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Wadi-Ramahi S, Lalonde RJ, Patel S, Conte A, Siddiqui ZA, Olson AC, Huq MSS. Failure Mode and Effects Analysis for Treatment Workflow of a Novel Ring Gantry Linac. Int J Radiat Oncol Biol Phys 2023; 117:S163. [PMID: 37784410 DOI: 10.1016/j.ijrobp.2023.06.258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) A new ring gantry Linac machine combined with a PET ring is available in the market. It has 3 separate centers, one for laser, one for CT imaging and a 3rd for the Linac. As a first-generation machine of its kind, the workflow heavily depends on user-input. As example, it uses two separate coordinate systems, IEC for lasers and CT localization offsets and DICOM for treatment planning. The planner must manually convert between the two systems. We hypothesize that the unique design of the machine that is heavily dependent on users' input increases the potential of failure of treatment. The present work investigates failure modes for treatment delivery using the methodology of failure modes and effects analysis (FMEA) and proposes solutions to mitigate some of the failure modes (FMs). MATERIALS/METHODS A group of two radiation oncologists, two radiation therapists and three medical physicists was assembled. The process map for treatment delivery on the X1 was created and FMs were identified. Members independently graded each FM on 3 parameters, likelihood of occurrence, detectability of FM and level of severity on patient treatment. A grading scale of 1-5 was used with five representing the worst outcome in each parameter. Each member also identified the origin of each FM to be human, machine or clinical process. Mitigation solutions were proposed. RESULTS The process map of treatment delivery on X1 consists of six major processes and 24 sub-processes. A total of 27 FMs were identified, with many 19/27 (70%) caused by human errors and 7/27 (27%) caused by machine. From all responses, we tallied a median of 11 FMs (40%) that have both S≥ 4 and O or D ≥ 4. To further focus our analysis, we looked at the highest PRN scores from each member and found 7 FMs that were common. 1 FM was in "initiation of Treatment" sub-process and 6 FMs in "Treatment delivery" sub-process. Proposed solutions to these FMs were concerned with software upgrades. Examples are, allow changes in fractionation, allow dose tracking, auto calculation of couch position for various sub processes, allow DICOM image transfer and many more. The current clinical workflow that we adopted for these FMs either puts the burden on the user to confirm/verify parameters or the use of third-party software. In addition to these high-scoring FMs, we adopted changes in clinical workflow to mitigate other FMs, most of them through third-party software. CONCLUSION This study confirmed that the unique design and user-dependent machine environment, human failures are high accounting for 70% of FMs in treatment delivery alone. Our current workflow of the machine depends on direct user input to calculate/confirm certain parameters or the use of third-party software, which also depends on the user for proper completion of the task. Suggested solutions also included proposed improvement to the machine's software and user interface.
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Affiliation(s)
| | - R J Lalonde
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA
| | - S Patel
- UPMC Cancer Center, Pittsburgh, PA, United States
| | - A Conte
- UPMC Shadyside Hospital, Pittsburgh, PA
| | - Z A Siddiqui
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | - A C Olson
- Department of Radiation Oncology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - M S S Huq
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA
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Wadi-Ramahi S, Tavakoli M, Elgohari B, Ashmeg S, Lalonde RJ, Siddiqui ZA. Conformality Indices and Brain Dose Objective for Multi-Lesion Brain Single Isocenter Linac-Based Stereotactic Radiosurgery. Int J Radiat Oncol Biol Phys 2023; 117:e154. [PMID: 37784742 DOI: 10.1016/j.ijrobp.2023.06.978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) The lack of recommendation on Linac-based stereotactic radiosurgery (SRS) and radiotherapy (SRT) plan quality for multi-lesion brain metastasis results in planning heterogeneity. The use of MLCs in the delivery is expected to add extra leakage when multi-lesions are treated simultaneously, and no recommendations availability in literature. We aimed to identify conformality indices and plan objectives that would guide multi-brain metastasis SRS & SRT MATERIALS/METHODS: We performed a retrospective analysis of clinically accepted brain metastasis radiotherapy plans treated using SRS and SRT at our department. Each plan was assessed for four metrics: Two conformality indices, including R50% referring to