuvant radiotherapy in Merkel cell carcinoma. J Invest Dermatol 2019. [DOI: 10.1016/j.jid.2019.03.626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Hallemeier CL, Olsen JR, Murphy JD, Tait D, Apisarnthanarax S, Huguet F, Jabbour SK. Gastrointestinal Cancers: Management of Rectal, Hepatocellular, Pancreatic, and Esophageal Cancers. Int J Radiat Oncol Biol Phys 2019; 104:1-9. [PMID: 30967220 DOI: 10.1016/j.ijrobp.2018.12.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 12/24/2018] [Accepted: 12/28/2018] [Indexed: 10/27/2022]
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Hartvigson PE, Apisarnthanarax S, Schaub S, Cohen S, Bernier G, Koh WJ, Kim EY. Radiation Therapy Dose Escalation to Clinically Involved Pelvic Sidewall Lymph Nodes in Locally Advanced Rectal Cancer. Adv Radiat Oncol 2019; 4:478-486. [PMID: 31360803 PMCID: PMC6639784 DOI: 10.1016/j.adro.2019.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 02/24/2019] [Accepted: 03/20/2019] [Indexed: 12/20/2022] Open
Abstract
Purpose Lateral pelvic sidewall lymph nodes (PSW LN) may be involved in up to 24% of locoregionally advanced rectal cancers. PSW LN are not resected in total mesorectal excision (TME), and no standard of care regarding the management of PSW LN exists in the United States. We assessed our institutional experience of preoperative radiation therapy (RT) boost to clinically involved PSW LN that were not planned for resection. Methods and materials Data from all patients with rectal adenocarcinoma treated between 2006 and 2018 were reviewed to identify those who received a cumulative dose of >50.4 Gy to suspicious PSW LN during neoadjuvant chemoradiation therapy (nCRT). Demographic, cancer characteristic, treatment, and toxicity data were derived from the chart. Results Of a total of 261 patients, 12 patients met the inclusion criteria. The median age was 47.5 years, and 83% of patients were men. All patients had T3/4 disease, 17% of patients had N1b disease and the remainder had N2 disease, and 33% had M1 disease (all ≤2 metastases). Seventy-five percent of patients had moderately or poorly differentiated histology. The mean distance from the anal verge was 4.85 cm (range, 2-8.9 cm), and 58% had ≥2 PSW LN with an average short axis diameter of 1.11 cm (range, 0.4-3.2 cm). Boost doses ranged from 53.48 Gy to 60.2 Gy in 27 to 30 fractions (1.8-2.15 Gy/fraction). The median follow-up time was 18 months. One patient who received concurrent capecitabine and irinotecan had grade 3 perineal dermatitis and anemia during nCRT. The median hospitalization time for TME was 6.5 days. Within 90 days of TME, 1 patient required surgical exploration for perineal wound breakdown, and another required a blood transfusion for anemia. At the time of the last follow up, 75% of patients were alive. Local control at 12 months was 90%. Conclusions RT dose escalation to nonresected PSW LN during nCRT was well tolerated with a low risk of acute toxicity and perioperative complications and has a high rate of local control at 12 months. RT boost warrants further study in patients with clinically involved nonresected PSW LN.
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Affiliation(s)
- Pehr E Hartvigson
- Department of Radiation Oncology, Seattle, Washington.,Department of Radiation Medicine, Oregon Health and Science University, Portland, Oregon
| | | | | | | | - Greta Bernier
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Wui-Jin Koh
- National Comprehensive Cancer Network, Plymouth Meeting, Pennsylvania
| | - Edward Y Kim
- Department of Radiation Oncology, Seattle, Washington
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Schaub SK, Apisarnthanarax S, Bowen SR. In Reply to Long and Ellsworth. Int J Radiat Oncol Biol Phys 2019; 103:1285-1286. [DOI: 10.1016/j.ijrobp.2018.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 12/04/2018] [Accepted: 12/05/2018] [Indexed: 11/25/2022]
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Labadie KP, Schaub SK, Khorsand D, Johnson G, Apisarnthanarax S, Park JO. Multidisciplinary approach for multifocal, bilobar hepatocellular carcinoma: A case report and literature review. World J Hepatol 2019; 11:119-126. [PMID: 30705724 PMCID: PMC6354116 DOI: 10.4254/wjh.v11.i1.119] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 11/30/2018] [Accepted: 12/13/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is the second most lethal malignancy worldwide. There has been virtually no change in the survivability of HCC in spite of improvement in therapies. Surgery is considered the ideal first, curative intervention, however most patients present in advanced stages with unresectable disease. Therefore, systemic and liver-directed non-operative therapies are initially offered to downstage the disease. To ensure optimal management, a multidisciplinary team approach is often warranted. Our case highlights the benefits of a multidisciplinary approach in a young woman with multifocal, bilobar HCC.
