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Kelly RJ, Landon BV, Zaidi AH, Singh D, Canzoniero JV, Balan A, Hales RK, Voong KR, Battafarano RJ, Jobe BA, Yang SC, Broderick S, Ha J, Marrone KA, Pereira G, Rao N, Borole A, Karaindrou K, Belcaid Z, White JR, Ke S, Amjad AI, Weksler B, Shin EJ, Thompson E, Smith KN, Pardoll DM, Hu C, Feliciano JL, Anagnostou V, Lam VK. Neoadjuvant nivolumab or nivolumab plus LAG-3 inhibitor relatlimab in resectable esophageal/gastroesophageal junction cancer: a phase Ib trial and ctDNA analyses. Nat Med 2024; 30:1023-1034. [PMID: 38504015 PMCID: PMC11031406 DOI: 10.1038/s41591-024-02877-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 02/16/2024] [Indexed: 03/21/2024]
Abstract
Gastroesophageal cancer dynamics and drivers of clinical responses with immune checkpoint inhibitors (ICI) remain poorly understood. Potential synergistic activity of dual programmed cell death protein 1 (PD-1) and lymphocyte-activation gene 3 (LAG-3) inhibition may help improve immunotherapy responses for these tumors. We report a phase Ib trial that evaluated neoadjuvant nivolumab (Arm A, n = 16) or nivolumab-relatlimab (Arm B, n = 16) in combination with chemoradiotherapy in 32 patients with resectable stage II/stage III gastroesophageal cancer together with an in-depth evaluation of pathological, molecular and functional immune responses. Primary endpoint was safety; the secondary endpoint was feasibility; exploratory endpoints included pathological complete (pCR) and major pathological response (MPR), recurrence-free survival (RFS) and overall survival (OS). The study met its primary safety endpoint in Arm A, although Arm B required modification to mitigate toxicity. pCR and MPR rates were 40% and 53.5% for Arm A and 21.4% and 57.1% for Arm B. Most common adverse events were fatigue, nausea, thrombocytopenia and dermatitis. Overall, 2-year RFS and OS rates were 72.5% and 82.6%, respectively. Higher baseline programmed cell death ligand 1 (PD-L1) and LAG-3 expression were associated with deeper pathological responses. Exploratory analyses of circulating tumor DNA (ctDNA) showed that patients with undetectable ctDNA post-ICI induction, preoperatively and postoperatively had a significantly longer RFS and OS; ctDNA clearance was reflective of neoantigen-specific T cell responses. Our findings provide insights into the safety profile of combined PD-1 and LAG-3 blockade in gastroesophageal cancer and highlight the potential of ctDNA analysis to dynamically assess systemic tumor burden during neoadjuvant ICI that may open a therapeutic window for future intervention. ClinicalTrials.gov registration: NCT03044613 .
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Affiliation(s)
- Ronan J Kelly
- The Charles A. Sammons Cancer Center, Baylor University Medical Center, Dallas, TX, USA.
| | - Blair V Landon
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ali H Zaidi
- Allegheny Health Network Cancer Institute, Allegheny Health Network, Pittsburgh, PA, USA
| | - Dipika Singh
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Bloomberg-Kimmel Institute of Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jenna V Canzoniero
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Archana Balan
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Russell K Hales
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Radiation Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - K Ranh Voong
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Radiation Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard J Battafarano
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Blair A Jobe
- Allegheny Health Network Cancer Institute, Allegheny Health Network, Pittsburgh, PA, USA
| | - Stephen C Yang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stephen Broderick
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jinny Ha
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kristen A Marrone
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Bloomberg-Kimmel Institute of Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gavin Pereira
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nisha Rao
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aryan Borole
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Katerina Karaindrou
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Zineb Belcaid
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - James R White
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Suqi Ke
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Ali I Amjad
- Allegheny Health Network Cancer Institute, Allegheny Health Network, Pittsburgh, PA, USA
| | - Benny Weksler
- Allegheny Health Network Cancer Institute, Allegheny Health Network, Pittsburgh, PA, USA
| | - Eun Ji Shin
- Department of Gastroenterology & Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elizabeth Thompson
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kellie N Smith
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Bloomberg-Kimmel Institute of Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Drew M Pardoll
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Bloomberg-Kimmel Institute of Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Chen Hu
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Josephine L Feliciano
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Valsamo Anagnostou
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- The Bloomberg-Kimmel Institute of Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Lung Cancer Precision Medicine Center of Excellence, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Vincent K Lam
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Landon BV, Kelly RJ, Zaidi AH, Balan A, Canzoniero JV, Pereira G, Belcaid Z, Hales RK, Voong KR, Battafarano RJ, Jobe BA, Yang SC, Broderick S, Ha J, Smith KN, Thompson E, Shaikh FY, White JR, Sears CL, Shin EJ, Amjad AI, Weksler B, Feliciano JL, Hu C, Lam VK, Anagnostou V. Abstract 3374: Circulating cell-free tumor DNA dynamics capture minimal residual disease with neoadjuvant immune checkpoint blockade plus chemoradiotherapy for patients with operable esophageal/gastroesophageal junction cancer. Cancer Res 2023. [DOI: 10.1158/1538-7445.am2023-3374] [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: 04/07/2023]
Abstract
Abstract
Introduction: There is a critical need to incorporate molecular assessments of minimal residual disease (MRD) during neoadjuvant immunotherapy, in order to identify individuals at high risk for disease recurrence based on analyses of circulating cell-free tumor DNA (ctDNA) landscapes. Here we employed longitudinal liquid biopsies to dynamically assess clinical outcomes with neoadjuvant immuno-chemoradiotherapy in patients with esophageal/gastroesophageal junction (E/GEJ) cancer.
Methods: We utilized targeted error-correction sequencing to perform high-depth ctDNA next-generation sequencing for 141 serial plasma and 32 matched white blood cell (WBC) DNA samples from 32 patients with operable stage II/III E/GEJ cancer that received neoadjuvant immune checkpoint blockade (ICB) with chemoradiotherapy prior to surgery (NCT03044613). ctDNA analyses were performed at baseline, post-ICB induction, after completion of chemoradiotherapy (pre-op), and post-operatively (post-op). Using a tumor-agnostic WBC DNA-informed panel NGS approach we determined the cellular origin of plasma variants, filtering out germline and clonal hematopoiesis (CH) variants and evaluated ctDNA clonal dynamics over time. Molecular MRD was evaluated post-ICB, pre-op and post-op and correlated with recurrence-free (RFS) and overall survival (OS).
Results: Twenty out of 32 patients had detectable ctDNA at any timepoint. Of the 12 patients with undetectable ctDNA, 9 had only CH- and/or germline-derived variants, while 3 patients had no detectable variants of any origin. ctDNA clearance post-ICB was correlated with tumor regression >80% at the time of resection (Fischer’s exact p=0.04). The subset of patients that did not attain complete pathologic response was heterogeneous with respect to ctDNA dynamics; such that ctDNA clearance pre-op identified patients with longer OS despite residual tumor of >0% at the time of resection (log rank p=0.06). Patients with undetectable ctDNA or ctDNA clearance pre-op had a longer RFS (log rank p=0.007) and OS (log rank p=0.03). Molecular MRD was associated with RFS and OS such that patients with ctDNA clearance post-op had longer RFS (log-rank p=0.007) and OS (log-rank p=0.017).
Conclusion: ctDNA clearance post-ICB, pre-op and post-op reflects differential clinical outcomes for patients with E/GEJ cancer receiving neoadjuvant immuno-chemoradiotherapy. Understanding ctDNA dynamics and their relationship with pathological response and long-term outcomes can help identify patients at higher risk for recurrence and open a therapeutic window for future intervention.
Citation Format: Blair V. Landon, Ronan J. Kelly, Ali H. Zaidi, Archana Balan, Jenna V. Canzoniero, Gavin Pereira, Zineb Belcaid, Russell K. Hales, K Ranh Voong, Richard J. Battafarano, Blair A. Jobe, Stephen C. Yang, Stephen Broderick, Jinny Ha, Kellie N. Smith, Elizabeth Thompson, Fyza Y. Shaikh, James R. White, Cynthia L. Sears, Eun J. Shin, Ali I. Amjad, Benny Weksler, Josephine L. Feliciano, Chen Hu, Vincent K. Lam, Valsamo Anagnostou. Circulating cell-free tumor DNA dynamics capture minimal residual disease with neoadjuvant immune checkpoint blockade plus chemoradiotherapy for patients with operable esophageal/gastroesophageal junction cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 3374.
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Affiliation(s)
| | | | - Ali H. Zaidi
- 3Allegheny Health Network Cancer Institute, Pittsburgh, PA
| | - Archana Balan
- 1Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Gavin Pereira
- 1Johns Hopkins University School of Medicine, Baltimore, MD
| | - Zineb Belcaid
- 1Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - K Ranh Voong
- 1Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Blair A. Jobe
- 3Allegheny Health Network Cancer Institute, Pittsburgh, PA
| | | | | | - Jinny Ha
- 1Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Fyza Y. Shaikh
- 1Johns Hopkins University School of Medicine, Baltimore, MD
| | - James R. White
- 1Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Eun J. Shin
- 1Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ali I. Amjad
- 3Allegheny Health Network Cancer Institute, Pittsburgh, PA
| | - Benny Weksler
- 3Allegheny Health Network Cancer Institute, Pittsburgh, PA
| | | | - Chen Hu
- 1Johns Hopkins University School of Medicine, Baltimore, MD
| | - Vincent K. Lam
- 1Johns Hopkins University School of Medicine, Baltimore, MD
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Pracon R, Spertus JA, Broderick S, Bangalore S, Rockhold FW, Ruzyllo W, Demchenko E, Mavromatis K, Stone GW, Mancini GBJ, Boden WE, Newman JD, Reynolds HR, Hochman JS, Maron DM. Factors associated with early catheterization in patients randomized to the conservative strategy in the ISCHEMIA Trial. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1215] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
In the ISCHEMIA trial, individuals randomized to the conservative strategy (CON) could undergo coronary catheterization (cath) for suspicion of an endpoint event, persistent symptoms despite optimal medical therapy, or through protocol non-adherence. Understanding the reasons for cath in CON participants can aid in ISCHEMIA results interpretation.
Purpose
To describe the frequency of and factors associated with early cath in ISCHEMIA CON participants.
Methods
A prespecified, post-hoc analysis of the 2591 CON participants was performed with multivariable analyses to identify independent factors associated with cath within 6 months of randomization (“early cath”).
Results
Overall 8.7% (225/2591) of CON participants underwent an early cath: with 4.6% (119/2591) for a suspected endpoint, 1.6% (41/2591) for medical treatment failure, and 2.6% (67/2591) for protocol non-adherence; 67% of all these caths (151/225) occurred within the first 3 months from randomization. Independent factors associated with cath among CON participants included daily (HR=5.84, CI: 2.73–12.47, p<0.01) and weekly (HR=2.64, CI: 1.52–4.58, p<0.01) baseline angina vs no angina, severe (HR=2.02, CI: 1.03–3.95, p=0.04) and moderate baseline quality of life impairment vs no impairment (HR=2.03, CI: 1.24–3.33, p=0.01), randomization in Europe vs Asia (HR=1.83, CI: 1.15–2.9, p=0.01), with the proviso that all these characteristics were associated with cath occurring within the first 3 months of follow-up (very early cath), but not those between 3 and 6 months (proportional hazard assumption violation). Other factors independently associated with early cath were new or increasing angina pattern over 3 months pre-randomization (HR=1.79, CI: 1.33–2.39, p<0.0001) and increases in anti-anginal medication use during follow-up (HR=1.45, CI: 1.06–1.98, p=0.02). Baseline LDL-C <70mg/dL (HR=0.65 CI: 0.46–0.91, p=0.01) and a subsiding angina pattern during follow-up (HR=0.65, CI: 0.6–0.71, p<0.01) were independently associated with a reduced hazard of early cath. Neither ischemia severity nor extent of atherosclerosis on coronary imaging showed association with cath in CON participants at 6 months.
Conclusions
The rate of early cath in the ISCHEMIA CON strategy was low and driven mainly by a suspected endpoint event. Severe/moderate baseline angina and quality of life impairment were independently associated with very early cath. Chances of early cath were greater with worsening pre-randomization angina and need for additional antianginal medication, and less with well controlled LDL-C and decreasing angina pattern. The baseline severity of ischemia or extent of disease on coronary imaging were not related to early cath. These results give important insight into the coronary disease treatment trajectory in the conservative strategy of the ISCHEMIA trial, further inform real-life decision making and point to the efficacy of optimal medical therapy in reducing the need for cath.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institutes of Health, National Heart Lunch and Blood Institute
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Affiliation(s)
- R Pracon
- National Institute of Cardiology , Warsaw , Poland
| | - J A Spertus
- University of Missouri , Kansas City , United States of America
| | - S Broderick
- Duke Clinical Research Institute , Durham , United States of America
| | - S Bangalore
- New York University School of Medicine , New York , United States of America
| | - F W Rockhold
- Duke Clinical Research Institute , Durham , United States of America
| | - W Ruzyllo
- National Institute of Cardiology , Warsaw , Poland
| | - E Demchenko
- Almazov National Medical Research Centre , Saint-Petersburg , Russian Federation
| | - K Mavromatis
- Emory University School of Medicine , Atlanta , United States of America
| | - G W Stone
- Columbia University Medical Center , New York , United States of America
| | | | - W E Boden
- Boston VA Healthcare System , Boston , United States of America
| | - J D Newman
- New York University School of Medicine , New York , United States of America
| | - H R Reynolds
- New York University School of Medicine , New York , United States of America
| | - J S Hochman
- New York University School of Medicine , New York , United States of America
| | - D M Maron
- Stanford University Medical Center , Stanford , United States of America
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Khan H, Awan A, Shishikura M, Blevins C, Rodgers K, Mei Y, Nizam W, Ishiyama S, Chen Y, Battafarano R, Bush E, Broderick S, Yang S, Orita H, Huang P, Tam A, Ha J, Housseau F, Brock M. Abstract 271: Monitoring of CCR2 and CCR5 expression on circulating myeloid derived suppressor cells (MDSCs) in non-small cell lung cancer as a correlate of minimum residual disease. Cancer Res 2022. [DOI: 10.1158/1538-7445.am2022-271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Objectives: Myeloid derived suppressor cells (MDSCs) are immature cells that aid in cancer progression and dissemination via immune system suppression. Previous work has shown that CCR 2 (C-C chemokine receptor) and CCR 5 expression on MDSCs is increased in non-small cell lung cancer (NSCLC). We hypothesized that patients with lung cancer will have detectable peripheral MDSCs with CCR2 and CCR5 expression preoperatively, that it would decrease immediately postoperatively, and then increase longitudinally if tumor recurs.
Materials & Methods: As part of a prospective longitudinal study, whole blood samples were obtained from patients suspected to have primary lung cancer prior to surgery. Patients were excluded if they were minors, could not provider consent, had malignancy within the past 10 years or any immunosuppressive condition. Blood samples were obtained prior to surgery or at follow-up in clinic and processed within 1 hour of acquisition. We stained samples via 2 different methods: 1) whole blood and 2) peripheral blood mononuclear cells (PBMC) extracted from Ficoll density gradient and determined that whole blood staining had superior results. Samples were analyzed via flow cytometer and gated after defining MO (monocytic)-MDSCs as CD33+HLADRlow/-CD14+ and PMN-MDSCs as CD33+HLADR-CD15+. MDSCs were reported as a percentage of live leukocytes and means were reported with T-test performed for statistical analysis.
Results: A total of 18 patients were recruited with a median age of 69 years (63.8-75) and 61% (11/18) females. Adenocarcinoma was present in 16, carcinoid tumor in 1 and both adenocarcinoma and carcinoid tumor in 1 patient. Stage I and Stage II were the most common (66.7% and 22.2%, respectively). Majority of the tumors were in the right upper lobe (55.6%). There were 7 healthy controls with a median age of 29 years (28-43) and 71% females. There was a significantly increased proportion of MO-MDSCs in NSCLC patients preoperatively compared to healthy controls (11.64% versus 5.02%, p = 0.02). CCR2+CCR5+ MO-MDSCs were 0.85% in patients versus 0.06% in controls (p=0.04). No differences were noted with PMN-MDSCs. Five patients had post-operative follow up (mean 152 days) with an average decrease of 63% in MO-MDSCs, 68% in CCR2+CCR5+ MO-MDSCs and no recurrence of tumor on CT scans.
Conclusion: Early results of this on-going study demonstrate the detection of circulating CCR2+CCR5+ MO-MDSCs in the preoperative whole blood of NSCLC patients compared to healthy controls. Resection of the tumor is associated with a decrease of these MO-MDSCs after treatment. We are evaluating if any increase in CCR2+CCR5+ MO-MDSC in long term will allow us to use it as an adjuvant tool along with CT monitoring as a biomarker of residual or recurrent disease.
Citation Format: Hamza Khan, Anas Awan, Maria Shishikura, Carley Blevins, Kristen Rodgers, Yuping Mei, Wasay Nizam, Shun Ishiyama, Yun Chen, Richard Battafarano, Errol Bush, Stephen Broderick, Stephen Yang, Hajime Orita, Peng Huang, Ada Tam, Jinny Ha, Franck Housseau, Malcolm Brock. Monitoring of CCR2 and CCR5 expression on circulating myeloid derived suppressor cells (MDSCs) in non-small cell lung cancer as a correlate of minimum residual disease [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 271.
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Affiliation(s)
- Hamza Khan
- 1Johns Hopkins University, Baltimore, MD
| | - Anas Awan
- 1Johns Hopkins University, Baltimore, MD
| | | | | | | | - Yuping Mei
- 1Johns Hopkins University, Baltimore, MD
| | | | | | - Yun Chen
- 1Johns Hopkins University, Baltimore, MD
| | | | - Errol Bush
- 1Johns Hopkins University, Baltimore, MD
| | | | | | | | - Peng Huang
- 1Johns Hopkins University, Baltimore, MD
| | - Ada Tam
- 1Johns Hopkins University, Baltimore, MD
| | - Jinny Ha
- 1Johns Hopkins University, Baltimore, MD
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Shaikh FY, White JR, Kelly RJ, Zaidi AH, Canzoniero JV, Feliciano JL, Hales RK, Voong KR, Battafarano RJ, Jobe BA, Yang SC, Broderick S, Ha J, Smith KN, Thompson E, Shin EJ, Amjad AI, Guerrieri P, Weksler B, Hu C, Anagnostou V, Lam VK, Sears CL. Abstract 1973: Patients with operable esophageal cancer and improved responses to combined chemoradiotherapy and immunotherapy display distinct microbiome profiles enriched in multiple Bacteroides species. Cancer Res 2022. [DOI: 10.1158/1538-7445.am2022-1973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Preclinical and clinical data indicate that neoadjuvant chemoradiotherapy (CRT) may prime an anti-tumor immunological response in esophageal cancer driven by intratumoral CD8+ T cells and PD-L1 expression. LAG-3 is also highly expressed in esophagogastric cancers. The microbiome, a novel and potentially modifiable, biomarker of IO response, has not yet been examined in the neoadjuvant setting in esophageal cancer and is the goal of our study.
Methods: Fecal samples were collected from patients with stage II/III esophageal or gastroesophageal junction carcinoma eligible for curative resection treated with the standard of care regimen of carboplatin paclitaxel (50mg/m2), radiation 50.4 Gy in 28 fractions and an Ivor-Lewis esophagectomy 6-10 weeks after last CRT and immunotherapy (IO) dose. Patients on arm A (n=11) received 2 cycles of induction with nivolumab plus 3 additional cycles on week 1, 3 and 5 of CRT. Patients on arm B (n=8) received nivolumab plus relatlimab on the same schedule (Clinical trial: NCT03044613). We examined longitudinal fecal samples from n=19 patients across both arms (n=90 samples) using 16S rRNA amplicon sequencing. Patients were classified based on pathological response: complete response (CR) and grades 1, 2, and 3 (G1, G2, G3) with increasing residual tumor visible in the resected specimen. Sequencing data was trimmed and filtered for contaminants, followed by high-resolution taxonomic assignment and normalization of reads across all samples. Analysis was performed using multiple metrics for alpha diversity and beta-diversity, with principal coordinates analysis/PERMANOVA, and pathway analysis using Phylogenetic Investigation of Communities by Reconstruction of Unobserved States (PICRUSt).
Results: Patients with improved response in the neoadjuvant setting (CR/G1 vs G2/G3) grouped in distinct clusters using Bray-Curtis (p < 0.001). Patients with CR had higher alpha diversity, using both measures of richness and evenness, compared to patients with a G3 responses (p < 0.03). Specifically, family Bacteroidaceae and genus Bacteroides were enriched in patients with CR vs G3 (p < 0.02). At the species level, B. finegoldii, B. ovatus, and B. uniformis were enriched in patients with CR vs G3 (p < 0.02). In contrast, genus Klebsiella and Clostridium termitidis were enriched in patients with a poor response, G3 (p <0.001, both). Pathway analysis found two metabolic pathways enriched in patients with CR: secondary bile acid biosynthesis (p=0.005) and lysine biosynthesis (p=0.02).
Conclusions: Patients with operable esophageal cancer and improved responses to combined CRT and IO had distinct microbiome profiles enriched in multiple Bacteroides species. Further analyses and validation efforts are underway to confirm metabolomic pathways.
Citation Format: Fyza Y. Shaikh, James R. White, Ronan J. Kelly, Ali H. Zaidi, Jenna V. Canzoniero, Josephine L. Feliciano, Russell K. Hales, K Ranh Voong, Richard J. Battafarano, Blair A. Jobe, Stephen C. Yang, Stephen Broderick, Jinny Ha, Kellie N. Smith, Elizabeth Thompson, Eun J. Shin, Ali I. Amjad, Patrizia Guerrieri, Benny Weksler, Chen Hu, Valsamo Anagnostou, Vincent K. Lam, Cynthia L. Sears. Patients with operable esophageal cancer and improved responses to combined chemoradiotherapy and immunotherapy display distinct microbiome profiles enriched in multiple Bacteroides species [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 1973.