the ratio of the 50% dose cloud to the PTV, and %D1cm referring to the percentage of dose at 1cm away from PTV in any direction. One dose objective, V12 Gy referring to the brain volume receiving 12 Gy, and one delivery efficiency parameter, the modulation factor, defined as the ratio of the total MU to the prescribed dose. Each parameter was evaluated as a function of total PTV volume and number of lesions. RESULTS A total of 107 plans were analyzed. The analyzed plans included pre- and post-operative treated brain metastasis with 86% with ≤ 4 lesions (median is 2, IQR is 3), 80% of the plans received single fraction and 43% of plans have a total PTV volumes of ≤ 1cc (median is 2.2cc and IQR is 7.5cc). We used a two tail T-test to check for correlation. The 50% relative dose gradient, R50%, was found to be dependent on PTV volume (P < 0.001), and a power law was used to fit the data. The brain volume, V12 Gy, was also found to be dependent on total PTV volume (P < 0.0001) and a linear curve was used to fit V12 Gy vs PTV. We did not find correlation between the number of lesions and R50% and or V12 Gy (p-value = 0.154 and 0.736, respectively). The dose gradient at 1cm away in any direction from PTV, %D1cm, has a median, average and a S.D. of 32%, 33% and 9%, respectively. 85% of all plans have %D1cm<42% which falls within 1 S.D. In addition, we found %D1cm to be dependent on both PTV volume and number of lesions (P < 0.001 for both). The modulation factor (MF) has a median, average and a S.D. of 2.9, 3.0 and 1.5, respectively. We found that 81% of all plans has MF < 4.5, which is within the 1 S.D. It has a positive correlation of 0.628 with the number of lesions. CONCLUSION We found a clear correlation between the total PTV volumes and R50% and V12 Gy, and a fit line was used to relate each parameter to the total PTV volume. As for %D1cm and MF, we found that the average value within 1 S.D. is adequate to include > 80% of the plan. We propose these four parameters to fill the gap for plan quality for Linac-based SRS and SRT. Further evaluation and validation of our results on larger cohort is needed to allow generalizability and applicability of the results and correlation with clinical outcomes to guide clinical decision making.
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Affiliation(s)
| | - M Tavakoli
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA
| | | | - S Ashmeg
- UPMC Hillman Cancer Center, Pittsburgh, PA
| | - R J Lalonde
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA
| | - Z A Siddiqui
- University of Pittsburgh Medical Center, Pittsburgh, PA
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Grzywacz VP, Quinn TJ, Almahariq MF, Siddiqui ZA, Kim SW, Guerrero TM, Stevens CW, Grills IS. Trimodality therapy for patients with stage III non-small-cell lung cancer: A comprehensive surveillance, epidemiology, and end results analysis. Cancer Treat Res Commun 2022; 32:100571. [PMID: 35533588 DOI: 10.1016/j.ctarc.2022.100571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/13/2022] [Accepted: 04/26/2022] [Indexed: 06/14/2023]
Abstract
PURPOSE Debate exists regarding the optimal management for patients with stage III non-small-cell lung cancer (NSCLC). Recent inclusion of chemotherapeutic data in the Surveillance, Epidemiology, and End Results (SEER) database has made it possible to identify patients with NSCLC who received chemotherapy. We hypothesized that patients with stage III NSCLC experience improved overall survival from trimodality therapy (TMT) versus definitive chemoradiation therapy (CRT) alone. MATERIALS AND METHODS We analyzed the overall survival of stage III NSCLC patients based on the receipt of TMT versus CRT alone. This included crude and adjusted univariate models as well as crude and doubly robust adjusted multivariable analyses, both utilizing propensity score matching and inverse probability of treatment weighting. Factors included in the multivariable analyses included: age, sex, marital status, income, date of diagnosis, primary site, histology, grade, T stage, N stage, and intended treatment. Planned subset analyses were performed for stage III(N2) patients. RESULTS Adult patients with stage III NSCLC (N = 9008) from the SEER database were included in our analyses. In our univariate analyses, an overall survival benefit was observed for TMT versus CRT (CrudeHR = 0.58, 95% CI = 0.55-0.61, p < 0.001; AdjHR = 0.58, 95% CI = 0.54-0.61, p < 0.001). This persisted in both crude and doubly robust multivariable analyses (CrudeHR = 0.57, 95% CI = 0.53-0.61, p < 0.001; AdjHR = 0.56, 95% CI = 0.53-0.59, p < 0.001). Patients with stage III(N2) disease also demonstrated a significant benefit to OS with TMT versus CRT alone. CONCLUSION The significant difference in overall survival seen with TMT suggests this may be an effective treatment approach for select patients.