CASE SUMMARY A 36-year-old Chinese woman with untreated hepatitis B was found to have large bilobar HCC during work up for abdominal pain. Her initial serum alpha-fetoprotein was significantly elevated to 311136 ng/mL. Computed tomography scan demonstrated bulky bilobar liver masses, consistent with intermediate stage HCC, Barcelona Clinic Liver Cancer Stage B. Her case was discussed and a personalized care plan was developed at the Multidisciplinary Center for Advanced Minimally Invasive Liver Oncologic Therapies at the University of Washington. She initially underwent bilobar transarterial chemoembolization with partial response of the left lobar tumor. Salvage hypofractionated proton beam radiation therapy was delivered to the right lobe followed by two additional transarterial chemoembolizations to the left lobe with good response. Finally, to remove left lobar residual disease, she was taken to the operating room for a left hepatectomy eleven months after her initial presentation. She continues to be without evidence of disease.
CONCLUSION Coordinating the multiple HCC treatment modalities is complex and our case highlights the benefits of a multidisciplinary approach.
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Affiliation(s)
- Kevin P Labadie
- Department of Surgery, University of Washington, Seattle, WA 98195, United States
| | - Stephanie K Schaub
- Department of Radiation Oncology, University of Washington, Seattle, WA 98195, United States
| | - Derek Khorsand
- Department of Radiology, University of Washington, Seattle, WA 98195, United States
| | - Guy Johnson
- Department of Radiology, University of Washington, Seattle, WA 98195, United States
| | - Smith Apisarnthanarax
- Department of Radiation Oncology, University of Washington, Seattle, WA 98195, United States
| | - James O Park
- Department of Surgery, University of Washington, Seattle, WA 98195, United States
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Schaub SK, Hartvigson PE, Lock MI, Høyer M, Brunner TB, Cardenes HR, Dawson LA, Kim EY, Mayr NA, Lo SS, Apisarnthanarax S. Stereotactic Body Radiation Therapy for Hepatocellular Carcinoma: Current Trends and Controversies. Technol Cancer Res Treat 2018; 17:1533033818790217. [PMID: 30068240 PMCID: PMC6071169 DOI: 10.1177/1533033818790217] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Hepatocellular carcinoma is the fourth leading cause of cancer-related death worldwide.
Depending on the extent of disease and competing comorbidities for mortality, multiple
liver-directed therapy options exist for the treatment of hepatocellular carcinoma.
Advancements in radiation oncology have led to the emergence of stereotactic body
radiation therapy as a promising liver-directed therapy, which delivers high doses of
radiation with a steep dose gradient to maximize local tumor control and minimize
radiation-induced treatment toxicity. In this study, we review the current clinical data
as well as the unresolved issues and controversies regarding stereotactic body radiation
therapy for hepatocellular carcinoma: (1) Is there a radiation dose–response relationship
with hepatocellular carcinoma? (2) What are the optimal dosimetric predictors of
radiation-induced liver disease, and do they differ for patients with varying liver
function? (3) How do we assess treatment response on imaging? (4) How does stereotactic
body radiation therapy compare to other liver-directed therapy modalities, including
proton beam therapy? Based on the current literature discussed, this review highlights
future possible research and clinical directions.