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Affiliation(s)
| | | | | | | | | | | | | | - K Ranh Voong
- 1Johns Hopkins School of Medicine, Baltimore, MD
| | | | | | | | | | - Jinny Ha
- 1Johns Hopkins School of Medicine, Baltimore, MD
| | | | | | - Eun J. Shin
- 1Johns Hopkins School of Medicine, Baltimore, MD
| | | | | | | | - Chen Hu
- 1Johns Hopkins School of Medicine, Baltimore, MD
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Provencio-Pulla M, Spicer J, Taube JM, Martin C, Spigel DR, Wang C, Girard N, Lu S, Mitsudomi T, Awad MM, Felip E, Brahmer JR, Broderick S, Swanson S, Kerr K, Li L, Cai J, Bushong J, Tran P, Forde PM. Neoadjuvant nivolumab (NIVO) + platinum-doublet chemotherapy (chemo) versus chemo for resectable (IB–IIIA) non-small cell lung cancer (NSCLC): Association of pathological regression with event-free survival (EFS) in CheckMate 816. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.17_suppl.lba8511] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
LBA8511 Background: Several studies have shown an association of pathological response, a common efficacy endpoint in neoadjuvant therapy trials, with survival for chemo in various cancers including resectable NSCLC. However, the association between pathological complete response (pCR) and survival as well as the degree of pathological regression that may be predictive of EFS for neoadjuvant immunotherapy has not been rigorously studied. CheckMate 816 (NCT02998528), a randomized phase 3 study of neoadjuvant NIVO + chemo vs chemo in resectable NSCLC, met both of its primary endpoints with a statistically significant and clinically meaningful improvement in EFS and pCR. Here, we report a post hoc analysis from CheckMate 816, characterizing the association between pathological regression and EFS. Methods: Adults with resectable NSCLC were randomized to NIVO 360 mg + platinum-doublet chemo Q3W or chemo alone Q3W for 3 cycles. Primary endpoints were EFS and pCR (0% residual viable tumor [RVT] in the primary tumor [PT] and lymph nodes [LN] based on immune-related pathological response criteria), both assessed by blinded independent review. Major pathological response (MPR; ≤10% RVT in the PT and LN) was a secondary endpoint. In this post hoc analysis, EFS was assessed based on depth of pathological regression (measured by %RVT) in the PT only. Also, a time-dependent receiver operating characteristic curve analysis assessed the predictive ability of %RVT (PT only) for EFS outcome at 2 years, using area under the curve (AUC) to summarize the overall diagnostic accuracy (0.5 = random chance; 1 = perfect accuracy). Results: Baseline characteristics in patients (pts) with pathologically evaluable samples were well balanced between the NIVO + chemo and chemo arms, similar to the overall population. In both treatment arms, EFS (minimum follow-up, 21 months) was improved in pts with vs without pCR or MPR (Table). %RVT appeared to be predictive of EFS at 2 years for NIVO + chemo (AUC = 0.74) but an association was not clear for chemo (AUC = 0.54). 2-year EFS rates for NIVO + chemo were 90%, 60%, 57%, and 39% for pts with 0–5%, >5–30%, >30–80%, and >80% RVT, respectively. Conclusions: In CheckMate 816, pathological response (pCR and MPR) in the PT was associated with improved EFS with neoadjuvant NIVO + chemo. Additionally, depth of pathological regression appeared to be predictive of improved EFS. Clinical trial information: NCT02998528. [Table: see text]
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Affiliation(s)
| | | | - Janis M. Taube
- Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins Kimmel Cancer Center, Baltimore, MD
| | | | | | - Changli Wang
- Tianjin Lung Cancer Center, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Nicolas Girard
- Institut du Thorax Curie-Montsouris, Institut Curie, Paris, France
| | - Shun Lu
- Shanghai Lung Cancer Center, Shanghai Chest Hospital, Shanghai, China
| | | | | | - Enriqueta Felip
- Vall d’Hebron University Hospital, Vall d’Hebron Institute of Oncology, Barcelona, Spain
| | - Julie R. Brahmer
- Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins Kimmel Cancer Center, Baltimore, MD
| | - Stephen Broderick
- Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins Kimmel Cancer Center, Baltimore, MD
| | | | - Keith Kerr
- Aberdeen Royal Infirmary, Aberdeen, United Kingdom
| | - Li Li
- Bristol Myers Squibb, Princeton, NJ
| | | | | | | | - Patrick M. Forde
- Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins Kimmel Cancer Center, Baltimore, MD
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Liang KL, Feliciano JL, Marrone K, Murray JC, Tackett S, Hales RK, Voong KR, Battafarano RJ, Yang S, Broderick S, Ha JS, Forde PM, Brahmer JR, Lam VK. Clinical and molecular characteristics of advanced esophageal/GEJ cancer with brain metastasis. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e16092] [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
e16092 Background: Brain metastasis (BRM) in gastroesophageal (GE) cancer is uncommon, but contributes to poor prognosis and significant symptom burden. While HER2 overexpression has been suggested as a potential driver of BRM, clinicopathologic and molecular determinants of BRM in GE cancer and their impact on clinical outcome remain incompletely understood. Methods: We retrospectively analyzed clinicopathologic data from 323 advanced esophageal/GEJ patients (pts) at Johns Hopkins from 2003 to 2021. Univariate and multivariate logistic regression were performed to investigate the association between several clinical and molecular features and the occurrence of BRM, with particular focus on HER2 overexpression (by IHC and FISH) and PD-L1 expression (by IHC) as measured by the combined positive score (CPS). Overall survival was estimated using the Kaplan-Meier method. Results: Median age was 64 and most pts were white (90.4%). Tumors were 73.7% esophageal primary, 82.7% adenocarcinoma, 43.8% HER2+, and 11.1% CPS ≥ 1. Cumulative incidence of BRM in overall cohort and within HER2+ subgroup was 14.6% (47 pts) and 25.4% (16 pts), respectively. Pts with BRM (not already present at time of stage IV diagnosis) had median onset of 10.8 months. Seventeen (36.2%) pts had a solitary brain lesion and 10 (21.7%) were asymptomatic. On univariate analysis, adenocarcinoma and HER2 overexpression were associated with increased risk of BRM (OR 3.45; 95% CI 0.09-0.96; p = 0.043 and OR 2.72; 95% CI 1.11-6.67; p = 0.028, respectively). Notably, the HER2 association was strengthened when HER2 equivocal tumors were re-classified as positive in an exploratory analysis (OR 3.55; 95% CI 1.38-9.14; p = 0.009). Adenocarcinoma and HER2 overexpression were collinear in the multivariate model. In pts with BRM, OS was improved in HER2+ pts (16.72 months; 95% CI 12.3-21.1 months; log-rank p = 0.039 and OR 0.33; 95% CI 0.11-0.99; Cox regression p = 0.049). CPS and primary tumor location were not associated with increased BRM. Conclusions: HER2 overexpression identifies an esophageal/GEJ molecular subtype that is significantly associated with increased risk of BRM; though with improved OS (compared to non-HER2+ BRM) and later onset CNS progression, likely reflecting durable extra-CNS control on targeted systemic therapy and a potential HER2+ subgroup with relatively indolent biology. Prevalence of asymptomatic and solitary brain lesions supports increased brain surveillance for this population.
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Affiliation(s)
- Kai-li Liang
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Kristen Marrone
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | - Joseph Christopher Murray
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sean Tackett
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - Russell K. Hales
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - K. Ranh Voong
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Richard James Battafarano
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Stephen Yang
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Stephen Broderick
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jinny Suk Ha
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Patrick M. Forde
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Vincent K. Lam
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
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Rosner S, Reuss JE, Zahurak M, Taube JM, Broderick S, Jones DR, Chaft JE, Forde PM. Neoadjuvant nivolumab in early-stage non–small cell lung cancer (NSCLC): Five-year outcomes. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.8537] [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
8537 Background: Neoadjuvant (neoadj) immune checkpoint blockade (ICB) with anti-PD-1 therapy has shown increasing promise for early stage NSCLC, with long-term clinical outcomes still maturing. Our group reported the first phase I/II trial of neoadj nivolumab (nivo) in resectable NSCLC, finding therapy to be safe and feasible. We now present final clinical results from this cohort, representing the longest follow up data for neoadj anti-PD-1 to date. Methods: Two doses of neoadj nivo (3 mg/kg) were given prior to resection in 21 patients (pts) with resectable NSCLC. 5-year (yr) follow-up data, including recurrence-free survival (RFS), overall survival (OS) and association with pathologic response were tabulated. Event time distributions were estimated with the Kaplan-Meier method. All p-values are two-sided with 0.05 significance level. Results: At a median follow up of 63 months, 3-, 4- and 5-yr survival rates were 85, 80, and 80% respectively. RFS rates at 3-, 4- and 5-yrs were 65, 60, and 60% respectively. As previously reported, major pathologic response (MPR: ≤10% viable tumor) was 45%, and pathologic complete response (pCR) rate was 10%. The hazard ratio (HR) for pathologic down-staging was in the direction of improved RFS, without meeting statistical significance (HR 0.36, 95% CI 0.07-1.75, p = 0.2). RFS HR estimates for MPR and an alternative pathologic cut-off of less than 50% residual tumor (RT), were 0.61, (95% CI 0.15-2.44, p = 0.48) and 0.36, (95% CI 0.09-1.51, p = 0.16) respectively. The direction of the effect of pre-treatment PD-L1 positivity (≥1%) was to improve RFS (HR 0.36, 95% CI 0.07-1.85, p = 0.22). At 5-yr follow up, 8 of 9 (89%) pts with MPR were alive and no cancer deaths have occurred. Amongst pts with MPR, 1/9 pts had a cancer recurrence in the mediastinum treated successfully with definitive chemoradiotherapy. Both pts with pCR are alive and without recurrence. Patterns of all recurrences in this cohort are summarized in table 1. No long-term immune-related adverse events have occurred other than one G3 dermatologic event. Conclusions: The 5-yr clinical outcomes for neoadj nivo in resectable NSCLC compare favorably to historical trends. MPR trended toward improved RFS, while definitive conclusions are limited by our cohort size and overall low recurrence rate. Thresholds of %RT beyond pCR and MPR in this setting should be explored in larger prospective studies. PD-L1 expression may play a role in predicting long-term response, but larger prospective studies are needed. Clinical trial information: NCT02259621. [Table: see text]
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Affiliation(s)
| | - Joshua E. Reuss
- Georgetown Lombardi Comprehensive Cancer Center, Washington, DC
| | - Marianna Zahurak
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD
| | - Janis M. Taube
- Johns Hopkins Departments of Dermatology, Pathology, Oncology and Bloomberg/Kimmel Institute for Cancer Immunotherapy, Baltimore, MD
| | - Stephen Broderick
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Patrick M. Forde
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
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Kelly RJ, Zaidi AH, Canzoniero JV, Feliciano JL, Hales RK, Voong KR, Battafarano RJ, Jobe BA, Yang S, Broderick S, Ha JS, Smith KN, Thompson ED, Shaikh F, Shin EJ, Amjad AI, Guerrieri P, Hu C, Anagnostou V, Lam VK. Multicenter phase II study of neoadjuvant nivolumab or nivolumab plus relatlimab (anti-LAG3 antibody) plus chemoradiotherapy in stage II/III esophageal/gastroesophageal junction (E/GEJ) carcinoma. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.4_suppl.321] [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
321 Background: The phase III CheckMate 577 study resulted in adjuvant nivolumab becoming a new standard of care for patients with completely resected E/GEJ cancer with residual pathologic disease post neoadjuvant chemoradiotherapy. We evaluated if neoadjuvant nivolumab (N) or nivolumab/relatlimab (N/R) combined with chemoradiotherapy (CRT) can further improve patient outcomes. Methods: Patients with stage II/III E/GEJ carcinoma eligible for curative resection were treated with standard of care regimen of carboplatin (AUC2), paclitaxel (50mg/m2), RT 41.1Gy in 23 fractions and an Ivor-Lewis esophagectomy (E/MIE) 6-10 weeks after last CRT/IO dose. Patients on arm A (n=16) received 2 cycles of induction N (240mg q2 wks) plus three additional cycles of N on week 1, 3 and 5 of CRT. After safety and feasibility evaluation of arm A, patients on arm B (n=16) received N (240mg q 2 wks) plus R (80mg q 2 wks) following the same schedule. The primary endpoints of the study were safety and feasibility. Secondary endpoints include pCR, MPR (<10% residual cancer cells), DFS and OS. We also evaluated pathologic response and molecular ctDNA responses via longitudinal targeted error correction sequencing. Results: From August 2017 to July 2021, 32 patients were enrolled. Median age 65 (39 to 73), male 81%, adeno/SCC (87.5%, 12.5%). CRT combined with N on arm A was well tolerated with 4/16 (25%, 95% CI: 9.3-52.6%) reporting grade 3 AEs. Dual IO inhibition targeting PD1 and LAG3 combined with CRT on arm B demonstrated unacceptable toxicities as per predefined early stopping rule after 9 patients which resulted in a protocol amendment; 6/9 patients (66%) in arm B developed G3 or higher IO-related toxicities including pericarditis (2/9, 22%) and adrenal insufficiency (2/9, 22%). The amended arm B (n=7) involved induction N + R for 2 cycles prior to standard CRT and was well tolerated. In 31 evaluable patients to date, the pCR rate is 29.0% (95% CI: 14.9-48.2%), (arm A, pCR 6/16 (37.5%, 95% CI: 16.3-64.1%) and MPR 8/16 (50.0%, 95% CI: 28.0-72.0%) (arm B, pCR 3/15 (20.0%, 95% CI: 5.3-48.6% and MPR 8/15 (53.3%, 95% CI: 27.4-77.7%). With a median follow-up time of 30m, the median DFS is 35.4m (95% CI: 24.7-NA) and 1 year DFS rate of 79.1% (95% CI: 65.5-95.6%). For patients in Arm A (arm B data pending), ctDNA clearance was associated with pathologic response, while ctDNA persistence was linked with disease recurrence. Conclusions: The addition of N to preoperative CRT is safe and is associated with a higher MPR rate and pCR in Arm A compared to historical controls. In this study, neoadjuvant anti PD-1/LAG3 combination IO-IO strategies with CRT were challenging due to enhanced IR toxicities. In depth immune correlates and liquid biopsy analyses will be presented. Clinical trial information: NCT03044613.
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Affiliation(s)
| | | | | | | | - Russell K. Hales
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - K. Ranh Voong
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | - Richard James Battafarano
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Stephen Yang
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Stephen Broderick
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jinny Suk Ha
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kellie Nicole Smith
- Johns Hopkins Kimmel Cancer Center and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Baltimore, MD
| | - Elizabeth D. Thompson
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD
| | - Fyza Shaikh
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | - Eun Ji Shin
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ali Imran Amjad
- The Esophageal and Lung Institute, Allegheny Health Network, Pittsburgh, PA
| | - Patrizia Guerrieri
- The Esophageal and Lung Institute, Allegheny Health Network, Pittsburgh, PA
| | - Chen Hu
- Johns Hopkins University School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | - Valsamo Anagnostou
- Johns Hopkins University School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | - Vincent K. Lam
- The University of Texas MD Anderson Cancer Center, Houston, TX
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Alfaifi S, Chu R, Hui X, Broderick S, Hooker C, Brock M, Bush E, Hales R, Anderson L, Hoff J, Friedes C, Han-Oh S, Mcnutt T, Ha J, Yang S, Battafarano R, Feliciano J, Voong KR. Trimodality therapy for esophageal cancer: The role of surgical and radiation treatment parameters in the development of anastomotic complications. Thorac Cancer 2021; 12:3121-3129. [PMID: 34651445 PMCID: PMC8636205 DOI: 10.1111/1759-7714.14130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/13/2021] [Accepted: 08/14/2021] [Indexed: 01/03/2023] Open
Abstract
Background Here, we investigated the relationship between clinical parameters, including the site of surgical anastomosis and radiation dose to the anastomotic region, and anastomotic complications in esophageal cancer patients treated with trimodality therapy. Methods Between 2007 and 2016, esophageal cancer patients treated with trimodality therapy at a tertiary academic cancer center were identified. Patient, treatment, and outcome parameters were collected. Radiation dose to the gastric regions were extracted. Anastomotic complication was defined as leak and/or stricture. We used Fisher's exact and Wilcoxon rank‐sum tests to compare the association between clinical parameters and anastomotic complications. Results Of 89 patients identified, the median age was 63 years, 82% (n = 73) were male, and 82% had distal (n = 47) or gastroesophageal junction (n = 26) tumors. Median follow‐up was 25.8 months. Esophagectomies were performed with cervical (65%, n = 58) or thoracic anastomoses (35%, n = 31). Anastomotic complications developed in 60% (n = 53). Cervical anastomosis was associated with anastomotic complications (83%, n = 44/53, p < 0.01). Radiation to any gastric substructure was not associated with anastomotic complications (p > 0.05). In the subset of patients with distal/gastroesophageal junction tumors undergoing esophagectomy with cervical anastomosis where radiation was delivered to the future neoesophagus, 80% (n = 35/44) developed anastomotic complications. In this high‐risk subgroup, radiation was not associated with anastomotic complications (p > 0.05). Conclusions Our analysis did not demonstrate an association between radiation dose to gastric substructures and anastomotic complications. However, it showed an association between esophagectomy with cervical anastomosis and anastomotic complications. Patients with distal/gastroesophageal junction tumors who undergo esophagectomy with cervical anastomosis have higher rates of anastomotic complications unrelated to radiation to gastric substructures.
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Affiliation(s)
- Salem Alfaifi
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Robert Chu
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Xuan Hui
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Stephen Broderick
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Craig Hooker
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Malcolm Brock
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Errol Bush
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Russell Hales
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Lori Anderson
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jeffrey Hoff
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Cole Friedes
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sarah Han-Oh
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Todd Mcnutt
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jinny Ha
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Stephen Yang
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Richard Battafarano
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Joy Feliciano
- Departments of Medical Oncology, Johns Hopkins University, Baltimore, Maryland, USA
| | - K Ranh Voong
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
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Forde PM, Spicer J, Lu S, Provencio M, Mitsudomi T, Awad MM, Felip E, Broderick S, Brahmer J, Swanson SJ, Kerr K, Wang C, Saylors GB, Tanaka F, Ito H, Chen KN, Dorange C, Cai J, Fiore J, Girard N. Abstract CT003: Nivolumab (NIVO) + platinum-doublet chemotherapy (chemo) vs chemo as neoadjuvant treatment (tx) for resectable (IB-IIIA) non-small cell lung cancer (NSCLC) in the phase 3 CheckMate 816 trial. Clin Trials 2021. [DOI: 10.1158/1538-7445.am2021-ct003] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Canzoniero JV, Lam V, Belcaid Z, Lanis M, Rhymee L, Landon B, Balan A, Marrone K, Forde P, Levy B, Ettinger D, Schneider H, Rodavia H, Battafarano R, Yang S, Broderick S, Ha J, Jobe B, Zaidi A, Thompson E, Brahmer J, Velculescu V, Kelly R, Feliciano J, Anagnostou V. Abstract 538: Liquid biopsy approaches for determining pathologic response to neoadjuvant immunotherapy in esophageal cancer. Cancer Res 2021. [DOI: 10.1158/1538-7445.am2021-538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
We examined the utility of serial liquid biopsies to monitor clonal dynamics and predict pathologic response in patients with esophageal/gastroesophageal junction (E/GEJ) cancer undergoing treatment with neoadjuvant immunotherapy and concurrent chemoradiation (CA209-906; NCT03044613).
Methods: Using Targeted Error Correction sequencing (TEC-Seq), we performed high-depth next generation sequencing on 79 serial plasma samples from 16 patients with operable stage II/III E/GEJ cancer undergoing treatment with neoadjuvant nivolumab, followed by nivolumab plus chemo-radiation and surgery as part of the CA209-906 trial. Liquid biopsies were evaluated pre-treatment, after each of two cycles of neoadjuvant nivolumab, and after concurrent nivolumab and chemoradiation immediately prior to surgery, for an average of 4 time points per patient. Deep sequencing of matched leukocyte DNA and whole exome sequencing (WES) of pre-treatment tumors was performed. The origin of plasma variants was determined by comparison to tumor WES (tumor-derived) and leukocyte TEC-Seq (clonal hematopoiesis (CH)-derived or germline) and their clonal dynamics over time were evaluated. Resected tumors were reviewed by central pathology and percent residual tumor was estimated. Patients were followed for an average of 2 years post-surgery.
Results: Eight of 16 patients had detectable circulating tumor-derived DNA (ctDNA) at any time point. Additionally, 13 CH-derived mutations were detected in plasma of 8 patients. The number of CH-derived mutations was correlated with increasing patient age. Identification and removal of CH-derived mutations via comparison to matched leukocyte sequencing allowed for accurate assessment of kinetics of bona fide tumor-derived mutations in plasma. Tumor mutation burden as determined by tumor WES was not associated with pathological response (mean baseline mutations per exome 90 vs 81 for patients with residual disease >20% and <20% respectively). Detectable ctDNA at the last pre-surgery time point was found in 3 patients and was associated with residual tumor >20% (50% vs 23% with or without detectable ctDNA respectively). ctDNA clearance, defined as detectable ctDNA at one or more earlier time points that subsequently becomes undetectable before surgery, occurred in 5 patients and was associated with improved pathologic response (80% of patients with ctDNA clearance had residual tumor <=20% and no evidence of disease progression). Furthermore, of the three patients who did not have ctDNA clearance, two subsequently developed disease progression.
Conclusion: Comprehensive analyses of ctDNA from E/GEJ patients undergoing neoadjuvant immunotherapy with concurrent chemoradiation revealed ctDNA dynamics that were associated with pathologic response and disease recurrence. These approaches may be used to identify patients at high risk for disease progression.