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Affiliation(s)
- Vincent P Grzywacz
- Department of Radiation Oncology, Beaumont Health, Royal Oak, MI United States.
| | - Thomas J Quinn
- Department of Radiation Oncology, Beaumont Health, Royal Oak, MI United States
| | - Muayad F Almahariq
- Department of Radiation Oncology, Beaumont Health, Royal Oak, MI United States
| | - Zaid A Siddiqui
- Department of Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA United States
| | - Sang W Kim
- Department of Thoracic Surgery, Beaumont Health, Royal Oak, MI United States
| | - Thomas M Guerrero
- Department of Radiation Oncology, Beaumont Health, Royal Oak, MI United States
| | - Craig W Stevens
- Department of Radiation Oncology, Beaumont Health, Royal Oak, MI United States
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health, Royal Oak, MI United States
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Abstract
Allergic rhinitis affects 20% of the population of the UK. It confers a significant health burden upon the individual as it affects the patient's quality of life and is associated with serious comorbidities including asthma, sinusitis and conjunctivitis. Owing to its prevalence, it has a significant economic impact through its effects on education, productivity and use of healthcare resources. This review focuses on the management of allergic rhinitis and potential future treatments, because of the lack of clear national guidelines and because this illness is often misdiagnosed and mismanaged. The article provides a comprehensive overview of allergic rhinitis and illustrates the assessment criteria for various subcategories.
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Affiliation(s)
- ZA Siddiqui
- Department of Ear, Nose and Throat Surgery, University Hospital Lewisham, London, UK
| | - A Walker
- Department of Ear, Nose and Throat Surgery, University Hospital Lewisham, London, UK
| | - MM Pirwani
- Department of Life Sciences and Medicine, King's College London, London, UK
| | - M Tahiri
- Department of Life Sciences and Medicine, King's College London, London, UK
| | - I Syed
- Department of Ear, Nose and Throat Surgery, University Hospital Lewisham, London, UK
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Cifarelli CP, Vargo JA, Fang W, Liscak R, Guseynova K, Warnick RE, Lee CC, Yang HC, Borghei-Razavi H, Maiti T, Siddiqui ZA, Yuan JC, Grills IS, Mathieu D, Touchette CJ, Cordeiro D, Chiang V, Hess J, Tien CJ, Faramand A, Kano H, Barnett GH, Sheehan JP, Lunsford LD. Role of Gamma Knife Radiosurgery in Small Cell Lung Cancer: A Multi-Institutional Retrospective Study of the International Radiosurgery Research Foundation (IRRF). Neurosurgery 2021. [DOI: 10.1093/neuros/nyz428_s020] [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: 11/12/2022] Open
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Chen CJ, Lee CC, Kano H, Kearns KN, Ding D, Tzeng SW, Atik AF, Joshi K, Huang PP, Kondziolka D, Ironside N, Mathieu D, Iorio-Morin C, Grills IS, Quinn TJ, Siddiqui ZA, Marvin K, Feliciano C, Starke RM, Faramand A, Barnett G, Lunsford LD, Sheehan JP. Radiosurgery for Unruptured Intervention-Naïve Pediatric Brain Arteriovenous Malformations. Neurosurgery 2021. [DOI: 10.1093/neuros/nyz558_s004] [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: 11/14/2022] Open
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Porter EM, Myziuk NK, Quinn TJ, Lozano D, Peterson AB, Quach DM, Siddiqui ZA, Guerrero TM. Synthetic pulmonary perfusion images from 4DCT for functional avoidance using deep learning. Phys Med Biol 2021; 66. [PMID: 34293726 DOI: 10.1088/1361-6560/ac16ec] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 07/22/2021] [Indexed: 01/14/2023]
Abstract
Purpose.To develop and evaluate the performance of a deep learning model to generate synthetic pulmonary perfusion images from clinical 4DCT images for patients undergoing radiotherapy for lung cancer.Methods. A clinical data set of 58 pre- and post-radiotherapy99mTc-labeled MAA-SPECT perfusion studies (32 patients) each with contemporaneous 4DCT studies was collected. Using the inhale and exhale phases of the 4DCT, a 3D-residual network was trained to create synthetic perfusion images utilizing the MAA-SPECT as ground truth. The training process was repeated for a 50-imaging study, five-fold validation with twenty model instances trained per fold. The highest performing model instance from each fold was selected for inference upon the eight-study test set. A manual lung segmentation was used to compute correlation metrics constrained to the voxels within the lungs. From the pre-treatment test cases (N = 5), 50th percentile contours of well-perfused lung were generated from both the clinical and synthetic perfusion images and the agreement was quantified.Results. Across the hold-out test set, our deep learning model predicted perfusion with a Spearman correlation coefficient of 0.70 (IQR: 0.61-0.76) and a Pearson correlation coefficient of 0.66 (IQR: 0.49-0.73). The agreement of the functional avoidance contour pairs was Dice of 0.803 (IQR: 0.750-0.810) and average surface distance of 5.92 mm (IQR: 5.68-7.55).Conclusion. We demonstrate that from 4DCT alone, a deep learning model can generate synthetic perfusion images with potential application in functional avoidance treatment planning.