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Affiliation(s)
- Stephanie K Schaub
- 1 Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Pehr E Hartvigson
- 1 Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Michael I Lock
- 2 Department of Radiation Oncology, University of Western Ontario, London, Canada
| | - Morten Høyer
- 3 Aarhus University Hospital, Danish Center for Particle Therapy, Aarhus, Denmark
| | - Thomas B Brunner
- 4 Klinik für Strahlentherapie, Universitätsklinikum Magdeburg, Magdeburg, Germany
| | | | - Laura A Dawson
- 6 Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Edward Y Kim
- 1 Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Nina A Mayr
- 1 Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Simon S Lo
- 1 Department of Radiation Oncology, University of Washington, Seattle, WA, USA
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Abstract
Charged particle therapy with proton beam therapy (PBT) and carbon ion radiotherapy (CIRT) has emerged as a promising radiation modality to minimize radiation hepatotoxicity while maintaining high rates of tumor local control. Both PBT and CIRT deposit the majority of their dose at the Bragg peak with little to no exit dose, resulting in superior sparing of normal liver tissue. CIRT has an additional biological advantage of increased relative biological effectiveness, which may allow for increased hypofractionation regimens. Retrospective and prospective studies have demonstrated encouragingly high rates of local control and overall survival and low rates of hepatotoxicity with PBT and CIRT. Ongoing randomized trials will evaluate the value of PBT over photons and other standard liver-directed therapies and future randomized trials are needed to assess the value of CIRT over PBT.
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Affiliation(s)
| | - Stephen R Bowen
- Departments of Radiation Oncology and Radiology, University of Washington, Seattle, WA
| | - Stephanie E Combs
- Department of Radiation Oncology, University Hospital Rechts der Isar, Technical University München, Munich, Germany; Institute of Innovative Radiotherapy, Helmholtzzentrum München, Munich, Germany
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Price RG, Apisarnthanarax S, Schaub SK, Nyflot MJ, Chapman TR, Matesan M, Vesselle HJ, Bowen SR. Regional Radiation Dose-Response Modeling of Functional Liver in Hepatocellular Carcinoma Patients With Longitudinal Sulfur Colloid SPECT/CT: A Proof of Concept. Int J Radiat Oncol Biol Phys 2018; 102:1349-1356. [DOI: 10.1016/j.ijrobp.2018.06.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 05/05/2018] [Accepted: 06/09/2018] [Indexed: 12/12/2022]
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Dinh T, Lee H, Macomber M, Ellis W, Schade G, Rengan R, Apisarnthanarax S, Zeng J, Liao J. Late Rectal Bleeding in Patients with and Without Pre-Rectal Hydrogel Spacer During Proton Beam Therapy for Prostate Cancer. Int J Radiat Oncol Biol Phys 2018. [DOI: 10.1016/j.ijrobp.2018.07.397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Schaub SK, Apisarnthanarax S, Price RG, Nyflot MJ, Chapman TR, Matesan M, Vesselle HJ, Bowen SR. Functional Liver Imaging and Dosimetry to Predict Hepatotoxicity Risk in Cirrhotic Patients With Primary Liver Cancer. Int J Radiat Oncol Biol Phys 2018; 102:1339-1348. [DOI: 10.1016/j.ijrobp.2018.08.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 07/27/2018] [Accepted: 08/18/2018] [Indexed: 12/17/2022]
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Schaub S, Bowen S, Price R, Nyflot M, Chapman T, Apisarnthanarax S. Value of Functional Liver Imaging in Heavily Pre-Treated Hepatocellular Carcinoma Patients. Int J Radiat Oncol Biol Phys 2018. [DOI: 10.1016/j.ijrobp.2018.07.490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Post A, Nguyen B, Bowen S, Macomber M, Zeng J, Apisarnthanarax S. Hematologic Toxicity of Single Posterior Pencil-Beam Scanning Approach for Esophageal Cancer. Int J Radiat Oncol Biol Phys 2018. [DOI: 10.1016/j.ijrobp.2018.07.539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Olsen JR, Murphy JD, Huguet F, Hallemeier CL, Apisarnthanarax S, Jabbour SK. Gastrointestinal Cancers-Carving Out the Optimal Local Therapies in the Gastrointestinal Tract. Int J Radiat Oncol Biol Phys 2018; 102:233-242. [PMID: 30191854 DOI: 10.1016/j.ijrobp.2018.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 05/08/2018] [Indexed: 11/22/2022]
Affiliation(s)
- Jeffrey R Olsen
- Department of Radiation Oncology, University of Colorado, Denver, Colorado
| | - James D Murphy
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, California
| | - Florence Huguet
- Department of Radiation Oncology, Tenon Hospital, Paris Sorbonne University, Paris, France
| | | | - Smith Apisarnthanarax
- Department of Radiation Oncology, Seattle Cancer Care Alliance, University of Washington, Seattle, Washington
| | - Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, New Jersey.