Citation Format: Jenna VanLiere Canzoniero, Vincent Lam, Zineb Belcaid, Mara Lanis, Lamia Rhymee, Blair Landon, Archana Balan, Kristen Marrone, Patrick Forde, Benjamin Levy, David Ettinger, Heather Schneider, Hanika Rodavia, Richard Battafarano, Stephen Yang, Stephen Broderick, Jinny Ha, Blair Jobe, Ali Zaidi, Elizabeth Thompson, Julie Brahmer, Victor Velculescu, Ronan Kelly, Josephine Feliciano, Valsamo Anagnostou. Liquid biopsy approaches for determining pathologic response to neoadjuvant immunotherapy in esophageal cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 538.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Blair Jobe
- 2Alleghany Health Network, Pittsburgh, PA
| | - Ali Zaidi
- 2Alleghany Health Network, Pittsburgh, PA
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Belcaid Z, Balan A, Cherry C, Lanis M, Marrone K, Levy BP, Schneider H, Rodavia H, Jobe BA, Thompson E, Velculescu VE, Battafarano RJ, Yang S, Broderick S, Ha JS, Zaidi AH, Kelly RJ, Feliciano JL, Anagnostou V, Lam VK. Immunogenomic features of pathologic response to neoadjuvant immune checkpoint blockade in esophageal cancer. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.4042] [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
4042 Background: Improving immunotherapy efficacy remains an unmet need in esophagogastric cancer and a deeper understanding of tumor and immune system dynamics during therapy may tailor immuno-oncology approaches. Methods: We performed whole exome sequencing (WES) and bulk RNA sequencing (RNAseq) of 70 serial tumor samples from 23 patients with stage II/III esophageal/gastroesophageal junction (E/GEJ) cancer treated on a phase 1B clinical trial with neoadjuvant nivolumab with or without relatlimab (anti-LAG-3) and chemoradiation followed by surgery (NCT03044613; CA209-906). Pathologic response was measured by tumor regression at the time of resection. Median follow up was 23 months post-surgery. Serial tumor samples were collected prior to therapy, after 2 cycles of induction immune checkpoint blockade (ICB), and at the time of resection. Twenty-two baseline tumor/normal DNA pairs were analyzed by WES and 48 serial tumor samples were analyzed by RNAseq. WES data was analyzed to identify somatic mutations, generate tumor mutation burden (TMB) estimates and assess the fraction of expressed mutations in conjunction with RNAseq data. Immune cell subset composition was determined by RNAseq data deconvolution by CIBERSORT and gene set enrichment analyses were performed utilizing GSEA. B-cell density was inferred by immunoglobulin rearrangements detected by RNAseq. Results: Gene set enrichment expression analyses revealed an upregulation of effector pro-inflammatory cytokines after induction ICB. Interferon-gamma, interferon-alpha and TNF-alpha related genes were significantly upregulated after induction ICB compared to baseline (p < 0.0001). In contrast, significant downregulation of E2F targets (p = 0.002), G2M checkpoint genes (p = 0.005) and DNA damage repair genes (p = 0.004) was observed post ICB; enrichment analyses were independent of response to therapy and treatment arm. While TMB was not predictive of pathologic response (p = 0.22), patients with tumors harboring a higher number of expressed mutations were more likely to achieve a pathologic complete response (pCR; p = 0.026). RNAseq deconvolution analyses revealed a higher B-cell density post ICB induction in tumors with pCR (p = 0.018). Furthermore, an increased baseline content of intra-tumoral activated M1 macrophages differentiated tumors from patients achieving a pCR (p = 0.0034), which was further exemplified post induction ICB. Conclusions: Neoadjuvant immunotherapy induces an inflammatory immune response in the tumor microenvironment that is linked with tumor elimination and pathologic response. Our findings highlight the importance of nuanced multi-omics analyses to understand the wiring of response to immunotherapy and guide therapy for E/GEJ cancer.
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Affiliation(s)
- Zineb Belcaid
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Archana Balan
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christopher Cherry
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mara Lanis
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kristen Marrone
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Benjamin Philip Levy
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Heather Schneider
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Hanika Rodavia
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Blair A Jobe
- Esophageal and Lung Institute, Allegheny Health Network, Pittsburgh, PA
| | - Elizabeth Thompson
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Victor E. Velculescu
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Richard James Battafarano
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Stephen Yang
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Stephen Broderick
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jinny Suk Ha
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ali H Zaidi
- Esophageal and Lung Institute, Allegheny Health Network, Pittsburgh, PA
| | - Ronan Joseph Kelly
- The Charles A. Sammons Cancer Center, Baylor University Medical Center, Dallas, TX
| | | | - Valsamo Anagnostou
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Vincent K. Lam
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
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14
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Spicer J, Wang C, Tanaka F, Saylors GB, Chen KN, Liberman M, Vokes EE, Girard N, Lu S, Provencio M, Mitsudomi T, Awad MM, Felip E, Forde PM, Swanson S, Brahmer JR, Kerr K, Dorange C, Cai J, Broderick S. Surgical outcomes from the phase 3 CheckMate 816 trial: Nivolumab (NIVO) + platinum-doublet chemotherapy (chemo) vs chemo alone as neoadjuvant treatment for patients with resectable non-small cell lung cancer (NSCLC). J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.8503] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [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
8503 Background: CheckMate 816 (NCT02998528) is a randomized phase 3 study of neoadjuvant NIVO + chemo vs chemo in resectable NSCLC. The study met its first primary endpoint, demonstrating significantly improved pathological complete response (pCR) with neoadjuvant NIVO + chemo. Here we report key surgical outcomes from the study. Methods: Adults with stage IB (≥ 4 cm)–IIIA (per AJCC 7th ed) resectable NSCLC, ECOG PS ≤ 1, and no known EGFR/ ALK alterations were randomized to NIVO 360 mg + platinum-doublet chemo Q3W or chemo Q3W for 3 cycles (n = 179 each). Definitive surgery was to be performed within 6 weeks of treatment. Primary endpoints are pCR (defined as 0% viable tumor cells in lung and lymph nodes) and event-free survival; both are evaluated by blinded independent review. Feasibility of surgery and surgery-related adverse events (AEs) are exploratory endpoints. Results: Baseline characteristics were comparable between arms; 64% of patients (pts) were stage IIIA. Definitive surgery rates were 83% with NIVO + chemo (n = 149) vs 75% with chemo (n = 135). Reasons for cancelled surgery were disease progression (12 and 17 pts, respectively), AEs (2 pts/arm), or other scenarios (14 and 19 pts, respectively; including pt refusal, unresectability, poor lung function). Minimally invasive surgery rates were 30% and 22%, and conversion from minimally invasive to open surgery rates were 11% and 16% for NIVO + chemo and chemo, respectively. Lobectomy was performed in 77% vs 61% of pts, and pneumonectomy in 17% and 25% for NIVO + chemo vs chemo, respectively. AEs were responsible for delays of surgery in 6 pts in the NIVO + chemo arm and 9 pts in the chemo arm. An R0 resection was achieved in 83% vs 78% of pts and median residual viable tumor (RVT) cells in the primary tumor bed were 10% vs 74% for NIVO + chemo vs chemo. There was no increase in median (Q1, Q3) duration of surgery and length of hospitalization between NIVO + chemo vs chemo (184 [130, 252] vs 217 [150, 283] min; and 10.0 [7, 14] vs 10.0 [7, 14] days, respectively). Any-grade and grade 3–4 surgery-related AEs were reported in 41% vs 47% and 11% vs 15% of the NIVO + chemo vs chemo arms, respectively. Grade 5 surgery-related AEs were reported in 2 vs 0 pts in the NIVO + chemo vs chemo arms; 0 vs 3 pts died due to treatment-related AEs, respectively. Conclusions: In CheckMate 816, neoadjuvant NIVO + chemo did not impede the feasibility and timing of surgery, nor the extent or completeness of resection vs chemo alone; treatment was tolerable and did not increase surgical complications. NIVO + chemo led to increased depth of pathological response. The surgical outcome data from CheckMate 816 along with significant improvement in pCR support NIVO + chemo as a potential neoadjuvant option for patients with stage IB to IIIA resectable NSCLC. Clinical trial information: NCT02998528.
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Affiliation(s)
| | - Changli Wang
- Tianjin Lung Cancer Center, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Fumihiro Tanaka
- University of Occupational and Environmental Health, Kitakyushu, Japan
| | | | - Ke-Neng Chen
- Peking University School of Oncology, Beijing Cancer Hospital, Beijing, China
| | - Moishe Liberman
- Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | | | - Nicolas Girard
- Institut du Thorax Curie-Montsouris, Institut Curie, Paris, France
| | - Shun Lu
- Shanghai Lung Cancer Center, Shanghai Chest Hospital, Shanghai JiaoTong University, Shanghai, China
| | | | - Tetsuya Mitsudomi
- Kindai University Faculty of Medicine, Ohno-Higashi, Osaka-Sayama, Japan
| | | | - Enriqueta Felip
- Vall d’Hebron University Hospital, Vall d’Hebron Institute of Oncology, Barcelona, Spain
| | | | | | | | - Keith Kerr
- Aberdeen Royal Infirmary, Aberdeen, United Kingdom
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15
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Gastman B, Agarwal PK, Berger A, Boland G, Broderick S, Butterfield LH, Byrd D, Fecci PE, Ferris RL, Fong Y, Goff SL, Grabowski MM, Ito F, Lim M, Lotze MT, Mahdi H, Malafa M, Morris CD, Murthy P, Neves RI, Odunsi A, Pai SI, Prabhakaran S, Rosenberg SA, Saoud R, Sethuraman J, Skitzki J, Slingluff CL, Sondak VK, Sunwoo JB, Turcotte S, Yeung CC, Kaufman HL. Defining best practices for tissue procurement in immuno-oncology clinical trials: consensus statement from the Society for Immunotherapy of Cancer Surgery Committee. J Immunother Cancer 2020; 8:e001583. [PMID: 33199512 PMCID: PMC7670953 DOI: 10.1136/jitc-2020-001583] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2020] [Indexed: 12/11/2022] Open
Abstract
Immunotherapy is now a cornerstone for cancer treatment, and much attention has been placed on the identification of prognostic and predictive biomarkers. The success of biomarker development is dependent on accurate and timely collection of biospecimens and high-quality processing, storage and shipping. Tumors are also increasingly used as source material for the generation of therapeutic T cells. There have been few guidelines or consensus statements on how to optimally collect and manage biospecimens and source material being used for immunotherapy and related research. The Society for Immunotherapy of Cancer Surgery Committee has brought together surgical experts from multiple subspecialty disciplines to identify best practices and to provide consensus on how best to access and manage specific tissues for immuno-oncology treatments and clinical investigation. In addition, the committee recommends early integration of surgeons and other interventional physicians with expertise in biospecimen collection, especially in clinical trials, to optimize the quality of tissue and the validity of correlative clinical studies in cancer immunotherapy.
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Affiliation(s)
- Brian Gastman
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Piyush K Agarwal
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Adam Berger
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey, USA
| | - Genevieve Boland
- Department of Surgical Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Stephen Broderick
- Oncology, Johns Hopkins Medicine Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland, USA
- Department of Surgery, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Lisa H Butterfield
- Parker Institute for Cancer Immunotherapy, San Francisco, California, USA
- Microbiology and Immunology, University of California San Francisco, San Francisco, California, USA
| | - David Byrd
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Peter E Fecci
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Robert L Ferris
- Departments of Otolaryngology, Immunology, and Radiation Oncology, University of Pittsburgh Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
| | - Yuman Fong
- Department of Surgery, City of Hope National Medical Center, Duarte, California, USA
| | | | - Matthew M Grabowski
- Department of Neurosurgery, Duke Center for Brain and Spine Metastasis, Durham, North Carolina, USA
| | - Fumito Ito
- Center for Immunotherapy, Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Michael Lim
- Departments of Neurosurgery, Oncology, Radiation Oncology, and Otolaryngology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael T Lotze
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Haider Mahdi
- OBGYN and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mokenge Malafa
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Carol D Morris
- Division of Orthopaedic Oncology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Pranav Murthy
- Department of Surgery, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Rogerio I Neves
- Department of Surgery, Penn State Cancer Institute, Hershey, Pennsylvania, USA
| | - Adekunle Odunsi
- Departments of Immunology and Gynecologic Oncology, Roswell Park Cancer Institute, Buffalo, New York, USA
| | - Sara I Pai
- Department of Surgical Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sangeetha Prabhakaran
- Division of Surgical Oncology, Department of Surgery, UNM Comprehensive Cancer Center, University of New Mexico, Albuquerque, New Mexico, USA
| | | | - Ragheed Saoud
- Department of Surgery, University of Chicago Hospitals, Chicago, Illinois, United States
| | | | - Joseph Skitzki
- Departments of Surgical Oncology and Immunology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Craig L Slingluff
- Department of Surgery, Division of Surgical Oncology, Breast and Melanoma Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Vernon K Sondak
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - John B Sunwoo
- Department of Otolaryngology, Stanford University School of Medicine, Stanford, California, USA
| | - Simon Turcotte
- Surgery Department, Centre Hospitalier de l'Universite de Montreal, Montreal, Quebec, Canada
| | - Cecilia Cs Yeung
- Department of Pathology, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Howard L Kaufman
- Department of Surgical Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Immuneering Corp, Cambridge, Massachusetts, USA
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16
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Reuss JE, Anagnostou V, Cottrell TR, Smith KN, Verde F, Zahurak M, Lanis M, Murray JC, Chan HY, McCarthy C, Wang D, White JR, Yang S, Battafarano R, Broderick S, Bush E, Brock M, Ha J, Jones D, Merghoub T, Taube J, Velculescu VE, Rosner G, Illei P, Pardoll DM, Topalian S, Naidoo J, Levy B, Hellmann M, Brahmer JR, Chaft JE, Forde PM. Neoadjuvant nivolumab plus ipilimumab in resectable non-small cell lung cancer. J Immunother Cancer 2020; 8:jitc-2020-001282. [PMID: 32929052 PMCID: PMC7488786 DOI: 10.1136/jitc-2020-001282] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [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] [Accepted: 08/05/2020] [Indexed: 12/25/2022] Open
Abstract
Background We conducted the first trial of neoadjuvant PD-1 blockade in resectable non-small cell lung cancer (NSCLC), finding nivolumab monotherapy to be safe and feasible with an encouraging rate of pathologic response. Building on these results, and promising data for nivolumab plus ipilimumab (anti-CTLA-4) in advanced NSCLC, we expanded our study to include an arm investigating neoadjuvant nivolumab plus ipilimumab. Methods Patients with resectable stage IB (≥4 cm)–IIIA (American Joint Committee on Cancer Tumor Node Metastases seventh edition), histologically confirmed, treatment-naïve NSCLC received nivolumab 3 mg/kg intravenously plus ipilimumab 1 mg/kg intravenously 6 weeks prior to planned resection. Nivolumab 3 mg/kg was given again approximately 4 and 2 weeks preoperatively. Primary endpoints were safety and feasibility with a planned enrollment of 15 patients. Pathologic response was a key secondary endpoint. Results While the treatment regimen was feasible per protocol, due to toxicity, the study arm was terminated early by investigator consensus after 9 of 15 patients were enrolled. All patients received every scheduled dose of therapy and were fit for planned surgery; however, 6 of 9 (67%) experienced treatment-related adverse events (TRAEs) and 3 (33%) experienced grade ≥3 TRAEs. Three of 9 patients (33%) had biopsy-confirmed tumor progression precluding definitive surgery. Of the 6 patients who underwent resection, 3 are alive and disease-free, 2 experienced recurrence and are actively receiving systemic treatment, and one died postoperatively due to acute respiratory distress syndrome. Two patients who underwent resection had tumor pathologic complete responses (pCRs) and continue to remain disease-free over 24 months since surgery. Pathologic response correlated with pre-treatment tumor PD-L1 expression, but not tumor mutation burden. Tumor KRAS/STK11 co-mutations were identified in 5 of 9 patients (59%), of whom two with disease progression precluding surgery had tumor KRAS/STK11/KEAP1 co-mutations. Conclusions Though treatment was feasible, due to toxicity the study arm was terminated early by investigator consensus. In light of this, and while the long-term disease-free status of patients who achieved pCR is encouraging, further investigation of neoadjuvant nivolumab plus ipilimumab in patients with resectable NSCLC requires the identification of predictive biomarkers that enrich for response.
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Affiliation(s)
- Joshua E Reuss
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, Maryland, USA.,The Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University, Baltimore, Maryland, USA
| | - Valsamo Anagnostou
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, Maryland, USA.,The Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University, Baltimore, Maryland, USA
| | - Tricia R Cottrell
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, Maryland, USA
| | - Kellie N Smith
- The Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University, Baltimore, Maryland, USA
| | - Franco Verde
- Department of Radiology, Johns Hopkins, Baltimore, Maryland, USA
| | - Marianna Zahurak
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, Maryland, USA
| | - Mara Lanis
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, Maryland, USA
| | - Joseph C Murray
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, Maryland, USA.,The Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University, Baltimore, Maryland, USA
| | - Hok Yee Chan
- The Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University, Baltimore, Maryland, USA
| | - Caroline McCarthy
- Thoracic Oncology Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Daphne Wang
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, Maryland, USA.,Department of Pathology, Johns Hopkins, Baltimore, Maryland, USA
| | - James R White
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, Maryland, USA
| | - Stephen Yang
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, Maryland, USA.,Department of Surgery, Johns Hopkins, Baltimore, Maryland, USA
| | - Richard Battafarano
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, Maryland, USA.,Department of Surgery, Johns Hopkins, Baltimore, Maryland, USA
| | - Stephen Broderick
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, Maryland, USA.,Department of Surgery, Johns Hopkins, Baltimore, Maryland, USA
| | - Errol Bush
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, Maryland, USA.,Department of Surgery, Johns Hopkins, Baltimore, Maryland, USA
| | - Malcolm Brock
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, Maryland, USA.,Department of Surgery, Johns Hopkins, Baltimore, Maryland, USA
| | - Jinny Ha
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, Maryland, USA.,Department of Surgery, Johns Hopkins, Baltimore, Maryland, USA
| | - David Jones
- Thoracic Surgery Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Druckenmiller Center for Lung Cancer Research, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Taha Merghoub
- Parker Institute for Cancer Immunotherapy, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Weill Cornell Medical College, New York, New York, USA
| | - Janis Taube
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, Maryland, USA.,Department of Pathology, Johns Hopkins, Baltimore, Maryland, USA
| | - Victor E Velculescu
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, Maryland, USA.,The Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University, Baltimore, Maryland, USA
| | - Gary Rosner
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, Maryland, USA
| | - Peter Illei
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, Maryland, USA.,Department of Pathology, Johns Hopkins, Baltimore, Maryland, USA
| | - Drew M Pardoll
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, Maryland, USA.,The Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University, Baltimore, Maryland, USA
| | - Suzanne Topalian
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, Maryland, USA.,The Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jarushka Naidoo
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, Maryland, USA.,The Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ben Levy
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, Maryland, USA.,The Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University, Baltimore, Maryland, USA
| | - Matthew Hellmann
- Thoracic Oncology Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Weill Cornell Medical College, New York, New York, USA
| | - Julie R Brahmer
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, Maryland, USA.,The Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jamie E Chaft
- Thoracic Oncology Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Weill Cornell Medical College, New York, New York, USA
| | - Patrick M Forde
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, Maryland, USA .,The Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University, Baltimore, Maryland, USA
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17
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Voong KR, Liang OS, Dugan P, Torto D, Padula WV, Senter JP, Lang M, Hooker CM, Feliciano J, Broderick S, Yarmus L, Khanna K, Narang A, Hales RK. Thoracic Oncology Multidisciplinary Clinic Reduces Unnecessary Health Care Expenditure Used in the Workup of Patients With Non-small-cell Lung Cancer. Clin Lung Cancer 2019; 20:e430-e441. [PMID: 30956040 DOI: 10.1016/j.cllc.2019.02.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 02/13/2019] [Accepted: 02/17/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND National costs of lung cancer care exceed $12 billion. We investigate the resource-savings benefit of a single-day thoracic oncology multidisciplinary clinic (MDC) in the diagnostic period prior to non-small-cell lung cancer (NSCLC) treatment. MATERIALS AND METHODS From July 2007 to January 2015, patients with NSCLC treated with multimodality therapy at a tertiary hospital-based cancer center in Maryland were identified. Patient and treatment details were collected. Health care resources utilized in the 90 days prior to receipt of first oncologic treatment were identified using billed activity codes. Associated total charges, including professional fees and hospital-based technical fees, were identified and inflated to 2014 dollars using the Consumer Price Index. Codes were categorized into provider visits, procedures, pathology/laboratory, radiology, and other tests. χ2, Student t, and Wilcoxon rank-sum tests compared charges of patients seen in and out of the MDC. RESULTS Two-hundred ninety-seven (non-MDC = 161, 54%; MDC = 136, 46%) of 308 patients identified had total charges available. Patients seen through MDC had on average a 23% decrease in total charges per patient incurred ($5839 savings; range, $5213-$6464) compared with patients seen through non-MDC settings. Evaluation through MDC reduced the average number of provider visits per patient (non-MDC, 6.8 vs. MDC, 4.8; P < .01) prior to treatment start, which led to a 50% (average $3092; range, $2451-$3732) reduction in provider charges per patient (P < .01). CONCLUSIONS Evaluation of patients with NSCLC through a coordinated single-day MDC reduced hospital charges per patient by 23% during the diagnostic period prior to treatment when compared with evaluation through traditional referral-based thoracic oncology clinics.