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Affiliation(s)
- Evan M Porter
- Department of Medical Physics, Wayne State University, Detroit, MI, United States of America.,Beaumont Artificial Intelligence Research Laboratory, Beaumont Health, Royal Oak, MI, United States of America.,Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Nicholas K Myziuk
- Beaumont Artificial Intelligence Research Laboratory, Beaumont Health, Royal Oak, MI, United States of America.,Department of Radiation Oncology, Beaumont Health, Royal Oak, MI, United States of America
| | - Thomas J Quinn
- Beaumont Artificial Intelligence Research Laboratory, Beaumont Health, Royal Oak, MI, United States of America.,Department of Radiation Oncology, Beaumont Health, Royal Oak, MI, United States of America
| | - Daniela Lozano
- Beaumont Artificial Intelligence Research Laboratory, Beaumont Health, Royal Oak, MI, United States of America.,Oakland University William Beaumont School of Medicine, Oakland University, Rochester, MI, United States of America
| | - Avery B Peterson
- Department of Medical Physics, Wayne State University, Detroit, MI, United States of America.,Beaumont Artificial Intelligence Research Laboratory, Beaumont Health, Royal Oak, MI, United States of America
| | - Duyen M Quach
- Beaumont Artificial Intelligence Research Laboratory, Beaumont Health, Royal Oak, MI, United States of America.,Oakland University William Beaumont School of Medicine, Oakland University, Rochester, MI, United States of America
| | - Zaid A Siddiqui
- Beaumont Artificial Intelligence Research Laboratory, Beaumont Health, Royal Oak, MI, United States of America.,Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Thomas M Guerrero
- Beaumont Artificial Intelligence Research Laboratory, Beaumont Health, Royal Oak, MI, United States of America.,Department of Radiation Oncology, Beaumont Health, Royal Oak, MI, United States of America.,Oakland University William Beaumont School of Medicine, Oakland University, Rochester, MI, United States of America
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8
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Parzen JS, Almahariq MF, Quinn TJ, Siddiqui ZA, Thompson AB, Guerrero T, Lee K, Stevens C, Grills IS. Higher biologically effective dose is associated with improved survival in patients with squamous cell carcinoma of the lung treated with stereotactic body radiation therapy. Radiother Oncol 2021; 160:25-31. [PMID: 33892021 DOI: 10.1016/j.radonc.2021.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/08/2021] [Accepted: 04/12/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Multiple studies have suggested that patients with early-stage SCC of the lung treated with SBRT are more susceptible to local failure compared to other NSCLC histologies. It is unknown if higher BED leads to improved outcomes in this patient population. We evaluated the effect of "high" BED versus "low" BED SBRT on overall survival (OS) in SCC and non-SCC NSCLC patients. METHODS The National Cancer Database was used to identify patients with cT1-2N0M0 NSCLC diagnosed between 2006-2016 treated with 3-5 fraction SBRT. Patients were grouped by BEDhigh (>150 Gy) and BEDlow (≤132 Gy). Univariate and multivariable analysis using Kaplan-Meier and Cox proportional hazards regression modeling were performed. Propensity-score matched analysis with inverse probability of treatment (IPTW) weighting was used to account for selection bias. RESULTS We identified 4,717 eligible SCC patients and 8,807 eligible non-SCC NSCLC patients. In SCC patients, BEDhigh was associated with improved OS in both univariate and multivariate analysis (MVA HR 0.84 95% CI 0.76-0.92, p < 0.001), with estimated IPTW-adjusted 3-year OS of 49% compared to 41% for the BEDlow group. In contrast, BEDhigh was not associated with improved OS compared to BEDlow for non-SCC NSCLC patients (MVA HR 0.94 95% CI 0.86-1.04, p = 0.23), with estimated IPTW-adjusted 3-year OS of 54% and 53%, respectively. CONCLUSIONS Our analysis suggests that in patients with early-stage NSCLC, SBRT regimens with BED > 150 Gy may confer a survival benefit in patients with SCC histology. Histology-based dose modification should be considered, and prospective validation may be warranted.