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Lee HJ, Macomber MW, Spraker MB, Bowen SR, Hippe DS, Fung A, Russell KJ, Laramore GE, Rengan R, Liao J, Apisarnthanarax S, Zeng J. Early toxicity and patient reported quality-of-life in patients receiving proton therapy for localized prostate cancer: a single institutional review of prospectively recorded outcomes. Radiat Oncol 2018; 13:179. [PMID: 30223877 PMCID: PMC6142310 DOI: 10.1186/s13014-018-1127-6] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 09/06/2018] [Indexed: 12/03/2022] Open
Abstract
Background We report prospectively captured clinical toxicity and patient reported outcomes in a single institutional cohort of patients treated for prostate cancer with proton beam therapy (PBT). This is the largest reported series of patients treated mostly with pencil beam scanning PBT. Methods We reviewed 231 patients treated on an IRB approved institutional registry from 2013 to 2016; final analysis included 192 patients with > 1-year of follow-up. Toxicity incidence was prospectively captured and scored using CTCAE v4.0. International Prostate Symptoms Score (IPSS), Sexual Health Inventory for Men (SHIM) score, and Expanded Prostate Cancer Index Composite (EPIC) bowel domain questionnaires were collected at each visit. Univariate Cox regression was used to explore associations of grade 2+ toxicity with clinical, treatment, and dosimetric variables. Results Median follow-up was 1.7 years. Grade 3 toxicity was seen in 5/192 patients. No grade 4 or 5 toxicity was seen. Patient reported quality-of-life showed no change in urinary function post-radiation by IPSS scores. Median SHIM scores declined by 3.7 points at 1-year post-treatment without further decrease beyond year 1. On univariate analysis, only younger age (HR = 0.61, p = 0.022) was associated with decreased sexual toxicity. EPIC bowel domain scores declined from 96 at baseline (median) by an average of 5.4 points at 1-year post-treatment (95% CI: 2.5–8.2 points, p < 0.001), with no further decrease over time. Bowel toxicity was mostly in the form of transient rectal bleeding and was associated with anticoagulation use (HR = 3.45, p = 0.002). Conclusions Grade 3 or higher toxicity was rare at 2-years after treatment with PBT for localized prostate cancer. Longer follow-up is needed to further characterize late toxicity and biochemical control. Trial registration NCT, NCT01255748. Registered 1 January 2013.
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Affiliation(s)
- Howard J Lee
- Duke University School of Medicine, 10 Duke Medicine Circle, Durham, NC, 27710, USA
| | - Meghan W Macomber
- Department of Radiation Oncology, University of Washington School of Medicine, 1959 NE Pacific Street, Campus, Box 356043, Seattle, WA, 98195, USA
| | - Matthew B Spraker
- Department of Radiation Oncology, University of Washington School of Medicine, 1959 NE Pacific Street, Campus, Box 356043, Seattle, WA, 98195, USA
| | - Stephen R Bowen
- Department of Radiation Oncology, University of Washington School of Medicine, 1959 NE Pacific Street, Campus, Box 356043, Seattle, WA, 98195, USA
| | - Daniel S Hippe
- Department of Radiology, University of Washington School of Medicine, 1959 NE Pacific Street, Campus, Box 357115, Seattle, WA, 98195, USA
| | - Angela Fung
- Seattle Cancer Care Alliance Proton Therapy Center, 1570 N 115th St, Seattle, WA, 98115, USA
| | - Kenneth J Russell
- Department of Radiation Oncology, University of Washington School of Medicine, 1959 NE Pacific Street, Campus, Box 356043, Seattle, WA, 98195, USA
| | - George E Laramore
- Department of Radiation Oncology, University of Washington School of Medicine, 1959 NE Pacific Street, Campus, Box 356043, Seattle, WA, 98195, USA
| | - Ramesh Rengan
- Department of Radiation Oncology, University of Washington School of Medicine, 1959 NE Pacific Street, Campus, Box 356043, Seattle, WA, 98195, USA
| | - Jay Liao
- Department of Radiation Oncology, University of Washington School of Medicine, 1959 NE Pacific Street, Campus, Box 356043, Seattle, WA, 98195, USA
| | - Smith Apisarnthanarax
- Department of Radiation Oncology, University of Washington School of Medicine, 1959 NE Pacific Street, Campus, Box 356043, Seattle, WA, 98195, USA
| | - Jing Zeng
- Department of Radiation Oncology, University of Washington School of Medicine, 1959 NE Pacific Street, Campus, Box 356043, Seattle, WA, 98195, USA.