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Affiliation(s)
- Khinh Ranh Voong
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD.
| | - Ou Stella Liang
- Department of Financial Analysis, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Patrick Dugan
- Department of Financial Analysis, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Deirdre Torto
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - William V Padula
- Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - James P Senter
- The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Margaret Lang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD
| | - Craig M Hooker
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, MD
| | | | - Stephen Broderick
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Lonny Yarmus
- Division of Pulmonary and Critical Care, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Kanika Khanna
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Amol Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD
| | - Russell K Hales
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD
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18
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Felip E, Brahmer J, Broderick S, Swanson S, Awad M, Mitsudomi T, Girard N, Kerr K, Spicer J, Cai J, Yang R, Forde P. P2.16-03 CheckMate 816: A Phase 3 Trial of Neoadjuvant Nivolumab Plus Ipilimumab or Chemotherapy vs Chemotherapy in Early-Stage NSCLC. J Thorac Oncol 2018. [DOI: 10.1016/j.jtho.2018.08.1478] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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19
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Guo W, Hui X, Alfaifi S, Anderson L, Robertson S, Hales R, Hu C, McNutt T, Broderick S, Naidoo J, Battafarano R, Yang S, Voong KR. Preoperative contralateral lung radiation dose is associated with postoperative pulmonary toxicity in patients with locally advanced non-small cell lung cancer treated with trimodality therapy. Pract Radiat Oncol 2018; 8:e239-e248. [PMID: 29960625 DOI: 10.1016/j.prro.2018.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 01/03/2018] [Accepted: 01/13/2018] [Indexed: 10/18/2022]
Abstract
PURPOSE In patients with non-small cell lung cancer (NSCLC) who undergo trimodality therapy (chemoradiation followed by surgical resection), it is unknown whether limiting preoperative radiation dose to the uninvolved lung reduces postsurgical morbidity. This study evaluated whether radiation fall-off dose parameters to the contralateral lung that is unaffected by NSCLC are associated with postoperative complications in NSCLC patients treated with trimodality therapy. METHODS AND MATERIALS We retrospectively reviewed NSCLC patients who underwent trimodality therapy between March 2008 and October 2016, with available restored digital radiation plans. Fischer's exact test was used to assess associations between patient and treatment characteristics and the development of treatment-related toxicity. Spearman rank correlation was used to measure the strength of association between dosimetric parameters. RESULTS Forty-six patients were identified who received trimodality therapy with intensity modulated radiation (median, 59.4 Gy; range, 45-70) and concurrent platinum doublet chemotherapy, followed by surgical resection. The median age was 64.9 years (range, 45.6-81.6). The median follow-up time was 1.9 years (range, 0.3-8.4). Twenty-four (52.2%) patients developed any-grade pulmonary toxicity and 14 (30.4%) patients developed grade 2+ pulmonary toxicity. There was an increased incidence of any-grade pulmonary toxicity in patients with contralateral lung volume receiving at least 20 Gy (V20) ≥7% compared with <7% (90%, n = 9 vs 41.7%, n = 15; P = .01). Similarly, contralateral lung V10 ≥20% was associated with an increased rate of any-grade pulmonary toxicity compared with V10 <20% (80%, n = 12 vs 38.7%, n = 12; P = .01). Pneumonectomy/bilobectomy was associated with grade 2+ pulmonary toxicity (P = .04). CONCLUSIONS Patients who received a higher radiation fall-off dose volume parameter (V20 ≥7% and V10 ≥20%) to the contralateral uninvolved lung had a higher incidence of any-grade postoperative pulmonary toxicity. Limiting radiation fall-off dose to the uninvolved lung may be an important modifiable radiation parameter in limiting postoperative toxicity in trimodality patients.
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Affiliation(s)
- Wenji Guo
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Xuan Hui
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Salem Alfaifi
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lori Anderson
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Scott Robertson
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Russell Hales
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Chen Hu
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Todd McNutt
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stephen Broderick
- Department of Surgery, Division of Thoracic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jarushka Naidoo
- Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Richard Battafarano
- Department of Surgery, Division of Thoracic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stephen Yang
- Department of Surgery, Division of Thoracic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - K Ranh Voong
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Samson P, Puri V, Lockhart AC, Robinson C, Broderick S, Patterson GA, Meyers B, Crabtree T. Adjuvant chemotherapy for patients with pathologic node-positive esophageal cancer after induction chemotherapy is associated with improved survival. J Thorac Cardiovasc Surg 2018; 156:1725-1735. [PMID: 30054137 DOI: 10.1016/j.jtcvs.2018.05.100] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 03/13/2018] [Accepted: 05/07/2018] [Indexed: 01/09/2023]
Abstract
OBJECTIVES The study objectives were to identify variables associated with the use of adjuvant chemotherapy among patients with node-positive esophageal cancer who received induction therapy and to evaluate its relationship with overall survival. METHODS Treatment data for patients with esophageal cancer receiving induction chemotherapy ± radiotherapy and esophagectomy were abstracted from the National Cancer Data Base. Pathologic node-positive patients were dichotomized by whether they received 2 or more cycles of adjuvant chemotherapy or none. Kaplan-Meier survival curves were generated, and a Cox proportional hazards model was done to identify factors associated with overall survival. RESULTS From 2006 to 2012, 3100 patients had pathologic positive nodes after induction therapy and esophagectomy. A total of 2625 patients (84.7%) did not receive adjuvant chemotherapy, and 475 patients (15.3%) did. N3 nodal stage was associated with an increased likelihood of receiving adjuvant chemotherapy (reference: N1, odds ratio, 1.82, 95% confidence interval, 1.15-2.97, P = .01), whereas increasing age (by year, odds ratio, 0.97, confidence interval, 0.96-0.98, P < .001), induction chemoradiation therapy (reference: induction chemotherapy, odds ratio, 0.39, confidence interval, 0.30-0.52, P < .001), and increasing inpatient length of stay after esophagectomy (per day: odds ratio, 0.98, confidence interval, 0.97-0.99, P = .007) were associated with a decreased likelihood. Patients receiving adjuvant chemotherapy had improved overall survival at each pathologic nodal stage: 31.6 months versus 22.7 months for N1 disease (P < .001), 32.4 months versus 19.2 months for N2 disease (P = .035), and 19.5 months versus 10.4 months for N3 disease (P < .001). Adjuvant therapy was independently associated with decreased mortality hazard (hazard ratio, 0.69, 95% confidence interval, 0.57-0.83, P < .001). CONCLUSIONS Patients receiving adjuvant chemotherapy after induction therapy and esophagectomy show a survival benefit at all positive nodal stages. Prospective studies may help further delineate this benefit.
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Affiliation(s)
- Pamela Samson
- Division of Cardiothoracic Surgery, Washington University in St Louis, St Louis, Mo
| | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University in St Louis, St Louis, Mo
| | | | - Clifford Robinson
- Department of Radiation Oncology, Washington University in St Louis, St Louis, Mo
| | - Stephen Broderick
- Division of Cardiothoracic Surgery, Johns Hopkins University, Baltimore, Md
| | | | - Bryan Meyers
- Division of Cardiothoracic Surgery, Washington University in St Louis, St Louis, Mo
| | - Traves Crabtree
- Division of Cardiothoracic Surgery, Southern Illinois University, Springfield, Ill.
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21
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Samson P, Pérez M, Roach M, Bradley J, Frederiksen C, Carpenter L, Mullen D, Kozower B, Meyers B, Broderick S, Puri V, Robinson C. (OA01) Prospective Baseline Quality of Life in Clinical Stage I Non-Small Cell Lung Cancer Patients Receiving Stereotactic Body Radiation Therapy Versus Surgery: The Starting Line Is not the Same. Int J Radiat Oncol Biol Phys 2018. [DOI: 10.1016/j.ijrobp.2018.02.040] [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: 10/17/2022]
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22
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Forde PM, Chaft JE, Smith KN, Anagnostou V, Cottrell TR, Hellmann MD, Zahurak M, Yang SC, Jones DR, Broderick S, Battafarano RJ, Velez MJ, Rekhtman N, Olah Z, Naidoo J, Marrone KA, Verde F, Guo H, Zhang J, Caushi JX, Chan HY, Sidhom JW, Scharpf RB, White J, Gabrielson E, Wang H, Rosner GL, Rusch V, Wolchok JD, Merghoub T, Taube JM, Velculescu VE, Topalian SL, Brahmer JR, Pardoll DM. Neoadjuvant PD-1 Blockade in Resectable Lung Cancer. N Engl J Med 2018; 378:1976-1986. [PMID: 29658848 PMCID: PMC6223617 DOI: 10.1056/nejmoa1716078] [Citation(s) in RCA: 1251] [Impact Index Per Article: 208.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Antibodies that block programmed death 1 (PD-1) protein improve survival in patients with advanced non-small-cell lung cancer (NSCLC) but have not been tested in resectable NSCLC, a condition in which little progress has been made during the past decade. METHODS In this pilot study, we administered two preoperative doses of PD-1 inhibitor nivolumab in adults with untreated, surgically resectable early (stage I, II, or IIIA) NSCLC. Nivolumab (at a dose of 3 mg per kilogram of body weight) was administered intravenously every 2 weeks, with surgery planned approximately 4 weeks after the first dose. The primary end points of the study were safety and feasibility. We also evaluated the tumor pathological response, expression of programmed death ligand 1 (PD-L1), mutational burden, and mutation-associated, neoantigen-specific T-cell responses. RESULTS Neoadjuvant nivolumab had an acceptable side-effect profile and was not associated with delays in surgery. Of the 21 tumors that were removed, 20 were completely resected. A major pathological response occurred in 9 of 20 resected tumors (45%). Responses occurred in both PD-L1-positive and PD-L1-negative tumors. There was a significant correlation between the pathological response and the pretreatment tumor mutational burden. The number of T-cell clones that were found in both the tumor and peripheral blood increased systemically after PD-1 blockade in eight of nine patients who were evaluated. Mutation-associated, neoantigen-specific T-cell clones from a primary tumor with a complete response on pathological assessment rapidly expanded in peripheral blood at 2 to 4 weeks after treatment; some of these clones were not detected before the administration of nivolumab. CONCLUSIONS Neoadjuvant nivolumab was associated with few side effects, did not delay surgery, and induced a major pathological response in 45% of resected tumors. The tumor mutational burden was predictive of the pathological response to PD-1 blockade. Treatment induced expansion of mutation-associated, neoantigen-specific T-cell clones in peripheral blood. (Funded by Cancer Research Institute-Stand Up 2 Cancer and others; ClinicalTrials.gov number, NCT02259621 .).
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Affiliation(s)
- Patrick M Forde
- From the Bloomberg-Kimmel Institute for Cancer Immunotherapy and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore (P.M.F., K.N.S., V.A., T.R.C., M.Z., S.C.Y., S.B., R.J.B., J.N., K.A.M., F.V., H.G., J.Z., J.X.C., H.Y.C., J.-W.S., R.B.S., J.W., E.G., H.W., G.L.R., J.M.T., V.E.V., S.L.T., J.R.B., D.M.P.); Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine (J.E.C., M.D.H., D.R.J., M.J.V., N.R., Z.O., V.R., J.D.W., T.M.) and the Ludwig Collaborative (J.D.W., T.M.) - all in New York; the Parker Institute for Cancer Immunotherapy, San Francisco (J.D.W., T.M.); and Swim Across America Laboratory, Charlotte, NC (J.D.W., T.M.)
| | - Jamie E Chaft
- From the Bloomberg-Kimmel Institute for Cancer Immunotherapy and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore (P.M.F., K.N.S., V.A., T.R.C., M.Z., S.C.Y., S.B., R.J.B., J.N., K.A.M., F.V., H.G., J.Z., J.X.C., H.Y.C., J.-W.S., R.B.S., J.W., E.G., H.W., G.L.R., J.M.T., V.E.V., S.L.T., J.R.B., D.M.P.); Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine (J.E.C., M.D.H., D.R.J., M.J.V., N.R., Z.O., V.R., J.D.W., T.M.) and the Ludwig Collaborative (J.D.W., T.M.) - all in New York; the Parker Institute for Cancer Immunotherapy, San Francisco (J.D.W., T.M.); and Swim Across America Laboratory, Charlotte, NC (J.D.W., T.M.)
| | - Kellie N Smith
- From the Bloomberg-Kimmel Institute for Cancer Immunotherapy and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore (P.M.F., K.N.S., V.A., T.R.C., M.Z., S.C.Y., S.B., R.J.B., J.N., K.A.M., F.V., H.G., J.Z., J.X.C., H.Y.C., J.-W.S., R.B.S., J.W., E.G., H.W., G.L.R., J.M.T., V.E.V., S.L.T., J.R.B., D.M.P.); Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine (J.E.C., M.D.H., D.R.J., M.J.V., N.R., Z.O., V.R., J.D.W., T.M.) and the Ludwig Collaborative (J.D.W., T.M.) - all in New York; the Parker Institute for Cancer Immunotherapy, San Francisco (J.D.W., T.M.); and Swim Across America Laboratory, Charlotte, NC (J.D.W., T.M.)
| | - Valsamo Anagnostou
- From the Bloomberg-Kimmel Institute for Cancer Immunotherapy and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore (P.M.F., K.N.S., V.A., T.R.C., M.Z., S.C.Y., S.B., R.J.B., J.N., K.A.M., F.V., H.G., J.Z., J.X.C., H.Y.C., J.-W.S., R.B.S., J.W., E.G., H.W., G.L.R., J.M.T., V.E.V., S.L.T., J.R.B., D.M.P.); Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine (J.E.C., M.D.H., D.R.J., M.J.V., N.R., Z.O., V.R., J.D.W., T.M.) and the Ludwig Collaborative (J.D.W., T.M.) - all in New York; the Parker Institute for Cancer Immunotherapy, San Francisco (J.D.W., T.M.); and Swim Across America Laboratory, Charlotte, NC (J.D.W., T.M.)
| | - Tricia R Cottrell
- From the Bloomberg-Kimmel Institute for Cancer Immunotherapy and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore (P.M.F., K.N.S., V.A., T.R.C., M.Z., S.C.Y., S.B., R.J.B., J.N., K.A.M., F.V., H.G., J.Z., J.X.C., H.Y.C., J.-W.S., R.B.S., J.W., E.G., H.W., G.L.R., J.M.T., V.E.V., S.L.T., J.R.B., D.M.P.); Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine (J.E.C., M.D.H., D.R.J., M.J.V., N.R., Z.O., V.R., J.D.W., T.M.) and the Ludwig Collaborative (J.D.W., T.M.) - all in New York; the Parker Institute for Cancer Immunotherapy, San Francisco (J.D.W., T.M.); and Swim Across America Laboratory, Charlotte, NC (J.D.W., T.M.)
| | - Matthew D Hellmann
- From the Bloomberg-Kimmel Institute for Cancer Immunotherapy and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore (P.M.F., K.N.S., V.A., T.R.C., M.Z., S.C.Y., S.B., R.J.B., J.N., K.A.M., F.V., H.G., J.Z., J.X.C., H.Y.C., J.-W.S., R.B.S., J.W., E.G., H.W., G.L.R., J.M.T., V.E.V., S.L.T., J.R.B., D.M.P.); Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine (J.E.C., M.D.H., D.R.J., M.J.V., N.R., Z.O., V.R., J.D.W., T.M.) and the Ludwig Collaborative (J.D.W., T.M.) - all in New York; the Parker Institute for Cancer Immunotherapy, San Francisco (J.D.W., T.M.); and Swim Across America Laboratory, Charlotte, NC (J.D.W., T.M.)
| | - Marianna Zahurak
- From the Bloomberg-Kimmel Institute for Cancer Immunotherapy and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore (P.M.F., K.N.S., V.A., T.R.C., M.Z., S.C.Y., S.B., R.J.B., J.N., K.A.M., F.V., H.G., J.Z., J.X.C., H.Y.C., J.-W.S., R.B.S., J.W., E.G., H.W., G.L.R., J.M.T., V.E.V., S.L.T., J.R.B., D.M.P.); Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine (J.E.C., M.D.H., D.R.J., M.J.V., N.R., Z.O., V.R., J.D.W., T.M.) and the Ludwig Collaborative (J.D.W., T.M.) - all in New York; the Parker Institute for Cancer Immunotherapy, San Francisco (J.D.W., T.M.); and Swim Across America Laboratory, Charlotte, NC (J.D.W., T.M.)
| | - Stephen C Yang
- From the Bloomberg-Kimmel Institute for Cancer Immunotherapy and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore (P.M.F., K.N.S., V.A., T.R.C., M.Z., S.C.Y., S.B., R.J.B., J.N., K.A.M., F.V., H.G., J.Z., J.X.C., H.Y.C., J.-W.S., R.B.S., J.W., E.G., H.W., G.L.R., J.M.T., V.E.V., S.L.T., J.R.B., D.M.P.); Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine (J.E.C., M.D.H., D.R.J., M.J.V., N.R., Z.O., V.R., J.D.W., T.M.) and the Ludwig Collaborative (J.D.W., T.M.) - all in New York; the Parker Institute for Cancer Immunotherapy, San Francisco (J.D.W., T.M.); and Swim Across America Laboratory, Charlotte, NC (J.D.W., T.M.)
| | - David R Jones
- From the Bloomberg-Kimmel Institute for Cancer Immunotherapy and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore (P.M.F., K.N.S., V.A., T.R.C., M.Z., S.C.Y., S.B., R.J.B., J.N., K.A.M., F.V., H.G., J.Z., J.X.C., H.Y.C., J.-W.S., R.B.S., J.W., E.G., H.W., G.L.R., J.M.T., V.E.V., S.L.T., J.R.B., D.M.P.); Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine (J.E.C., M.D.H., D.R.J., M.J.V., N.R., Z.O., V.R., J.D.W., T.M.) and the Ludwig Collaborative (J.D.W., T.M.) - all in New York; the Parker Institute for Cancer Immunotherapy, San Francisco (J.D.W., T.M.); and Swim Across America Laboratory, Charlotte, NC (J.D.W., T.M.)
| | - Stephen Broderick
- From the Bloomberg-Kimmel Institute for Cancer Immunotherapy and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore (P.M.F., K.N.S., V.A., T.R.C., M.Z., S.C.Y., S.B., R.J.B., J.N., K.A.M., F.V., H.G., J.Z., J.X.C., H.Y.C., J.-W.S., R.B.S., J.W., E.G., H.W., G.L.R., J.M.T., V.E.V., S.L.T., J.R.B., D.M.P.); Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine (J.E.C., M.D.H., D.R.J., M.J.V., N.R., Z.O., V.R., J.D.W., T.M.) and the Ludwig Collaborative (J.D.W., T.M.) - all in New York; the Parker Institute for Cancer Immunotherapy, San Francisco (J.D.W., T.M.); and Swim Across America Laboratory, Charlotte, NC (J.D.W., T.M.)
| | - Richard J Battafarano
- From the Bloomberg-Kimmel Institute for Cancer Immunotherapy and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore (P.M.F., K.N.S., V.A., T.R.C., M.Z., S.C.Y., S.B., R.J.B., J.N., K.A.M., F.V., H.G., J.Z., J.X.C., H.Y.C., J.-W.S., R.B.S., J.W., E.G., H.W., G.L.R., J.M.T., V.E.V., S.L.T., J.R.B., D.M.P.); Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine (J.E.C., M.D.H., D.R.J., M.J.V., N.R., Z.O., V.R., J.D.W., T.M.) and the Ludwig Collaborative (J.D.W., T.M.) - all in New York; the Parker Institute for Cancer Immunotherapy, San Francisco (J.D.W., T.M.); and Swim Across America Laboratory, Charlotte, NC (J.D.W., T.M.)
| | - Moises J Velez
- From the Bloomberg-Kimmel Institute for Cancer Immunotherapy and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore (P.M.F., K.N.S., V.A., T.R.C., M.Z., S.C.Y., S.B., R.J.B., J.N., K.A.M., F.V., H.G., J.Z., J.X.C., H.Y.C., J.-W.S., R.B.S., J.W., E.G., H.W., G.L.R., J.M.T., V.E.V., S.L.T., J.R.B., D.M.P.); Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine (J.E.C., M.D.H., D.R.J., M.J.V., N.R., Z.O., V.R., J.D.W., T.M.) and the Ludwig Collaborative (J.D.W., T.M.) - all in New York; the Parker Institute for Cancer Immunotherapy, San Francisco (J.D.W., T.M.); and Swim Across America Laboratory, Charlotte, NC (J.D.W., T.M.)
| | - Natasha Rekhtman
- From the Bloomberg-Kimmel Institute for Cancer Immunotherapy and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore (P.M.F., K.N.S., V.A., T.R.C., M.Z., S.C.Y., S.B., R.J.B., J.N., K.A.M., F.V., H.G., J.Z., J.X.C., H.Y.C., J.-W.S., R.B.S., J.W., E.G., H.W., G.L.R., J.M.T., V.E.V., S.L.T., J.R.B., D.M.P.); Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine (J.E.C., M.D.H., D.R.J., M.J.V., N.R., Z.O., V.R., J.D.W., T.M.) and the Ludwig Collaborative (J.D.W., T.M.) - all in New York; the Parker Institute for Cancer Immunotherapy, San Francisco (J.D.W., T.M.); and Swim Across America Laboratory, Charlotte, NC (J.D.W., T.M.)
| | - Zachary Olah
- From the Bloomberg-Kimmel Institute for Cancer Immunotherapy and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore (P.M.F., K.N.S., V.A., T.R.C., M.Z., S.C.Y., S.B., R.J.B., J.N., K.A.M., F.V., H.G., J.Z., J.X.C., H.Y.C., J.-W.S., R.B.S., J.W., E.G., H.W., G.L.R., J.M.T., V.E.V., S.L.T., J.R.B., D.M.P.); Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine (J.E.C., M.D.H., D.R.J., M.J.V., N.R., Z.O., V.R., J.D.W., T.M.) and the Ludwig Collaborative (J.D.W., T.M.) - all in New York; the Parker Institute for Cancer Immunotherapy, San Francisco (J.D.W., T.M.); and Swim Across America Laboratory, Charlotte, NC (J.D.W., T.M.)
| | - Jarushka Naidoo
- From the Bloomberg-Kimmel Institute for Cancer Immunotherapy and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore (P.M.F., K.N.S., V.A., T.R.C., M.Z., S.C.Y., S.B., R.J.B., J.N., K.A.M., F.V., H.G., J.Z., J.X.C., H.Y.C., J.-W.S., R.B.S., J.W., E.G., H.W., G.L.R., J.M.T., V.E.V., S.L.T., J.R.B., D.M.P.); Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine (J.E.C., M.D.H., D.R.J., M.J.V., N.R., Z.O., V.R., J.D.W., T.M.) and the Ludwig Collaborative (J.D.W., T.M.) - all in New York; the Parker Institute for Cancer Immunotherapy, San Francisco (J.D.W., T.M.); and Swim Across America Laboratory, Charlotte, NC (J.D.W., T.M.)
| | - Kristen A Marrone
- From the Bloomberg-Kimmel Institute for Cancer Immunotherapy and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore (P.M.F., K.N.S., V.A., T.R.C., M.Z., S.C.Y., S.B., R.J.B., J.N., K.A.M., F.V., H.G., J.Z., J.X.C., H.Y.C., J.-W.S., R.B.S., J.W., E.G., H.W., G.L.R., J.M.T., V.E.V., S.L.T., J.R.B., D.M.P.); Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine (J.E.C., M.D.H., D.R.J., M.J.V., N.R., Z.O., V.R., J.D.W., T.M.) and the Ludwig Collaborative (J.D.W., T.M.) - all in New York; the Parker Institute for Cancer Immunotherapy, San Francisco (J.D.W., T.M.); and Swim Across America Laboratory, Charlotte, NC (J.D.W., T.M.)
| | - Franco Verde
- From the Bloomberg-Kimmel Institute for Cancer Immunotherapy and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore (P.M.F., K.N.S., V.A., T.R.C., M.Z., S.C.Y., S.B., R.J.B., J.N., K.A.M., F.V., H.G., J.Z., J.X.C., H.Y.C., J.-W.S., R.B.S., J.W., E.G., H.W., G.L.R., J.M.T., V.E.V., S.L.T., J.R.B., D.M.P.); Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine (J.E.C., M.D.H., D.R.J., M.J.V., N.R., Z.O., V.R., J.D.W., T.M.) and the Ludwig Collaborative (J.D.W., T.M.) - all in New York; the Parker Institute for Cancer Immunotherapy, San Francisco (J.D.W., T.M.); and Swim Across America Laboratory, Charlotte, NC (J.D.W., T.M.)
| | - Haidan Guo
- From the Bloomberg-Kimmel Institute for Cancer Immunotherapy and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore (P.M.F., K.N.S., V.A., T.R.C., M.Z., S.C.Y., S.B., R.J.B., J.N., K.A.M., F.V., H.G., J.Z., J.X.C., H.Y.C., J.-W.S., R.B.S., J.W., E.G., H.W., G.L.R., J.M.T., V.E.V., S.L.T., J.R.B., D.M.P.); Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine (J.E.C., M.D.H., D.R.J., M.J.V., N.R., Z.O., V.R., J.D.W., T.M.) and the Ludwig Collaborative (J.D.W., T.M.) - all in New York; the Parker Institute for Cancer Immunotherapy, San Francisco (J.D.W., T.M.); and Swim Across America Laboratory, Charlotte, NC (J.D.W., T.M.)
| | - Jiajia Zhang
- From the Bloomberg-Kimmel Institute for Cancer Immunotherapy and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore (P.M.F., K.N.S., V.A., T.R.C., M.Z., S.C.Y., S.B., R.J.B., J.N., K.A.M., F.V., H.G., J.Z., J.X.C., H.Y.C., J.-W.S., R.B.S., J.W., E.G., H.W., G.L.R., J.M.T., V.E.V., S.L.T., J.R.B., D.M.P.); Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine (J.E.C., M.D.H., D.R.J., M.J.V., N.R., Z.O., V.R., J.D.W., T.M.) and the Ludwig Collaborative (J.D.W., T.M.) - all in New York; the Parker Institute for Cancer Immunotherapy, San Francisco (J.D.W., T.M.); and Swim Across America Laboratory, Charlotte, NC (J.D.W., T.M.)
| | - Justina X Caushi
- From the Bloomberg-Kimmel Institute for Cancer Immunotherapy and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore (P.M.F., K.N.S., V.A., T.R.C., M.Z., S.C.Y., S.B., R.J.B., J.N., K.A.M., F.V., H.G., J.Z., J.X.C., H.Y.C., J.-W.S., R.B.S., J.W., E.G., H.W., G.L.R., J.M.T., V.E.V., S.L.T., J.R.B., D.M.P.); Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine (J.E.C., M.D.H., D.R.J., M.J.V., N.R., Z.O., V.R., J.D.W., T.M.) and the Ludwig Collaborative (J.D.W., T.M.) - all in New York; the Parker Institute for Cancer Immunotherapy, San Francisco (J.D.W., T.M.); and Swim Across America Laboratory, Charlotte, NC (J.D.W., T.M.)
| | - Hok Yee Chan
- From the Bloomberg-Kimmel Institute for Cancer Immunotherapy and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore (P.M.F., K.N.S., V.A., T.R.C., M.Z., S.C.Y., S.B., R.J.B., J.N., K.A.M., F.V., H.G., J.Z., J.X.C., H.Y.C., J.-W.S., R.B.S., J.W., E.G., H.W., G.L.R., J.M.T., V.E.V., S.L.T., J.R.B., D.M.P.); Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine (J.E.C., M.D.H., D.R.J., M.J.V., N.R., Z.O., V.R., J.D.W., T.M.) and the Ludwig Collaborative (J.D.W., T.M.) - all in New York; the Parker Institute for Cancer Immunotherapy, San Francisco (J.D.W., T.M.); and Swim Across America Laboratory, Charlotte, NC (J.D.W., T.M.)
| | - John-William Sidhom
- From the Bloomberg-Kimmel Institute for Cancer Immunotherapy and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore (P.M.F., K.N.S., V.A., T.R.C., M.Z., S.C.Y., S.B., R.J.B., J.N., K.A.M., F.V., H.G., J.Z., J.X.C., H.Y.C., J.-W.S., R.B.S., J.W., E.G., H.W., G.L.R., J.M.T., V.E.V., S.L.T., J.R.B., D.M.P.); Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine (J.E.C., M.D.H., D.R.J., M.J.V., N.R., Z.O., V.R., J.D.W., T.M.) and the Ludwig Collaborative (J.D.W., T.M.) - all in New York; the Parker Institute for Cancer Immunotherapy, San Francisco (J.D.W., T.M.); and Swim Across America Laboratory, Charlotte, NC (J.D.W., T.M.)
| | - Robert B Scharpf
- From the Bloomberg-Kimmel Institute for Cancer Immunotherapy and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore (P.M.F., K.N.S., V.A., T.R.C., M.Z., S.C.Y., S.B., R.J.B., J.N., K.A.M., F.V., H.G., J.Z., J.X.C., H.Y.C., J.-W.S., R.B.S., J.W., E.G., H.W., G.L.R., J.M.T., V.E.V., S.L.T., J.R.B., D.M.P.); Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine (J.E.C., M.D.H., D.R.J., M.J.V., N.R., Z.O., V.R., J.D.W., T.M.) and the Ludwig Collaborative (J.D.W., T.M.) - all in New York; the Parker Institute for Cancer Immunotherapy, San Francisco (J.D.W., T.M.); and Swim Across America Laboratory, Charlotte, NC (J.D.W., T.M.)
| | - James White
- From the Bloomberg-Kimmel Institute for Cancer Immunotherapy and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore (P.M.F., K.N.S., V.A., T.R.C., M.Z., S.C.Y., S.B., R.J.B., J.N., K.A.M., F.V., H.G., J.Z., J.X.C., H.Y.C., J.-W.S., R.B.S., J.W., E.G., H.W., G.L.R., J.M.T., V.E.V., S.L.T., J.R.B., D.M.P.); Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine (J.E.C., M.D.H., D.R.J., M.J.V., N.R., Z.O., V.R., J.D.W., T.M.) and the Ludwig Collaborative (J.D.W., T.M.) - all in New York; the Parker Institute for Cancer Immunotherapy, San Francisco (J.D.W., T.M.); and Swim Across America Laboratory, Charlotte, NC (J.D.W., T.M.)
| | - Edward Gabrielson
- From the Bloomberg-Kimmel Institute for Cancer Immunotherapy and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore (P.M.F., K.N.S., V.A., T.R.C., M.Z., S.C.Y., S.B., R.J.B., J.N., K.A.M., F.V., H.G., J.Z., J.X.C., H.Y.C., J.-W.S., R.B.S., J.W., E.G., H.W., G.L.R., J.M.T., V.E.V., S.L.T., J.R.B., D.M.P.); Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine (J.E.C., M.D.H., D.R.J., M.J.V., N.R., Z.O., V.R., J.D.W., T.M.) and the Ludwig Collaborative (J.D.W., T.M.) - all in New York; the Parker Institute for Cancer Immunotherapy, San Francisco (J.D.W., T.M.); and Swim Across America Laboratory, Charlotte, NC (J.D.W., T.M.)
| | - Hao Wang
- From the Bloomberg-Kimmel Institute for Cancer Immunotherapy and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore (P.M.F., K.N.S., V.A., T.R.C., M.Z., S.C.Y., S.B., R.J.B., J.N., K.A.M., F.V., H.G., J.Z., J.X.C., H.Y.C., J.-W.S., R.B.S., J.W., E.G., H.W., G.L.R., J.M.T., V.E.V., S.L.T., J.R.B., D.M.P.); Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine (J.E.C., M.D.H., D.R.J., M.J.V., N.R., Z.O., V.R., J.D.W., T.M.) and the Ludwig Collaborative (J.D.W., T.M.) - all in New York; the Parker Institute for Cancer Immunotherapy, San Francisco (J.D.W., T.M.); and Swim Across America Laboratory, Charlotte, NC (J.D.W., T.M.)
| | - Gary L Rosner
- From the Bloomberg-Kimmel Institute for Cancer Immunotherapy and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore (P.M.F., K.N.S., V.A., T.R.C., M.Z., S.C.Y., S.B., R.J.B., J.N., K.A.M., F.V., H.G., J.Z., J.X.C., H.Y.C., J.-W.S., R.B.S., J.W., E.G., H.W., G.L.R., J.M.T., V.E.V., S.L.T., J.R.B., D.M.P.); Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine (J.E.C., M.D.H., D.R.J., M.J.V., N.R., Z.O., V.R., J.D.W., T.M.) and the Ludwig Collaborative (J.D.W., T.M.) - all in New York; the Parker Institute for Cancer Immunotherapy, San Francisco (J.D.W., T.M.); and Swim Across America Laboratory, Charlotte, NC (J.D.W., T.M.)
| | - Valerie Rusch
- From the Bloomberg-Kimmel Institute for Cancer Immunotherapy and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore (P.M.F., K.N.S., V.A., T.R.C., M.Z., S.C.Y., S.B., R.J.B., J.N., K.A.M., F.V., H.G., J.Z., J.X.C., H.Y.C., J.-W.S., R.B.S., J.W., E.G., H.W., G.L.R., J.M.T., V.E.V., S.L.T., J.R.B., D.M.P.); Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine (J.E.C., M.D.H., D.R.J., M.J.V., N.R., Z.O., V.R., J.D.W., T.M.) and the Ludwig Collaborative (J.D.W., T.M.) - all in New York; the Parker Institute for Cancer Immunotherapy, San Francisco (J.D.W., T.M.); and Swim Across America Laboratory, Charlotte, NC (J.D.W., T.M.)
| | - Jedd D Wolchok
- From the Bloomberg-Kimmel Institute for Cancer Immunotherapy and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore (P.M.F., K.N.S., V.A., T.R.C., M.Z., S.C.Y., S.B., R.J.B., J.N., K.A.M., F.V., H.G., J.Z., J.X.C., H.Y.C., J.-W.S., R.B.S., J.W., E.G., H.W., G.L.R., J.M.T., V.E.V., S.L.T., J.R.B., D.M.P.); Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine (J.E.C., M.D.H., D.R.J., M.J.V., N.R., Z.O., V.R., J.D.W., T.M.) and the Ludwig Collaborative (J.D.W., T.M.) - all in New York; the Parker Institute for Cancer Immunotherapy, San Francisco (J.D.W., T.M.); and Swim Across America Laboratory, Charlotte, NC (J.D.W., T.M.)
| | - Taha Merghoub
- From the Bloomberg-Kimmel Institute for Cancer Immunotherapy and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore (P.M.F., K.N.S., V.A., T.R.C., M.Z., S.C.Y., S.B., R.J.B., J.N., K.A.M., F.V., H.G., J.Z., J.X.C., H.Y.C., J.-W.S., R.B.S., J.W., E.G., H.W., G.L.R., J.M.T., V.E.V., S.L.T., J.R.B., D.M.P.); Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine (J.E.C., M.D.H., D.R.J., M.J.V., N.R., Z.O., V.R., J.D.W., T.M.) and the Ludwig Collaborative (J.D.W., T.M.) - all in New York; the Parker Institute for Cancer Immunotherapy, San Francisco (J.D.W., T.M.); and Swim Across America Laboratory, Charlotte, NC (J.D.W., T.M.)
| | - Janis M Taube
- From the Bloomberg-Kimmel Institute for Cancer Immunotherapy and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore (P.M.F., K.N.S., V.A., T.R.C., M.Z., S.C.Y., S.B., R.J.B., J.N., K.A.M., F.V., H.G., J.Z., J.X.C., H.Y.C., J.-W.S., R.B.S., J.W., E.G., H.W., G.L.R., J.M.T., V.E.V., S.L.T., J.R.B., D.M.P.); Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine (J.E.C., M.D.H., D.R.J., M.J.V., N.R., Z.O., V.R., J.D.W., T.M.) and the Ludwig Collaborative (J.D.W., T.M.) - all in New York; the Parker Institute for Cancer Immunotherapy, San Francisco (J.D.W., T.M.); and Swim Across America Laboratory, Charlotte, NC (J.D.W., T.M.)
| | - Victor E Velculescu
- From the Bloomberg-Kimmel Institute for Cancer Immunotherapy and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore (P.M.F., K.N.S., V.A., T.R.C., M.Z., S.C.Y., S.B., R.J.B., J.N., K.A.M., F.V., H.G., J.Z., J.X.C., H.Y.C., J.-W.S., R.B.S., J.W., E.G., H.W., G.L.R., J.M.T., V.E.V., S.L.T., J.R.B., D.M.P.); Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine (J.E.C., M.D.H., D.R.J., M.J.V., N.R., Z.O., V.R., J.D.W., T.M.) and the Ludwig Collaborative (J.D.W., T.M.) - all in New York; the Parker Institute for Cancer Immunotherapy, San Francisco (J.D.W., T.M.); and Swim Across America Laboratory, Charlotte, NC (J.D.W., T.M.)
| | - Suzanne L Topalian
- From the Bloomberg-Kimmel Institute for Cancer Immunotherapy and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore (P.M.F., K.N.S., V.A., T.R.C., M.Z., S.C.Y., S.B., R.J.B., J.N., K.A.M., F.V., H.G., J.Z., J.X.C., H.Y.C., J.-W.S., R.B.S., J.W., E.G., H.W., G.L.R., J.M.T., V.E.V., S.L.T., J.R.B., D.M.P.); Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine (J.E.C., M.D.H., D.R.J., M.J.V., N.R., Z.O., V.R., J.D.W., T.M.) and the Ludwig Collaborative (J.D.W., T.M.) - all in New York; the Parker Institute for Cancer Immunotherapy, San Francisco (J.D.W., T.M.); and Swim Across America Laboratory, Charlotte, NC (J.D.W., T.M.)
| | - Julie R Brahmer
- From the Bloomberg-Kimmel Institute for Cancer Immunotherapy and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore (P.M.F., K.N.S., V.A., T.R.C., M.Z., S.C.Y., S.B., R.J.B., J.N., K.A.M., F.V., H.G., J.Z., J.X.C., H.Y.C., J.-W.S., R.B.S., J.W., E.G., H.W., G.L.R., J.M.T., V.E.V., S.L.T., J.R.B., D.M.P.); Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine (J.E.C., M.D.H., D.R.J., M.J.V., N.R., Z.O., V.R., J.D.W., T.M.) and the Ludwig Collaborative (J.D.W., T.M.) - all in New York; the Parker Institute for Cancer Immunotherapy, San Francisco (J.D.W., T.M.); and Swim Across America Laboratory, Charlotte, NC (J.D.W., T.M.)
| | - Drew M Pardoll
- From the Bloomberg-Kimmel Institute for Cancer Immunotherapy and the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore (P.M.F., K.N.S., V.A., T.R.C., M.Z., S.C.Y., S.B., R.J.B., J.N., K.A.M., F.V., H.G., J.Z., J.X.C., H.Y.C., J.-W.S., R.B.S., J.W., E.G., H.W., G.L.R., J.M.T., V.E.V., S.L.T., J.R.B., D.M.P.); Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine (J.E.C., M.D.H., D.R.J., M.J.V., N.R., Z.O., V.R., J.D.W., T.M.) and the Ludwig Collaborative (J.D.W., T.M.) - all in New York; the Parker Institute for Cancer Immunotherapy, San Francisco (J.D.W., T.M.); and Swim Across America Laboratory, Charlotte, NC (J.D.W., T.M.)
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Schneider BJ, Daly ME, Kennedy EB, Antonoff MB, Broderick S, Feldman J, Jolly S, Meyers B, Rocco G, Rusthoven C, Slotman BJ, Sterman DH, Stiles BM. Stereotactic Body Radiotherapy for Early-Stage Non-Small-Cell Lung Cancer: American Society of Clinical Oncology Endorsement of the American Society for Radiation Oncology Evidence-Based Guideline. J Clin Oncol 2018; 36:710-719. [PMID: 29106810 DOI: 10.1200/jco.2017.74.9671] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Purpose The American Society for Radiation Oncology (ASTRO) produced an evidence-based guideline on treatment with stereotactic body radiotherapy (SBRT) for patients with early-stage non-small-cell lung cancer. ASCO has a policy and set of procedures for endorsing and/or adapting clinical practice guidelines that have been developed by other professional organizations. Methods The ASTRO Evidence-Based Guideline for Stereotactic Body Radiotherapy for Early-Stage Non-Small-Cell Lung Cancer was reviewed for developmental rigor by methodologists. An ASCO Expert Panel updated the literature search and reviewed the guideline content and recommendations. Results The ASCO Expert Panel determined that the recommendations from the ASTRO guideline, published in 2017, are clear, thorough, and based on the most relevant scientific evidence. ASCO statements and minor modifications were added to enhance the applicability of the ASTRO guideline for the broader ASCO audience. Recommendations For standard operative risk patients with stage I NSCLC, SBRT is not recommended outside of a clinical trial. Lobectomy with systematic lymph node evaluation remains the recommended treatment, although a sublobar resection may be considered in select clinical scenarios. Recommendations are provided regarding the use of SBRT in high operative risk patients and for inoperative patients, including in challenging scenarios where tumors are: centrally located, > 5 cm in diameter, lacking tissue diagnosis, synchronous primary or multifocal, second primary after pneumonectomy, proximal to or involved with mediastinal structures, abutting the chest wall, or recurring after previous treatment. Qualifying statements are included to provide further guidance for implementation, and the importance of a discussion of treatment options among members of the multidisciplinary cancer care team is emphasized. Additional information is available at: www.asco.org/thoracic-cancer-guidelines and www.asco.org/guidelineswiki .