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Olsen JR, Murphy JD, Hallemeier CL, Apisarnthanarax S, Huguet F, Jabbour SK. Cross-Modality Comparisons Between Radiofrequency Ablation and Stereotactic Body Radiotherapy for Treatment of Hepatocellular Carcinoma: Limitations of the National Cancer Database. J Clin Oncol 2018; 36:2564-2565. [PMID: 29945521 DOI: 10.1200/jco.2018.78.2904] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023] Open
Affiliation(s)
- Jeffrey R Olsen
- Jeffrey R. Olsen, University of Colorado School of Medicine, Aurora, CO; James D. Murphy, Moores Cancer Center, University of California, San Diego, La Jolla, CA; Christopher L. Hallemeier, Mayo Clinic, Rochester, MN; Smith Apisarnthanarax, University of Washington, Seattle, WA; Florence Huguet, Tenon Hospital, Assistance Publique-Hôpitaux de Paris, Paris Sorbonne University, Paris, France; and Salma K. Jabbour, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ
| | - James D Murphy
- Jeffrey R. Olsen, University of Colorado School of Medicine, Aurora, CO; James D. Murphy, Moores Cancer Center, University of California, San Diego, La Jolla, CA; Christopher L. Hallemeier, Mayo Clinic, Rochester, MN; Smith Apisarnthanarax, University of Washington, Seattle, WA; Florence Huguet, Tenon Hospital, Assistance Publique-Hôpitaux de Paris, Paris Sorbonne University, Paris, France; and Salma K. Jabbour, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ
| | - Christopher L Hallemeier
- Jeffrey R. Olsen, University of Colorado School of Medicine, Aurora, CO; James D. Murphy, Moores Cancer Center, University of California, San Diego, La Jolla, CA; Christopher L. Hallemeier, Mayo Clinic, Rochester, MN; Smith Apisarnthanarax, University of Washington, Seattle, WA; Florence Huguet, Tenon Hospital, Assistance Publique-Hôpitaux de Paris, Paris Sorbonne University, Paris, France; and Salma K. Jabbour, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ
| | - Smith Apisarnthanarax
- Jeffrey R. Olsen, University of Colorado School of Medicine, Aurora, CO; James D. Murphy, Moores Cancer Center, University of California, San Diego, La Jolla, CA; Christopher L. Hallemeier, Mayo Clinic, Rochester, MN; Smith Apisarnthanarax, University of Washington, Seattle, WA; Florence Huguet, Tenon Hospital, Assistance Publique-Hôpitaux de Paris, Paris Sorbonne University, Paris, France; and Salma K. Jabbour, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ
| | - Florence Huguet
- Jeffrey R. Olsen, University of Colorado School of Medicine, Aurora, CO; James D. Murphy, Moores Cancer Center, University of California, San Diego, La Jolla, CA; Christopher L. Hallemeier, Mayo Clinic, Rochester, MN; Smith Apisarnthanarax, University of Washington, Seattle, WA; Florence Huguet, Tenon Hospital, Assistance Publique-Hôpitaux de Paris, Paris Sorbonne University, Paris, France; and Salma K. Jabbour, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ
| | - Salma K Jabbour
- Jeffrey R. Olsen, University of Colorado School of Medicine, Aurora, CO; James D. Murphy, Moores Cancer Center, University of California, San Diego, La Jolla, CA; Christopher L. Hallemeier, Mayo Clinic, Rochester, MN; Smith Apisarnthanarax, University of Washington, Seattle, WA; Florence Huguet, Tenon Hospital, Assistance Publique-Hôpitaux de Paris, Paris Sorbonne University, Paris, France; and Salma K. Jabbour, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ
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