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Affiliation(s)
- Bryan J Schneider
- Bryan J. Schneider and Shruti Jolly, University of Michigan, Ann Arbor, MI; Megan E. Daly, University of California, Davis, CA; Erin B. Kennedy, American Society of Clinical Oncology, Alexandria, VA; Mara B. Antonoff, MD Anderson Cancer Center, Houston TX; Stephen Broderick, Johns Hopkins Medicine, Baltimore, MD; Jill Feldman, Lungevity Foundation, Chicago, IL; Bryan Meyers, Washington University, St Louis, MO; Gaetano Rocco, Istituto Nazionale Tumori, Istituto di Ricovero e Cura a Carattere Scientifico, Naples, Italy; Chad Rusthoven, University of Colorado Hospital, Aurora, CO; Ben J. Slotman, Vrije Universiteit Medical Center, Amsterdam, Netherlands; Daniel H. Sterman, New York University Langone Medical Center; and Brendon M. Stiles, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY
| | - Megan E Daly
- Bryan J. Schneider and Shruti Jolly, University of Michigan, Ann Arbor, MI; Megan E. Daly, University of California, Davis, CA; Erin B. Kennedy, American Society of Clinical Oncology, Alexandria, VA; Mara B. Antonoff, MD Anderson Cancer Center, Houston TX; Stephen Broderick, Johns Hopkins Medicine, Baltimore, MD; Jill Feldman, Lungevity Foundation, Chicago, IL; Bryan Meyers, Washington University, St Louis, MO; Gaetano Rocco, Istituto Nazionale Tumori, Istituto di Ricovero e Cura a Carattere Scientifico, Naples, Italy; Chad Rusthoven, University of Colorado Hospital, Aurora, CO; Ben J. Slotman, Vrije Universiteit Medical Center, Amsterdam, Netherlands; Daniel H. Sterman, New York University Langone Medical Center; and Brendon M. Stiles, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY
| | - Erin B Kennedy
- Bryan J. Schneider and Shruti Jolly, University of Michigan, Ann Arbor, MI; Megan E. Daly, University of California, Davis, CA; Erin B. Kennedy, American Society of Clinical Oncology, Alexandria, VA; Mara B. Antonoff, MD Anderson Cancer Center, Houston TX; Stephen Broderick, Johns Hopkins Medicine, Baltimore, MD; Jill Feldman, Lungevity Foundation, Chicago, IL; Bryan Meyers, Washington University, St Louis, MO; Gaetano Rocco, Istituto Nazionale Tumori, Istituto di Ricovero e Cura a Carattere Scientifico, Naples, Italy; Chad Rusthoven, University of Colorado Hospital, Aurora, CO; Ben J. Slotman, Vrije Universiteit Medical Center, Amsterdam, Netherlands; Daniel H. Sterman, New York University Langone Medical Center; and Brendon M. Stiles, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY
| | - Mara B Antonoff
- Bryan J. Schneider and Shruti Jolly, University of Michigan, Ann Arbor, MI; Megan E. Daly, University of California, Davis, CA; Erin B. Kennedy, American Society of Clinical Oncology, Alexandria, VA; Mara B. Antonoff, MD Anderson Cancer Center, Houston TX; Stephen Broderick, Johns Hopkins Medicine, Baltimore, MD; Jill Feldman, Lungevity Foundation, Chicago, IL; Bryan Meyers, Washington University, St Louis, MO; Gaetano Rocco, Istituto Nazionale Tumori, Istituto di Ricovero e Cura a Carattere Scientifico, Naples, Italy; Chad Rusthoven, University of Colorado Hospital, Aurora, CO; Ben J. Slotman, Vrije Universiteit Medical Center, Amsterdam, Netherlands; Daniel H. Sterman, New York University Langone Medical Center; and Brendon M. Stiles, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY
| | - Stephen Broderick
- Bryan J. Schneider and Shruti Jolly, University of Michigan, Ann Arbor, MI; Megan E. Daly, University of California, Davis, CA; Erin B. Kennedy, American Society of Clinical Oncology, Alexandria, VA; Mara B. Antonoff, MD Anderson Cancer Center, Houston TX; Stephen Broderick, Johns Hopkins Medicine, Baltimore, MD; Jill Feldman, Lungevity Foundation, Chicago, IL; Bryan Meyers, Washington University, St Louis, MO; Gaetano Rocco, Istituto Nazionale Tumori, Istituto di Ricovero e Cura a Carattere Scientifico, Naples, Italy; Chad Rusthoven, University of Colorado Hospital, Aurora, CO; Ben J. Slotman, Vrije Universiteit Medical Center, Amsterdam, Netherlands; Daniel H. Sterman, New York University Langone Medical Center; and Brendon M. Stiles, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY
| | - Jill Feldman
- Bryan J. Schneider and Shruti Jolly, University of Michigan, Ann Arbor, MI; Megan E. Daly, University of California, Davis, CA; Erin B. Kennedy, American Society of Clinical Oncology, Alexandria, VA; Mara B. Antonoff, MD Anderson Cancer Center, Houston TX; Stephen Broderick, Johns Hopkins Medicine, Baltimore, MD; Jill Feldman, Lungevity Foundation, Chicago, IL; Bryan Meyers, Washington University, St Louis, MO; Gaetano Rocco, Istituto Nazionale Tumori, Istituto di Ricovero e Cura a Carattere Scientifico, Naples, Italy; Chad Rusthoven, University of Colorado Hospital, Aurora, CO; Ben J. Slotman, Vrije Universiteit Medical Center, Amsterdam, Netherlands; Daniel H. Sterman, New York University Langone Medical Center; and Brendon M. Stiles, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY
| | - Shruti Jolly
- Bryan J. Schneider and Shruti Jolly, University of Michigan, Ann Arbor, MI; Megan E. Daly, University of California, Davis, CA; Erin B. Kennedy, American Society of Clinical Oncology, Alexandria, VA; Mara B. Antonoff, MD Anderson Cancer Center, Houston TX; Stephen Broderick, Johns Hopkins Medicine, Baltimore, MD; Jill Feldman, Lungevity Foundation, Chicago, IL; Bryan Meyers, Washington University, St Louis, MO; Gaetano Rocco, Istituto Nazionale Tumori, Istituto di Ricovero e Cura a Carattere Scientifico, Naples, Italy; Chad Rusthoven, University of Colorado Hospital, Aurora, CO; Ben J. Slotman, Vrije Universiteit Medical Center, Amsterdam, Netherlands; Daniel H. Sterman, New York University Langone Medical Center; and Brendon M. Stiles, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY
| | - Bryan Meyers
- Bryan J. Schneider and Shruti Jolly, University of Michigan, Ann Arbor, MI; Megan E. Daly, University of California, Davis, CA; Erin B. Kennedy, American Society of Clinical Oncology, Alexandria, VA; Mara B. Antonoff, MD Anderson Cancer Center, Houston TX; Stephen Broderick, Johns Hopkins Medicine, Baltimore, MD; Jill Feldman, Lungevity Foundation, Chicago, IL; Bryan Meyers, Washington University, St Louis, MO; Gaetano Rocco, Istituto Nazionale Tumori, Istituto di Ricovero e Cura a Carattere Scientifico, Naples, Italy; Chad Rusthoven, University of Colorado Hospital, Aurora, CO; Ben J. Slotman, Vrije Universiteit Medical Center, Amsterdam, Netherlands; Daniel H. Sterman, New York University Langone Medical Center; and Brendon M. Stiles, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY
| | - Gaetano Rocco
- Bryan J. Schneider and Shruti Jolly, University of Michigan, Ann Arbor, MI; Megan E. Daly, University of California, Davis, CA; Erin B. Kennedy, American Society of Clinical Oncology, Alexandria, VA; Mara B. Antonoff, MD Anderson Cancer Center, Houston TX; Stephen Broderick, Johns Hopkins Medicine, Baltimore, MD; Jill Feldman, Lungevity Foundation, Chicago, IL; Bryan Meyers, Washington University, St Louis, MO; Gaetano Rocco, Istituto Nazionale Tumori, Istituto di Ricovero e Cura a Carattere Scientifico, Naples, Italy; Chad Rusthoven, University of Colorado Hospital, Aurora, CO; Ben J. Slotman, Vrije Universiteit Medical Center, Amsterdam, Netherlands; Daniel H. Sterman, New York University Langone Medical Center; and Brendon M. Stiles, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY
| | - Chad Rusthoven
- Bryan J. Schneider and Shruti Jolly, University of Michigan, Ann Arbor, MI; Megan E. Daly, University of California, Davis, CA; Erin B. Kennedy, American Society of Clinical Oncology, Alexandria, VA; Mara B. Antonoff, MD Anderson Cancer Center, Houston TX; Stephen Broderick, Johns Hopkins Medicine, Baltimore, MD; Jill Feldman, Lungevity Foundation, Chicago, IL; Bryan Meyers, Washington University, St Louis, MO; Gaetano Rocco, Istituto Nazionale Tumori, Istituto di Ricovero e Cura a Carattere Scientifico, Naples, Italy; Chad Rusthoven, University of Colorado Hospital, Aurora, CO; Ben J. Slotman, Vrije Universiteit Medical Center, Amsterdam, Netherlands; Daniel H. Sterman, New York University Langone Medical Center; and Brendon M. Stiles, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY
| | - Ben J Slotman
- Bryan J. Schneider and Shruti Jolly, University of Michigan, Ann Arbor, MI; Megan E. Daly, University of California, Davis, CA; Erin B. Kennedy, American Society of Clinical Oncology, Alexandria, VA; Mara B. Antonoff, MD Anderson Cancer Center, Houston TX; Stephen Broderick, Johns Hopkins Medicine, Baltimore, MD; Jill Feldman, Lungevity Foundation, Chicago, IL; Bryan Meyers, Washington University, St Louis, MO; Gaetano Rocco, Istituto Nazionale Tumori, Istituto di Ricovero e Cura a Carattere Scientifico, Naples, Italy; Chad Rusthoven, University of Colorado Hospital, Aurora, CO; Ben J. Slotman, Vrije Universiteit Medical Center, Amsterdam, Netherlands; Daniel H. Sterman, New York University Langone Medical Center; and Brendon M. Stiles, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY
| | - Daniel H Sterman
- Bryan J. Schneider and Shruti Jolly, University of Michigan, Ann Arbor, MI; Megan E. Daly, University of California, Davis, CA; Erin B. Kennedy, American Society of Clinical Oncology, Alexandria, VA; Mara B. Antonoff, MD Anderson Cancer Center, Houston TX; Stephen Broderick, Johns Hopkins Medicine, Baltimore, MD; Jill Feldman, Lungevity Foundation, Chicago, IL; Bryan Meyers, Washington University, St Louis, MO; Gaetano Rocco, Istituto Nazionale Tumori, Istituto di Ricovero e Cura a Carattere Scientifico, Naples, Italy; Chad Rusthoven, University of Colorado Hospital, Aurora, CO; Ben J. Slotman, Vrije Universiteit Medical Center, Amsterdam, Netherlands; Daniel H. Sterman, New York University Langone Medical Center; and Brendon M. Stiles, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY
| | - Brendon M Stiles
- Bryan J. Schneider and Shruti Jolly, University of Michigan, Ann Arbor, MI; Megan E. Daly, University of California, Davis, CA; Erin B. Kennedy, American Society of Clinical Oncology, Alexandria, VA; Mara B. Antonoff, MD Anderson Cancer Center, Houston TX; Stephen Broderick, Johns Hopkins Medicine, Baltimore, MD; Jill Feldman, Lungevity Foundation, Chicago, IL; Bryan Meyers, Washington University, St Louis, MO; Gaetano Rocco, Istituto Nazionale Tumori, Istituto di Ricovero e Cura a Carattere Scientifico, Naples, Italy; Chad Rusthoven, University of Colorado Hospital, Aurora, CO; Ben J. Slotman, Vrije Universiteit Medical Center, Amsterdam, Netherlands; Daniel H. Sterman, New York University Langone Medical Center; and Brendon M. Stiles, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY
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Ha JS, Fraser C, Zhou X, Hansaraj N, Burrows W, Broderick S, Battafarano RJ. Morbidity and mortality outcomes after esophagectomy following chemoradiation using a standardized operative technique. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.4_suppl.166] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
166 Background: Esophagogastrectomy following neoadjuvant chemo-radiation therapy for the treatment of locally advanced esophageal cancer is associated with significant morbidity and mortality. We hypothesized that the avoidance of neck anastomoses unless absolutely necessary to achieve negative margins and standardization of the anastomotic technique among surgeons would significantly decrease perioperative morbidity and potential mortality and improve oncologic outcomes for these patients. Methods: A HIPAA-compliant, prospectively maintained data base was retrospectively analyzed on 115 patients who underwent esophagogastrectomy following chemo-RT from 2007-2017 performed via a laparotomy and right thoracotomy using a standardized anastomotic technique. These procedures were performed by 5 different attending surgeons at 2 different academic medical centers. Peri-operative morbidity was assessed by standard measures and post-operative survival was assessed using Kaplan-Meyer survival. Results: There was 1 anastomotic leak and 1 mortality at 30 and 90 days. The overall 5-year survival was 40%. Major morbidity, defined as re-operation for bleeding, anastomotic leak, pneumonia, reintubation, chyle leak, and initial mechanical ventilation > 48 hours was 26% (30/113). Conclusions: Low anastomotic complication rates are associated with decreased perioperative morbidity and prolonged oncologic survival when compared to historical controls.
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Affiliation(s)
| | | | - Xun Zhou
- Johns Hopkins Hospital, Baltimore, MD
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Voong K, Liang S, Dugan P, Torto D, Padula W, Senter J, Lang M, Hooker C, Khanna K, Feliciano J, Broderick S, Hales R. Reducing Unnecessary Healthcare Expenditure: Thoracic Oncology Multidisciplinary Clinic Reduces Resources Used in the Diagnosis and Staging of Patients with Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2017. [DOI: 10.1016/j.ijrobp.2017.06.038] [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: 10/18/2022]
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Scher D, Broderick S, Holly B. Retrieval of an Essure Device from the Pulmonary Arterial System. J Vasc Interv Radiol 2017; 28:1297-1299. [PMID: 28841942 DOI: 10.1016/j.jvir.2017.03.033] [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: 02/06/2017] [Revised: 03/23/2017] [Accepted: 03/24/2017] [Indexed: 10/19/2022] Open
Affiliation(s)
- Daniel Scher
- Department of Vascular and Interventional Radiology, Johns Hopkins Hospital, 1800 Orleans Street, Baltimore, MD 21287
| | - Stephen Broderick
- Department of Vascular and Interventional Radiology, Johns Hopkins Hospital, 1800 Orleans Street, Baltimore, MD 21287
| | - Brian Holly
- Department of Vascular and Interventional Radiology, Johns Hopkins Hospital, 1800 Orleans Street, Baltimore, MD 21287
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Forde PM, Chaft JE, Felip E, Broderick S, Girard N, Awad MM, Kerr K, Blackwood-Chirchir A, Yang R, Geese WJ, Brahmer JR. Checkmate 816: A phase 3, randomized, open-label trial of nivolumab plus ipilimumab vs platinum-doublet chemotherapy as neoadjuvant treatment for early-stage NSCLC. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.tps8577] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [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
TPS8577 Background: At initial diagnosis, 20% of patients (pts) with NSCLC present with early-stage disease. The 5-year overall survival (OS) rate after surgery for stage IB–IIIA NSCLC is 25%–60%. Addition of adjuvant chemotherapy to surgery only provides a 5% absolute OS benefit at 5 years. Neoadjuvant treatment with immune checkpoint inhibitors may extend OS in early-stage NSCLC by enhancing systemic immunity and eradicating micrometastatic disease. In contrast to the adjuvant setting, the neoadjuvant setting is associated with a higher tumor burden, the presence of abundant tumor antigens, and the consequent potential for tumor-associated neoantigen presentation to the immune system. In an ongoing feasibility trial in pts with stage IB–IIIA NSCLC, nivolumab (nivo; a fully human PD-1 immune checkpoint inhibitor antibody) given alone as neoadjuvant treatment induced a major pathological response (MPR; < 10% residual viable tumor cells) rate of 39% (7/18), did not delay or interfere with surgery, and was not associated with new safety signals. In a phase 1 study in pts with stage IIIB/IV NSCLC, first-line nivo + ipilimumab (ipi; a CTLA-4 immune checkpoint inhibitor antibody) showed a greater radiologic objective response rate than nivo alone (39% vs 23%). These data provided the rationale for Checkmate 816 (NCT02998528), a phase 3 study evaluating nivo + ipi vs platinum-doublet chemotherapy as neoadjuvant treatment for early-stage NSCLC. Methods: Approximately 326 pts aged ≥18 years with resectable stage IB/II/IIIA NSCLC, ECOG performance status 0–1, pulmonary function capable of tolerating lung resection, and available lung tumor tissue will be enrolled in North America, South America, Europe, and Asia. Pts are ineligible if they have autoimmune disease or had received prior treatment with immune checkpoint inhibitors. Pts will be randomized to receive nivo + ipi or platinum-doublet chemotherapy. The primary endpoint is MPR rate. Secondary endpoints include event-free survival, OS, and complete pathological response. Start date is January 2017. The estimated primary completion date is July 2019. Clinical trial information: NCT02998528.
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Affiliation(s)
- Patrick M. Forde
- Johns Hopkins Kimmel Cancer Center and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Baltimore, MD
| | | | | | - Stephen Broderick
- Johns Hopkins Kimmel Cancer Center and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Baltimore, MD
| | | | | | - Keith Kerr
- Aberdeen Royal Infirmary, Aberdeen, United Kingdom
| | | | | | | | - Julie R. Brahmer
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD
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Chaft JE, Forde PM, Smith KN, Anagnostou V, Cottrell T, Taube JM, Rekhtman N, Merghoub T, Jones DR, Hellmann MD, Yang SC, Broderick S, Rusch VW, Velculescu VE, Topalian SL, Pardoll DM, Brahmer JR. Neoadjuvant nivolumab in early-stage, resectable non-small cell lung cancers. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.8508] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [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
8508 Background: Anti-PD-1 therapy produces objective and often durable responses in ~20% of unselected patients (pts) with metastatic non-small cell lung cancer (NSCLC). However, the role of PD-1 blockade in treating resectable NSCLC is unknown. This is the first study to test nivolumab in the neoadjuvant setting. This trial design provides an opportunity to examine anti-PD-1 mechanism of action and immunologic correlates of outcomes. Methods: Patients with Stage IB - IIIA NSCLC received 2 doses of nivolumab 3mg/kg over 4 weeks before surgery. The primary endpoint was safety in 20 patients with resected NSCLC. Efficacy was explored using objective pathologic response criteria. Correlative studies of the tumor immune microenvironment, tumor mutation and predicted neoantigen loads, and changes in T cell receptor (TCR) clonality in tumor and blood pre and post treatment were conducted. Results: 22 pts were treated. Nivolumab was well-tolerated and no surgeries were delayed. 1 pt withdrew from study preop without progression or toxicity. Among the 21 attempted resections, 1 tumor was unresectable. 9/21 (43%, 95% CI 24-63%) had a major pathologic response ( < 10% viable tumor cells in resection specimen). With a median postop follow-up of 9 months, 18 pts (86%) remain alive and recurrence free. Pre-treatment tumor exome sequencing showed a correlation between both tumor mutation and predicted neoantigen loads with pathologic response. Multiplex immunohistochemistry of pre- and post-treatment tumors showed an influx of PD-1+CD8+ T cells into responding tumors. TCR sequencing demonstrated that expanded peripheral T cell clones after treatment match clones found in the tumor. Conclusions: Neoadjuvant nivolumab in resectable NSCLC did not delay surgery. Major pathologic response rate was encouraging and compares favorably to outcomes with cisplatin-based neoadjuvant chemotherapy. Genomic analyses suggest that higher mutational and neoantigen burden could result in deeper pathologic response. Immunologic analyses support the detection of intra-tumoral T cell clones in the blood after treatment with nivolumab and may provide further insight into the molecular and immunologic features of response and non-response to PD-1 blockade. Clinical trial information: NCT02259621.
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Affiliation(s)
| | - Patrick M. Forde
- Johns Hopkins Kimmel Cancer Center and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Baltimore, MD
| | - Kellie Nicole Smith
- Johns Hopkins Kimmel Cancer Center and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Baltimore, MD
| | - Valsamo Anagnostou
- Johns Hopkins Kimmel Cancer Center and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Baltimore, MD
| | - Tricia Cottrell
- Johns Hopkins Kimmel Cancer Center and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Baltimore, MD
| | - Janis M. Taube
- Johns Hopkins Kimmel Cancer Center and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Baltimore, MD
| | | | - Taha Merghoub
- Memorial Sloan-Kettering Cancer Center, New York, NY
| | | | | | - Stephen C. Yang
- Johns Hopkins Kimmel Cancer Center and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Baltimore, MD
| | - Stephen Broderick
- Johns Hopkins Kimmel Cancer Center and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Baltimore, MD
| | | | - Victor E. Velculescu
- Johns Hopkins Kimmel Cancer Center and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Baltimore, MD
| | - Suzanne Louise Topalian
- The Sidney Kimmel Comprehensive Cancer Center and Bloomberg-Kimmel Institute for Cancer Immunotherapy at Johns Hopkins, Baltimore, MD
| | - Drew M. Pardoll
- Johns Hopkins Kimmel Cancer Center and Bloomberg-Kimmel Institute for Cancer Immunotherapy, Baltimore, MD
| | - Julie R. Brahmer
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD
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Guo W, Hui X, Alfaifi S, Robertson S, Anderson L, Hales R, Hu C, McNutt T, Broderick S, Voong R. Is Radiation Fall-off Dose to the Uninvolved Lung Important? The Impact of Pre-Operative Contralateral Lung Radiation Dose on Post-Operative Pulmonary Toxicity. Int J Radiat Oncol Biol Phys 2017. [DOI: 10.1016/j.ijrobp.2017.01.152] [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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Crawford T, Suarez-Pierre A, Magruder J, Grimm J, Ha J, Stephens R, Kim B, Merlo C, Broderick S, Bush E. 5-Year Mortality Is Superior in COPD Patients That Receive Double vs Single Lung Transplants. J Heart Lung Transplant 2017. [DOI: 10.1016/j.healun.2017.01.1516] [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: 11/27/2022] Open
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Samson P, Puri V, Broderick S, Patterson GA, Meyers B, Crabtree T. Adhering to Quality Measures in Esophagectomy Is Associated With Improved Survival in All Stages of Esophageal Cancer. Ann Thorac Surg 2017; 103:1101-1108. [PMID: 28109569 PMCID: PMC5444909 DOI: 10.1016/j.athoracsur.2016.09.032] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 09/04/2016] [Accepted: 09/08/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Quality measures for patients with early and locally advanced esophageal cancer undergoing esophagectomy have been made by national organizations. The rate of adherence to these measures as well as their association with overall survival are unknown. METHODS Esophagectomy patients were abstracted from the National Cancer Database. Because neoadjuvant status was available since 2006, the analysis of locally advanced patients began at this time point. Selected measures included: R0 resection, evaluation of 15 or more lymph nodes, and induction therapy for locally advanced tumors. Multivariate models identified variables associated with achieving quality measures. A Cox proportional hazards model evaluated factors associated with mortality. RESULTS From 1998 to 2012, 4,908 of 16,040 (30.6%) early-stage esophageal cancer patients (clinical T1A to T2N0 <2cm, well-differentiated) underwent esophagectomy. Of 4,672 patients 4,518 (96.7%) achieved R0 resection and 1,395 of 4,686 (29.8%) had 15 or more lymph nodes sampled. High-volume center type (>20 esophagectomies/year) was independently associated with meeting both measures (odds ratio [OR] 2.2, 95% confidence interval [CI]: 1.9 to 2.5). From 2006 to 2012, 7,747 of 20,437 (37.9%) locally advanced patients (clinical Stage IIB to IIIB) received esophagectomy. Of 6,966 patients 5,977 (85.8%) received induction therapy, 6,394 (91.8%) had R0 resection, and 2,852 (40.9%) had 15 or more lymph nodes sampled. High-volume center type was, again, associated with increased likelihood of meeting all quality measures (OR 2.17, 95% CI: 1.92 to 2.46). Meeting all quality measures was associated with the largest decrease in mortality for both early-stage (hazard ratio [HR] 0.27, 95% CI: 0.18 to 0.39) and locally advanced (HR 0.54, 95% CI: 0.40 to 0.73) esophageal cancer patients. CONCLUSIONS Adherence to recommended quality measures is independently associated with improved overall survival in both early and locally advanced stages of esophageal cancer. Currently, few patients are receiving care in accordance with these recommendations.
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Affiliation(s)
- Pamela Samson
- Division of Cardiothoracic Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Stephen Broderick
- Division of Cardiothoracic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Bryan Meyers
- Division of Cardiothoracic Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Traves Crabtree
- Division of Cardiothoracic Surgery, Southern Illinois University, Springfield, Illinois.
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Samson P, Crabtree TD, Robinson CG, Morgensztern D, Broderick S, Krupnick AS, Kreisel D, Patterson GA, Meyers B, Puri V. Defining the Ideal Time Interval Between Planned Induction Therapy and Surgery for Stage IIIA Non-Small Cell Lung Cancer. Ann Thorac Surg 2017; 103:1070-1075. [PMID: 28110809 PMCID: PMC5444908 DOI: 10.1016/j.athoracsur.2016.09.053] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 09/03/2016] [Accepted: 09/12/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Induction therapy leads to significant improvement in survival for selected patients with stage IIIA non-small cell lung cancer. The ideal time interval between induction therapy and surgery remains unknown. METHODS Clinical stage IIIA non-small cell lung cancer patients receiving induction therapy and surgery were identified in the National Cancer Database. Delayed surgery was defined as greater than or equal to 3 months after starting induction therapy. A logistic regression model identified variables associated with delayed surgery. Cox proportional hazards modeling and Kaplan-Meier analysis were performed to evaluate variables independently associated with overall survival. RESULTS From 2006 to 2010, 1,529 of 2,380 (64.2%) received delayed surgery. Delayed surgery patients were older (61.2 ± 10.0 years versus 60.3 ± 9.2; p = 0.03), more likely to be non-white (12.4% versus 9.7%; p = 0.046), and less likely to have private insurance (50% versus 58.2%; p = 0.002). Delayed surgery patients were also more likely to have a sublobar resection (6.3% versus 2.9%). On multivariate analysis, age greater than 68 years (odds ratio [OR], 1.37; 95% confidence interval [CI], 1.1 to 1.7) was associated with delayed surgery, whereas white race (OR, 0.75; 95% CI, 0.57 to 0.99) and private insurance status (OR, 0.82; 95% CI, 0.68 to 0.99) were associated with early surgery. Delayed surgery was associated with higher risk of long-term mortality (hazard ratio, 1.25; 95% CI, 1.07 to 1.47). CONCLUSIONS Delayed surgery after induction therapy for stage IIIA lung cancer is associated with shorter survival, and is influenced by both social and physiologic factors. Prospective work is needed to further characterize the relationship between patient comorbidities and functional status with receipt of timely surgery.
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Affiliation(s)
- Pamela Samson
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Traves D Crabtree
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Cliff G Robinson
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Daniel Morgensztern
- Division of Medical Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Stephen Broderick
- Division of Cardiothoracic Surgery, St. Luke's Hospital, Chesterfield, Missouri
| | - A Sasha Krupnick
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Bryan Meyers
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri.
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Samson P, Crabtree T, Broderick S, Kreisel D, Krupnick AS, Patterson GA, Meyers B, Puri V. Quality Measures in Clinical Stage I Non-Small Cell Lung Cancer: Improved Performance Is Associated With Improved Survival. Ann Thorac Surg 2017; 103:303-311. [PMID: 27665480 PMCID: PMC5182109 DOI: 10.1016/j.athoracsur.2016.07.003] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 06/30/2016] [Accepted: 07/05/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND National organizations have recommended quality measures for operations in early-stage non-small cell lung cancer (NSCLC). The outcomes of adherence to these guidelines are unknown. METHODS Information about patients who underwent an operation for clinical stage I NSCLC was abstracted from the National Cancer Database. After reviewing current guidelines, the following quality measures were selected: anatomic resection, operation within 8 weeks of diagnosis, achievement of negative surgical margins, and sampling of 10 or more lymph nodes. Multivariate models identified variables independently associated with receiving quality measures and a Cox model created to evaluate overall survival. RESULTS Between 2004 and 2013, 133,026 of 133,366 (99.7%), 126,598 of 133,366 (94.9%), 91,472 of 133,366 (68.6%), and 30,041 of 133,366 (22.5%) patients met one, two, three, or four measures. Income of at least $38,000/year (odds ratio [OR] 1.20, 95% CI: 1.15 to 1.24), insurance type (private insurance: OR 1.22, 95% CI: 1.09 to 1.36; Medicare: OR 1.16, 95% CI:1.04 to 1.30), centers with at least 38 cases/year (OR 1.18, 95% CI: 1.14 to 1.22), academic institutions (OR 1.31, 95% CI: 1.27 to 1.35), and clinical stage IB patients (OR 1.50, 95% CI: 1.40 to 1.60) were more likely to meet all four measures; whereas increasing age (OR 0.99, 95% CI: 0.99 to 0.99), women (OR 0.93, 95% CI: 0.91 to 0.96), non-Caucasian race (OR 0.83, 95% CI: 0.79 to 0.87), and increasing Charlson/Deyo comorbidity score (1: OR 0.90, 95% CI: 0.87 to 0.93; ≥2: OR 0.82, 95% CI: 0.79 to 0.86) were associated with lower likelihood. Pathologic upstaging (hazard ratio [HR] 1.84, 95% CI: 1.78 to 1.89) and meeting all four measures (HR 0.39, 95% CI: 0.31 to 0.48) were most powerfully associated with overall survival. CONCLUSIONS National adherence to quality measures in stage I NSCLC resection is suboptimal. Guideline compliance is strongly associated with survival, and vigorous efforts should be instituted by national societies to improve adherence.
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Affiliation(s)
- Pamela Samson
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Traves Crabtree
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Stephen Broderick
- Division of Cardiothoracic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - A Sasha Krupnick
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Bryan Meyers
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri.
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Samson P, Puri V, Broderick S, Patterson GA, Meyers B, Crabtree T. Extent of Lymphadenectomy Is Associated With Improved Overall Survival After Esophagectomy With or Without Induction Therapy. Ann Thorac Surg 2016; 103:406-415. [PMID: 28024648 DOI: 10.1016/j.athoracsur.2016.08.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 07/04/2016] [Accepted: 08/05/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND National Comprehensive Cancer Network (NCCN) guidelines recommend sampling 15 or more lymph nodes during esophagectomy. The proportion of patients meeting this guideline is unknown, as is its influence on overall survival (OS). METHODS Univariate analysis and logistic regression were performed to identify variables associated with sampling 15 or more lymph nodes among patients undergoing esophagectomy in the National Cancer Data Base (NCDB). The NCCN guideline was evaluated in Cox proportional hazards modeling, along with alternative lymph node thresholds. Positive to examined node (PEN) ratios were calculated, and OS was compared using Kaplan-Meier analysis. RESULTS From 2006 to 2012, only 6,961 of 18,777 (37.1%) patients undergoing esophagectomy had sampling of 15 or more lymph nodes. Variables associated with sampling 15 or more lymph nodes included income greater than or equal to $38,000, procedure performed in an academic facility, and increasing clinical T and N stages. Induction therapy was associated with a decreased likelihood of 15 or more lymph nodes being sampled. The largest decrease in mortality hazard in patients undergoing upfront esophagectomy was detected when 25 lymph nodes or more were sampled (hazard ratio [HR], 0.77; 95% confidence interval [CI], 0.67-0.89; p < 0.001), whereas for patients undergoing induction therapy, sampling of 10 or 15 or more lymph nodes was associated with optimal survival benefit (HR, 0.81; 95% CI, 0.74-0.90; p < 0.001). PEN ratios of 0 to 0.10 were associated with maximum survival benefit among all patients undergoing esophagectomy. For patients with a PEN ratio of 0, increases in OS were detected with higher lymph node sampling (85.3 months for sampling of 20 or more lymph nodes versus 52.0 months for sampling 1-9 lymph nodes; p < 0.001). CONCLUSIONS For patients undergoing upfront esophagectomy, there may be an increased survival benefit for examining 20 to 25 lymph nodes, which is higher than current recommendations. However, only a minority of patients are meeting current guidelines.
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Affiliation(s)
- Pamela Samson
- Division of Cardiothoracic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Stephen Broderick
- St. Luke's Hospital, Division of Cardiothoracic Surgery, Chesterfield, Missouri
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Bryan Meyers
- Division of Cardiothoracic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Traves Crabtree
- Division of Cardiothoracic Surgery, Southern Illinois University College of Medicine, Springfield, Illinois.
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Puri V, Broderick S. Reply. Ann Thorac Surg 2016; 102:1029-1030. [PMID: 27549530 DOI: 10.1016/j.athoracsur.2016.04.076] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 04/15/2016] [Accepted: 04/18/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Varun Puri
- Washington University School of Medicine, Division of Cardiothoracic Surgery, Campus Box 8234, 660 S Euclid Ave, St. Louis, MO 63110.
| | - Stephen Broderick
- Washington University School of Medicine, Division of Cardiothoracic Surgery, Campus Box 8234, 660 S Euclid Ave, St. Louis, MO 63110
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Puri V, Broderick S. Reply. Ann Thorac Surg 2016; 102:1030-1031. [PMID: 27549531 DOI: 10.1016/j.athoracsur.2016.04.074] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 04/15/2016] [Accepted: 04/18/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Varun Puri
- Washington University School of Medicine, Division of Cardiothoracic Surgery, Campus Box 8234, 660 S Euclid Ave, St. Louis, MO 63110
| | - Stephen Broderick
- Washington University School of Medicine, Division of Cardiothoracic Surgery, Campus Box 8234, 660 S Euclid Ave, St. Louis, MO 63110.
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Bott MJ, Patel AP, Verma V, Crabtree TD, Morgensztern D, Robinson CG, Colditz GA, Waqar S, Kreisel D, Krupnick AS, Patterson GA, Broderick S, Meyers BF, Puri V. Patterns of care in hilar node-positive (N1) non-small cell lung cancer: A missed treatment opportunity? J Thorac Cardiovasc Surg 2016; 151:1549-1558.e2. [PMID: 27207124 PMCID: PMC4876013 DOI: 10.1016/j.jtcvs.2016.01.058] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 12/17/2015] [Accepted: 01/27/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND For patients with non-small cell lung cancer (NSCLC) metastatic to hilar lymph nodes (N1), guidelines recommend surgery and adjuvant chemotherapy in operable patients and chemoradiation (CRT) for those deemed inoperable. It is unclear how these recommendations are applied nationally, however. METHODS The National Cancer Database was queried to identify patients with a tumor <7 cm (T1/T2) with clinically positive N1 nodes. Patients undergoing CRT (comprising chemotherapy and radiation >45 Gy) or surgical resection were considered adequately treated. Remaining patients were classified as receiving inadequate or no treatment. RESULTS Of the 20,366 patients who met the study criteria, 63% underwent adequate treatment (48% surgical resection, 15% CRT). The remainder received inadequate treatment (23%) or no treatment (14%). In univariate analysis, the patients receiving inadequate or no treatment were older, tended to be non-Caucasian, had a lower income, and had a higher comorbidity score. Patients undergoing adequate treatment had improved overall survival (OS) compared with those receiving inadequate or no treatment (median OS, 34.0 months vs 11.7 months; P < .001). Of those receiving adequate treatment, logistic regression identified several variables associated with surgical resection, including treatment at an academic facility, Caucasian race, and annual income >$35,000. Increasing age and T2 stage were associated with nonoperative management. Following propensity score matching of 2308 patient pairs undergoing surgery or CRT, resection was associated with longer median OS (34.1 months vs 22.0 months; P < .001). CONCLUSIONS Despite the established guidelines, many patients with T1-2N1 NSCLC do not receive adequate treatment. Surgery is associated with prolonged survival in selected patients. Surgical input in the multidisciplinary evaluation of these patients should be mandatory.
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Affiliation(s)
- Matthew J Bott
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Aalok P Patel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Vivek Verma
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, Neb
| | - Traves D Crabtree
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Daniel Morgensztern
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St Louis, Mo
| | - Clifford G Robinson
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Mo
| | - Graham A Colditz
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Saiama Waqar
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St Louis, Mo
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - A Sasha Krupnick
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Stephen Broderick
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo.
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Samson P, Puri V, Robinson C, Lockhart C, Carpenter D, Broderick S, Kreisel D, Krupnick AS, Patterson GA, Meyers B, Crabtree T. Clinical T2N0 Esophageal Cancer: Identifying Pretreatment Characteristics Associated With Pathologic Upstaging and the Potential Role for Induction Therapy. Ann Thorac Surg 2016; 101:2102-11. [PMID: 27083246 DOI: 10.1016/j.athoracsur.2016.01.033] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 12/30/2015] [Accepted: 01/06/2016] [Indexed: 12/28/2022]
Abstract
BACKGROUND Although studies have suggested standard therapy for clinical T2N0 esophageal cancer should be primary surgery, we hypothesize there is a subgroup for whom induction therapy may result in improved overall survival. METHODS Patients with cT2N0 esophageal cancer receiving induction therapy or upfront esophagectomy (UE) were identified in the National Cancer Data Base. The UE patients were dichotomized as (1) pathologically upstaged, or (2) same-staged or downstaged. Logistic regression models identified variables associated with upstaging, and Kaplan-Meier analysis compared median overall survival. RESULTS From 2006 to 2012, 932 cT2N0 patients (52.2%) received UE, and 853 (47.8%) received induction therapy first. In all, 326 of 713 UE patients (45.7%) were upstaged: 87 of 326 (26.7%) had T upstaging; 98 of 326 (30.1%) had N upstaging; and 141 of 326 (43.3%) had both. Patients upstaged after UE had a higher tumor grade (35.1% versus 57.1% grade 3), and a higher rate of lymphovascular invasion (57.1% versus 17.7%; both p < 0.001). Variables associated with upstaging included lymphovascular invasion (odds ratio 6.0, 95% confidence interval: 2.9 to 12.5, p < 0.001) and tumor grade 3 (odds ratio 9.4, 95% confidence interval: 1.8 to 48.4, p = 0.007). Of upstaged UE patients, only 144 (44.2%) received adjuvant therapy. The median overall survival for cT2N0 patients upstaged after UE was 27.5 ± 2.5 months versus 43.9 ± 2.9 months for induction therapy patients (any resultant pathologic stage, p < 0.001). CONCLUSIONS Half of all cT2N0 patients were pathologically upstaged after UE, with worse survival compared with patients receiving induction therapy. Refining an upstaging model would help select patients for induction therapy and increase the rate of chemotherapy in patients at risk for systemic disease.
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Affiliation(s)
- Pamela Samson
- Division of Cardiothoracic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Clifford Robinson
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, Missouri
| | - Craig Lockhart
- Division of Medical Oncology, Washington University in St. Louis, St. Louis, Missouri
| | - Danielle Carpenter
- Department of Pathology and Immunology, Washington University in St. Louis, St. Louis, Missouri
| | - Stephen Broderick
- Division of Cardiothoracic Surgery, St. Luke's Hospital, Chesterfield, Missouri
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - A Sasha Krupnick
- Division of Cardiothoracic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Bryan Meyers
- Division of Cardiothoracic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Traves Crabtree
- Division of Cardiothoracic Surgery, Washington University in St. Louis, St. Louis, Missouri.
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Samson P, Robinson CG, Bradley J, Lee A, Broderick S, Kreisel D, Krupnick AS, Patterson GA, Puri V, Meyers BF, Crabtree T. The National Surgical Quality Improvement Program risk calculator does not adequately stratify risk for patients with clinical stage I non-small cell lung cancer. J Thorac Cardiovasc Surg 2015; 151:697-705.e1. [PMID: 26410001 DOI: 10.1016/j.jtcvs.2015.08.058] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 08/11/2015] [Accepted: 08/18/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The study objective was to validate the National Surgical Quality Improvement Program (NSQIP) Risk Calculator in stratifying risk estimates for patients who received surgery or stereotactic body radiation therapy for clinical stage I non-small cell lung cancer. METHODS A retrospective analysis of patients with clinical stage I non-small cell lung cancer undergoing surgery (N = 279) or stereotactic body radiation therapy (N = 206) from 2009 to 2012 was performed. NSQIP complication risk estimates were calculated for both surgical and stereotactic body radiation therapy cases using the NSQIP Surgical Risk Calculator. NSQIP complication risk estimates were compared as continuous variables and by quartile ranges. RESULTS Compared with patients undergoing video-assisted thoracoscopic surgery wedge resection, patients receiving stereotactic body radiation therapy were older, had larger tumors, had lower forced expiratory volume (FEV1) in 1 second and diffusing capacity of the lungs (DLCO) for carbon monoxide values, had higher American Society of Anesthesiologists scores, had higher rates of dyspnea, and had higher NSQIP serious complication risk estimates (all P < .05). Compared with patients undergoing video-assisted thoracoscopic surgery lobectomy, patients receiving stereotactic body radiation therapy had similar disparities, along with higher Adult Comorbidity Evaluation-27 (ACE) scores comorbidity scores, higher rates of cardiac comorbidities, and worse functional status (all P < .05). Variables associated with receiving stereotactic body radiation therapy treatment, rather than wedge resection, included increasing age, higher Adult Comorbidity Evaluation (ACE)-27 comorbidity score, dyspnea status, and decreasing FEV1 in 1 second and DLCO for carbon monoxide, but NSQIP serious complication risk score. In addition, surgical patients' actual serious complication rate (16.6% vs 8.8%) and pneumonia rate (6.0% vs 3.2%) were significantly higher than the NSQIP risk calculator predicted (all P < .05). CONCLUSIONS The National Surgical Quality Improvement Program risk calculator does not effectively classify or stratify risk in patients with stage I non-small cell lung cancer. Continued efforts are needed to assess risk in this population and develop more tailored treatment decision aids.
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Affiliation(s)
- Pamela Samson
- Division of Cardiothoracic Surgery, Washington University in St Louis, Mo
| | | | - Jeffrey Bradley
- Department of Radiation Oncology, Washington University in St Louis, Mo
| | - Audrey Lee
- Division of Cardiothoracic Surgery, Washington University in St Louis, Mo
| | - Stephen Broderick
- Division of Cardiothoracic Surgery, St Luke's Hospital in Chesterfield, Mo
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Washington University in St Louis, Mo
| | - A Sasha Krupnick
- Division of Cardiothoracic Surgery, Washington University in St Louis, Mo
| | | | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University in St Louis, Mo
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Washington University in St Louis, Mo
| | - Traves Crabtree
- Division of Cardiothoracic Surgery, Washington University in St Louis, Mo.
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Samson P, Patel A, Crabtree TD, Morgensztern D, Robinson CG, Colditz GA, Waqar S, Kreisel D, Krupnick AS, Patterson GA, Broderick S, Meyers BF, Puri V. Multidisciplinary Treatment for Stage IIIA Non-Small Cell Lung Cancer: Does Institution Type Matter? Ann Thorac Surg 2015; 100:1773-9. [PMID: 26228601 DOI: 10.1016/j.athoracsur.2015.04.144] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 04/15/2015] [Accepted: 04/17/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Improved survival of patients with early-stage non-small cell lung cancer (NSCLC) undergoing resection at high-volume centers has been reported. However, the effect of institution is unclear in stage IIIA NSCLC, where a variety of neoadjuvant and adjuvant therapies are used. METHODS Treatment and outcomes data of clinical stage IIIA NSCLC patients undergoing resection as part of multimodality therapy was obtained from the National Cancer Database. Multivariable regression models were fitted to evaluate variables influencing 30-day mortality and overall survival. RESULTS From 1998 to 2010, 11,492 clinical stage IIIA patients underwent resection at community centers, and 7,743 patients received resection at academic centers. Academic center patients were more likely to be younger, female, non-Caucasian, have a lower Charlson-Deyo comorbidity score, and to receive neoadjuvant chemotherapy (49.6% vs 40.6%; all p < 0.001). Higher 30-day mortality was associated with increasing age, male gender, preoperative radiotherapy, and pneumonectomy. Patients undergoing operations at academic centers experienced lower 30-day mortality (3.3% vs 4.5%; odds ratio, 0.75; 95% confidence interval [CI], 0.60 to 0.93; p < 0.001). Decreased long-term survival was associated with increasing age, male gender, higher Charlson-Deyo comorbidity score, and larger tumors. Neoadjuvant chemotherapy (hazard ratio, 0.66; 95% CI, 0.62 to 0.70), surgical intervention at an academic center (hazard ratio, 0.92; 95% CI, 0.88 to 0.97), and lobectomy (hazard ratio, 0.72; 95% CI, 0.67 to 0.77) were associated with improved overall survival. CONCLUSIONS Stage IIIA NSCLC patients undergoing resection at academic centers had lower 30-day mortality and increased overall survival compared with patients treated at community centers, possibly due to higher patient volume and an increased rate of neoadjuvant chemotherapy.
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Affiliation(s)
- Pamela Samson
- Division of Cardiothoracic Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Aalok Patel
- Division of Cardiothoracic Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Traves D Crabtree
- Division of Cardiothoracic Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Daniel Morgensztern
- Division of Medical Oncology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Cliff G Robinson
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Graham A Colditz
- Institute for Public Health, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Saiama Waqar
- Division of Medical Oncology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - A Sasha Krupnick
- Division of Cardiothoracic Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Stephen Broderick
- Division of Cardiothoracic Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri.
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Bott MJ, Patel AP, Crabtree TD, Morgensztern D, Robinson CG, Colditz GA, Waqar S, Kreisel D, Krupnicka AS, Patterson GA, Broderick S, Meyers BF, Puri V. Role for Surgical Resection in the Multidisciplinary Treatment of Stage IIIB Non-Small Cell Lung Cancer. Ann Thorac Surg 2015; 99:1921-8. [PMID: 25912748 DOI: 10.1016/j.athoracsur.2015.02.033] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 01/22/2015] [Accepted: 02/12/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The role of multimodality therapy in stage IIIB non-small cell lung cancer (NSCLC) remains inadequately studied. Although chemoradiation is currently the mainstay of treatment, randomized trials evaluating surgical intervention are lacking, and resection is offered selectively. METHODS Data from patients with clinical stage IIIB NSCLC (T4N2 or any N3) undergoing definitive multimodality therapy were obtained from the National Cancer Database (NCDB). Multivariable Cox regression models were fitted to evaluate variables influencing overall survival (OS). RESULTS From 1998 to 2010, 7,459 patients with clinical stage IIIB NSCLC were treated with definitive chemoradiation (CR group), whereas 1,714 patients underwent chemotherapy, radiation, and surgical intervention in any sequence (CRS group). CRS patients were more likely to be younger and white and have slightly smaller tumors (all p < 0.01). There was no difference in Charlson Comorbidity Index (CCI) between the groups (p = 0.5). In the CRS group, 79% of patients received neoadjuvant therapy. Thirty-day surgical mortality was 3%. Factors associated with improved OS in multivariate analysis included younger age, female sex, decreased CCI, smaller tumor size, and surgical resection (hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.52-0.63). Among patients treated with surgical intervention, incomplete resection was associated with decreased OS (HR, 1.52; 95% CI, 1.20-1.92). Median OS was longer in the CRS group (25.9 months versus 16.3 months; p < 0.001). Propensity matched analysis on 631 patient pairs treated with CRS versus CR confirmed these findings (median OS, 28.9 versus 17.2 months; p < 0.001). CONCLUSIONS Surgical resection as a part of multimodality therapy may be associated with improved OS in highly selected patients with stage IIIB NSCLC. Multidisciplinary evaluation of these patients is critical.
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Affiliation(s)
- Matthew J Bott
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Aalok P Patel
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Traves D Crabtree
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Daniel Morgensztern
- Department of Medicine, Division of Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Clifford G Robinson
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Graham A Colditz
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Saiama Waqar
- Department of Medicine, Division of Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Daniel Kreisel
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - A Sasha Krupnicka
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - G Alexander Patterson
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Stephen Broderick
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Bryan F Meyers
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Varun Puri
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri.
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Crabtree TD, Puri V, Chen SB, Gierada DS, Bell JM, Broderick S, Krupnick AS, Kreisel D, Patterson GA, Meyers BF. Does the method of radiologic surveillance affect survival after resection of stage I non-small cell lung cancer? J Thorac Cardiovasc Surg 2014; 149:45-52, 53.e1-3. [PMID: 25218540 DOI: 10.1016/j.jtcvs.2014.07.095] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 07/28/2014] [Accepted: 07/31/2014] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Controversy persists regarding appropriate radiographic surveillance strategies after lung cancer resection. We compared the impact of surveillance computed tomography scan versus chest radiography in patients who underwent resection for stage I lung cancer. METHODS A retrospective analysis was performed of all patients undergoing resection for pathologic stage I lung cancer from January 2000 to April 2013. After resection, follow-up included routine history and physical examination in conjunction with chest radiography or computed tomography at the discretion of the treating physician. Identification of successive lung malignancy (ie, recurrence at any new site or new primary) and survival were recorded. RESULTS There were 554 evaluable patients, with 232 receiving routine postoperative computed tomography and 322 receiving routine chest radiography. Postoperative 5-year survival was 67.8% in the computed tomography group versus 74.8% in the chest radiography group (P = .603). Successive lung malignancy was found in 27% (63/232) of patients receiving computed tomography versus 22% (72/322) receiving chest radiography (P = .19). The mean time from surgery to diagnosis of successive malignancy was 1.93 years for computed tomography versus 2.56 years for chest radiography (P = .046). For the computed tomography group, 41% (26/63) of successive malignancies were treated with curative intent versus 40% (29/72) in the chest radiography group (P = .639). Cox proportional hazard analysis indicated imaging modality (computed tomography vs chest radiography) was not associated with survival (P = .958). CONCLUSIONS Surveillance computed tomography may result in earlier diagnosis of successive malignancy versus chest radiography in stage I lung cancer, although no difference in survival was demonstrated. A randomized trial would help determine the impact of postoperative surveillance strategies on survival.
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Affiliation(s)
- Traves D Crabtree
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo.
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Simon B Chen
- Washington University School of Medicine, St Louis, Mo
| | - David S Gierada
- Department of Radiology, Washington University School of Medicine, St Louis, Mo
| | - Jennifer M Bell
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Stephen Broderick
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - A Sasha Krupnick
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
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Antonoff MB, Puri V, Meyers BF, Baumgartner K, Bell JM, Broderick S, Krupnick AS, Kreisel D, Patterson GA, Crabtree TD. Comparison of pyloric intervention strategies at the time of esophagectomy: is more better? Ann Thorac Surg 2014; 97:1950-7; discussion 1657-8. [PMID: 24751155 DOI: 10.1016/j.athoracsur.2014.02.046] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Revised: 02/09/2014] [Accepted: 02/20/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Controversy remains regarding the role of pyloric drainage procedures after esophagectomy with gastric conduit reconstruction. We aimed to compare the effect of pyloric drainage strategies upon subsequent risk of complications suggestive of conduit distention, including aspiration and anastomotic leak. METHODS A retrospective study was conducted reviewing patients undergoing esophagectomy between January 2007 and April 2012. Prospectively collected data included baseline comorbidities, operative details, hospital course, and complications. Statistical comparisons were performed using analysis of variance for continuous variables and χ(2) testing for categorical variables. RESULTS There were 361 esophagectomies performed during the study period; 68 were excluded from analysis (for prior esophagogastric surgery or benign disease or both). Among 293 esophagectomies included, emptying procedures were performed as follows: 44 (15%), no drainage procedure; 197 (67%), pyloromyotomy/pyloroplasty; 8 (3%), dilation alone; 44 (15%), dilation plus onabotulinumtoxinA. Aspiration occurred more frequently when no pyloric intervention was performed (5 of 44 [11.4%] versus 6 of 249 [2.4%], p = 0.030). The incidences of anastomotic leak (18 [6.1%]) and gastric outlet obstruction (5 [1.7%]) were statistically similar among groups. Subgroup analysis demonstrated persistence of these findings when limiting the comparison to transthoracic esophagectomies. Major complications directly related to pyloroplasty/pyloromyotomy occurred in 2 patients (0.6%), including 1 death (0.3%). CONCLUSIONS These data suggest that omission of pyloric intervention at the index operation results in more frequent aspiration events. The combination of dilation plus onabotulinumtoxinA provided for a similar complication profile compared with surgical drainage. Future prospective comparisons are needed to evaluate these short-term effects of pyloric intervention as well as long-term sequelae such as dumping syndrome and bile reflux.
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Affiliation(s)
- Mara B Antonoff
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
| | - Varun Puri
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
| | - Bryan F Meyers
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
| | - Kevin Baumgartner
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
| | - Jennifer M Bell
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
| | - Stephen Broderick
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
| | - A Sasha Krupnick
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
| | - Daniel Kreisel
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
| | - G Alexander Patterson
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
| | - Traves D Crabtree
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri.
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Puri V, Crabtree TD, Bell JM, Kreisel D, Krupnick AS, Broderick S, Patterson GA, Meyers BF. National cooperative group trials of "high-risk" patients with lung cancer: are they truly "high-risk"? Ann Thorac Surg 2014; 97:1678-83; discussion 1683-5. [PMID: 24534644 DOI: 10.1016/j.athoracsur.2013.12.028] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 12/02/2013] [Accepted: 12/09/2013] [Indexed: 12/22/2022]
Abstract
BACKGROUND The American College of Surgery Oncology Group (ACOSOG) trials z4032 and z4033 prospectively characterized lung cancer patients as "high-risk" for surgical intervention, and these results have appeared frequently in the literature. We hypothesized that many patients who meet the objective enrollment criteria for these trials ("high-risk") have similar perioperative outcomes as "normal-risk" patients. METHODS We reviewed a prospective institutional database and classified patients undergoing resection for clinical stage I lung cancer as "high-risk" and "normal-risk" by ACOSOG major criteria. RESULTS From 2000 to 2010, 1,066 patients underwent resection for clinical stage I lung cancer. Of these, 194 (18%) met ACOSOG major criteria for risk (preoperative forced expiratory volume in 1 second or diffusion capacity of the lung for carbon monoxide≤50% predicted). "High-risk" patients were older (66.4 vs 64.6 years, p=0.02) but similar to controls in sex, prevalence of hypertension, diabetes, and coronary artery disease. "High-risk" patients were less likely than "normal-risk" patients to undergo a lobectomy (117 of 194 [60%] vs 665 of 872 [76%], p<0.001). "High-risk" and control patients experienced similar morbidity (any complication: 55 of 194 [28%] vs 230 of 872 [26%], p=0.59) and 30-day mortality (2 of 194 [1%] vs 14 of 872 [ 2%], p=0.75). A regression analysis showed age (hazard risk, 1.04; 95% confidence interval, 1.02 to 1.06) and coronary artery disease (hazard risk, 1.58; 95% confidence interval, 1.05 to 2.40) were associated with an elevated risk of complications in those undergoing lobectomy, whereas female sex (hazard ratio, 0.63; 95% confidence interval, 0.44 to 0.91) was protective. ACOSOG "high-risk" status was not associated with perioperative morbidity. CONCLUSIONS There are no important differences in early postsurgical outcomes between lung cancer patients characterized as "high-risk" and "normal-risk" by ACOSOG trial enrollment criteria, despite a significant proportion of "high-risk" patients undergoing lobectomy.
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Affiliation(s)
- Varun Puri
- Department of Surgery, Washington University, St. Louis, St. Louis, Missouri.
| | - Traves D Crabtree
- Department of Surgery, Washington University, St. Louis, St. Louis, Missouri
| | - Jennifer M Bell
- Department of Surgery, Washington University, St. Louis, St. Louis, Missouri
| | - Daniel Kreisel
- Department of Surgery, Washington University, St. Louis, St. Louis, Missouri
| | | | - Stephen Broderick
- Department of Surgery, Washington University, St. Louis, St. Louis, Missouri
| | | | - Bryan F Meyers
- Department of Surgery, Washington University, St. Louis, St. Louis, Missouri
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Chitale D, Gong Y, Taylor BS, Broderick S, Brennan C, Somwar R, Golas B, Wang L, Motoi N, Szoke J, Reinersman JM, Major J, Sander C, Seshan VE, Zakowski MF, Rusch V, Pao W, Gerald W, Ladanyi M. An integrated genomic analysis of lung cancer reveals loss of DUSP4 in EGFR-mutant tumors. Oncogene 2009; 28:2773-83. [PMID: 19525976 PMCID: PMC2722688 DOI: 10.1038/onc.2009.135] [Citation(s) in RCA: 184] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
To address the biological heterogeneity of lung cancer, we studied 199 lung adenocarcinomas by integrating genome-wide data on copy number alterations and gene expression with full annotation for major known somatic mutations in this cancer. This revealed non-random patterns of copy number alterations significantly linked to EGFR and KRAS mutation status and to distinct clinical outcomes, and led to the discovery of a striking association of EGFR mutations with under-expression of DUSP4, a gene within a broad region of frequent single-copy loss on 8p. DUSP4 is involved in negative feedback control of EGFR signaling and we provide functional validation for its role as a growth suppressor in EGFR-mutant lung adenocarcinoma. DUSP4 loss also associates with p16/CDKN2A deletion and defines a distinct clinical subset of lung cancer patients. Another novel observation is that of reciprocal relationship between EGFR and LKB1 mutations. These results highlight the power of integrated genomics to identify candidate driver genes within recurrent broad regions of copy number alteration and to delineate distinct oncogenetic pathways in genetically complex common epithelial cancers.
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Affiliation(s)
- D Chitale
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
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Ding L, Getz G, Wheeler DA, Mardis ER, McLellan MD, Cibulskis K, Sougnez C, Greulich H, Muzny DM, Morgan MB, Fulton L, Fulton RS, Zhang Q, Wendl MC, Lawrence MS, Larson DE, Chen K, Dooling DJ, Sabo A, Hawes AC, Shen H, Jhangiani SN, Lewis LR, Hall O, Zhu Y, Mathew T, Ren Y, Yao J, Scherer SE, Clerc K, Metcalf GA, Ng B, Milosavljevic A, Gonzalez-Garay ML, Osborne JR, Meyer R, Shi X, Tang Y, Koboldt DC, Lin L, Abbott R, Miner TL, Pohl C, Fewell G, Haipek C, Schmidt H, Dunford-Shore BH, Kraja A, Crosby SD, Sawyer CS, Vickery T, Sander S, Robinson J, Winckler W, Baldwin J, Chirieac LR, Dutt A, Fennell T, Hanna M, Johnson BE, Onofrio RC, Thomas RK, Tonon G, Weir BA, Zhao X, Ziaugra L, Zody MC, Giordano T, Orringer MB, Roth JA, Spitz MR, Wistuba II, Ozenberger B, Good PJ, Chang AC, Beer DG, Watson MA, Ladanyi M, Broderick S, Yoshizawa A, Travis WD, Pao W, Province MA, Weinstock GM, Varmus HE, Gabriel SB, Lander ES, Gibbs RA, Meyerson M, Wilson RK. Somatic mutations affect key pathways in lung adenocarcinoma. Nature 2008; 455:1069-75. [PMID: 18948947 PMCID: PMC2694412 DOI: 10.1038/nature07423] [Citation(s) in RCA: 2027] [Impact Index Per Article: 126.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2008] [Accepted: 09/10/2008] [Indexed: 02/08/2023]
Abstract
Determining the genetic basis of cancer requires comprehensive analyses of large collections of histopathologically well-classified primary tumours. Here we report the results of a collaborative study to discover somatic mutations in 188 human lung adenocarcinomas. DNA sequencing of 623 genes with known or potential relationships to cancer revealed more than 1,000 somatic mutations across the samples. Our analysis identified 26 genes that are mutated at significantly high frequencies and thus are probably involved in carcinogenesis. The frequently mutated genes include tyrosine kinases, among them the EGFR homologue ERBB4; multiple ephrin receptor genes, notably EPHA3; vascular endothelial growth factor receptor KDR; and NTRK genes. These data provide evidence of somatic mutations in primary lung adenocarcinoma for several tumour suppressor genes involved in other cancers--including NF1, APC, RB1 and ATM--and for sequence changes in PTPRD as well as the frequently deleted gene LRP1B. The observed mutational profiles correlate with clinical features, smoking status and DNA repair defects. These results are reinforced by data integration including single nucleotide polymorphism array and gene expression array. Our findings shed further light on several important signalling pathways involved in lung adenocarcinoma, and suggest new molecular targets for treatment.
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Affiliation(s)
- Li Ding
- The Genome Center at Washington University, Department of Genetics, Washington University School of Medicine, St Louis, Missouri 63108, USA
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Bean J, Brennan C, Shih JY, Riely G, Viale A, Wang L, Chitale D, Motoi N, Szoke J, Broderick S, Balak M, Chang WC, Yu CJ, Gazdar A, Pass H, Rusch V, Gerald W, Huang SF, Yang PC, Miller V, Ladanyi M, Yang CH, Pao W. MET amplification occurs with or without T790M mutations in EGFR mutant lung tumors with acquired resistance to gefitinib or erlotinib. Proc Natl Acad Sci U S A 2007; 104:20932-7. [PMID: 18093943 PMCID: PMC2409244 DOI: 10.1073/pnas.0710370104] [Citation(s) in RCA: 1340] [Impact Index Per Article: 78.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2007] [Indexed: 11/18/2022] Open
Abstract
In human lung adenocarcinomas harboring EGFR mutations, a second-site point mutation that substitutes methionine for threonine at position 790 (T790M) is associated with approximately half of cases of acquired resistance to the EGFR kinase inhibitors, gefitinib and erlotinib. To identify other potential mechanisms that contribute to disease progression, we used array-based comparative genomic hybridization (aCGH) to compare genomic profiles of EGFR mutant tumors from untreated patients with those from patients with acquired resistance. Among three loci demonstrating recurrent copy number alterations (CNAs) specific to the acquired resistance set, one contained the MET proto-oncogene. Collectively, analysis of tumor samples from multiple independent patient cohorts revealed that MET was amplified in tumors from 9 of 43 (21%) patients with acquired resistance but in only two tumors from 62 untreated patients (3%) (P = 0.007, Fisher's Exact test). Among 10 resistant tumors from the nine patients with MET amplification, 4 also harbored the EGFR(T790M) mutation. We also found that an existing EGFR mutant lung adenocarcinoma cell line, NCI-H820, harbors MET amplification in addition to a drug-sensitive EGFR mutation and the T790M change. Growth inhibition studies demonstrate that these cells are resistant to both erlotinib and an irreversible EGFR inhibitor (CL-387,785) but sensitive to a multikinase inhibitor (XL880) with potent activity against MET. Taken together, these data suggest that MET amplification occurs independently of EGFR(T790M) mutations and that MET may be a clinically relevant therapeutic target for some patients with acquired resistance to gefitinib or erlotinib.
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Affiliation(s)
| | | | - Jin-Yuan Shih
- Department of Internal Medicine, College of Medicine and
| | - Gregory Riely
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine
- Department of Medicine, Weill Medical College of Cornell University, New York, NY 10021
| | | | - Lu Wang
- Department of Pathology, Memorial Sloan–Kettering Cancer Center, New York, NY 10021
| | - Dhananjay Chitale
- Department of Pathology, Memorial Sloan–Kettering Cancer Center, New York, NY 10021
| | - Noriko Motoi
- Department of Pathology, Memorial Sloan–Kettering Cancer Center, New York, NY 10021
- Department of Pathology, Japanese Foundation for Cancer Research, 3-10-6 Ariake, Koto-ku, Tokyo 135-8550, Japan
| | - Janos Szoke
- Department of Pathology, Memorial Sloan–Kettering Cancer Center, New York, NY 10021
- Department of Molecular Pathology, National Institute of Oncology, Rath Gy. u. 7-9, 1122, Budapest, Hungary
| | | | | | - Wen-Cheng Chang
- Department of Hematology–Oncology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Chong-Jen Yu
- Department of Internal Medicine, College of Medicine and
| | - Adi Gazdar
- Hamon Center for Therapeutic Oncology Research, University of Texas Southwestern Medical Center, Dallas, TX 75390
| | - Harvey Pass
- Department of Cardiothoracic Surgery, New York University Medical Center, New York, NY 10016; and
| | | | - William Gerald
- Human Oncology and Pathogenesis Program
- Department of Pathology, Memorial Sloan–Kettering Cancer Center, New York, NY 10021
| | - Shiu-Feng Huang
- Division of Molecular and Genomic Medicine, National Health Research Institutes, Miaoli 350, Taiwan
| | - Pan-Chyr Yang
- Department of Internal Medicine, College of Medicine and
| | - Vincent Miller
- Department of Medicine, Weill Medical College of Cornell University, New York, NY 10021
| | - Marc Ladanyi
- Human Oncology and Pathogenesis Program
- Department of Pathology, Memorial Sloan–Kettering Cancer Center, New York, NY 10021
| | - Chih-Hsin Yang
- Department of Oncology, National Taiwan University Hospital and Graduate Institute of Clinical Medicine, National Taiwan University Hospital, Taipei 100, Taiwan
| | - William Pao
- Human Oncology and Pathogenesis Program
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine
- Department of Medicine, Weill Medical College of Cornell University, New York, NY 10021
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Marks JL, McLellan MD, Zakowski MF, Lash AE, Kasai Y, Broderick S, Sarkaria IS, Pham D, Singh B, Miner TL, Fewell GA, Fulton LL, Mardis ER, Wilson RK, Kris MG, Rusch VW, Varmus H, Pao W. Mutational analysis of EGFR and related signaling pathway genes in lung adenocarcinomas identifies a novel somatic kinase domain mutation in FGFR4. PLoS One 2007; 2:e426. [PMID: 17487277 PMCID: PMC1855985 DOI: 10.1371/journal.pone.0000426] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2007] [Accepted: 03/30/2007] [Indexed: 11/18/2022] Open
Abstract
Background Fifty percent of lung adenocarcinomas harbor somatic mutations in six genes that encode proteins in the EGFR signaling pathway, i.e., EGFR, HER2/ERBB2, HER4/ERBB4, PIK3CA, BRAF, and KRAS. We performed mutational profiling of a large cohort of lung adenocarcinomas to uncover other potential somatic mutations in genes of this signaling pathway that could contribute to lung tumorigenesis. Methodology/Principal Findings We analyzed genomic DNA from a total of 261 resected, clinically annotated non-small cell lung cancer (NSCLC) specimens. The coding sequences of 39 genes were screened for somatic mutations via high-throughput dideoxynucleotide sequencing of PCR-amplified gene products. Mutations were considered to be somatic only if they were found in an independent tumor-derived PCR product but not in matched normal tissue. Sequencing of 9MB of tumor sequence identified 239 putative genetic variants. We further examined 22 variants found in RAS family genes and 135 variants localized to exons encoding the kinase domain of respective proteins. We identified a total of 37 non-synonymous somatic mutations; 36 were found collectively in EGFR, KRAS, BRAF, and PIK3CA. One somatic mutation was a previously unreported mutation in the kinase domain (exon 16) of FGFR4 (Glu681Lys), identified in 1 of 158 tumors. The FGFR4 mutation is analogous to a reported tumor-specific somatic mutation in ERBB2 and is located in the same exon as a previously reported kinase domain mutation in FGFR4 (Pro712Thr) in a lung adenocarcinoma cell line. Conclusions/Significance This study is one of the first comprehensive mutational analyses of major genes in a specific signaling pathway in a sizeable cohort of lung adenocarcinomas. Our results suggest the majority of gain-of-function mutations within kinase genes in the EGFR signaling pathway have already been identified. Our findings also implicate FGFR4 in the pathogenesis of a subset of lung adenocarcinomas.
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Affiliation(s)
- Jenifer L. Marks
- Human Oncology and Pathogenesis Program, Memorial Sloan-Kettering Cancer Center, New York, New York, United States of America
| | - Michael D. McLellan
- Genome Sequencing Center, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Maureen F. Zakowski
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York, United States of America
| | - Alex E. Lash
- Computational Biology Program, Memorial Sloan-Kettering Cancer Center, New York, New York, United States of America
| | - Yumi Kasai
- Genome Sequencing Center, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Stephen Broderick
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, United States of America
| | - Inderpal S. Sarkaria
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, United States of America
| | - DuyKhanh Pham
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, United States of America
| | - Bhuvanesh Singh
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, United States of America
| | - Tracie L. Miner
- Genome Sequencing Center, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Ginger A. Fewell
- Genome Sequencing Center, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Lucinda L. Fulton
- Genome Sequencing Center, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Elaine R. Mardis
- Genome Sequencing Center, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Richard K. Wilson
- Genome Sequencing Center, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Mark G. Kris
- Thoracic Oncology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York, United States of America
- Department of Medicine, Weill Medical College of Cornell University, New York, New York, United States of America
| | - Valerie W. Rusch
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, United States of America
| | - Harold Varmus
- Program in Cancer Biology and Genetics, Memorial Sloan-Kettering Cancer Center
| | - William Pao
- Human Oncology and Pathogenesis Program, Memorial Sloan-Kettering Cancer Center, New York, New York, United States of America
- Thoracic Oncology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York, United States of America
- Department of Medicine, Weill Medical College of Cornell University, New York, New York, United States of America
- * To whom correspondence should be addressed. E-mail:
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Kissane M, O'Shea E, Cooney P, Broderick S, Doherty W, Thirion P, Smith V, Downes A, Sutton P, Armstrong I. 543 Establishing QA for implementing table-top height as a treatment set-up parameter in prostate radiotherapy. Radiother Oncol 2005. [DOI: 10.1016/s0167-8140(05)81519-1] [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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Broderick S. The role of the practice nurse in: treating common skin problems. World Ir Nurs (1995) 1997; 5:14. [PMID: 9444280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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