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Affiliation(s)
- Jacob S Parzen
- Beaumont Health, Department of Radiation Oncology, Royal Oak, United States
| | - Muayad F Almahariq
- Beaumont Health, Department of Radiation Oncology, Royal Oak, United States.
| | - Thomas J Quinn
- Beaumont Health, Department of Radiation Oncology, Royal Oak, United States
| | - Zaid A Siddiqui
- University of Pittsburgh Medical Center, Pittsburgh, United States
| | - Andrew B Thompson
- Beaumont Health, Department of Radiation Oncology, Royal Oak, United States
| | - Thomas Guerrero
- Beaumont Health, Department of Radiation Oncology, Royal Oak, United States
| | - Kuei Lee
- Beaumont Health, Department of Radiation Oncology, Royal Oak, United States
| | - Craig Stevens
- Beaumont Health, Department of Radiation Oncology, Royal Oak, United States
| | - Inga S Grills
- Beaumont Health, Department of Radiation Oncology, Royal Oak, United States
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9
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Cifarelli CP, Vargo JA, Fang W, Liscak R, Guseynova K, Warnick RE, Lee CC, Yang HC, Borghei-Razavi H, Maiti T, Siddiqui ZA, Yuan JC, Grills IS, Mathieu D, Touchette CJ, Cordeiro D, Chiang V, Hess J, Tien CJ, Faramand A, Kano H, Barnett GH, Sheehan JP, Lunsford LD. Role of Gamma Knife Radiosurgery in Small Cell Lung Cancer: A Multi-Institutional Retrospective Study of the International Radiosurgery Research Foundation (IRRF). Neurosurgery 2021; 87:664-671. [PMID: 31599324 DOI: 10.1093/neuros/nyz428] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 08/04/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Despite a high incidence of brain metastases in patients with small-cell lung cancer (SCLC), limited data exist on the use of stereotactic radiosurgery (SRS), specifically Gamma Knife™ radiosurgery (Elekta AB), for SCLC brain metastases. OBJECTIVE To provide a detailed analysis of SCLC patients treated with SRS, focusing on local failure, distant brain failure, and overall survival (OS). METHODS A multi-institutional retrospective review was performed on 293 patients undergoing SRS for SCLC brain metastases at 10 medical centers from 1991 to 2017. Data collection was performed according to individual institutional review boards, and analyses were performed using binary logistic regression, Cox-proportional hazard models, Kaplan-Meier survival analysis, and competing risks analysis. RESULTS Two hundred thirty-two (79%) patients received SRS as salvage following prior whole-brain irradiation (WBRT) or prophylactic cranial irradiation, with a median marginal dose of 18 Gy. At median follow-up after SRS of 6.4 and 18.0 mo for surviving patients, the 1-yr local failure, distant brain failure, and OS were 31%, 49%, and 28%. The interval between WBRT and SRS was predictive of improved OS for patients receiving SRS more than 1 yr after initial treatment (21%, <1 yr vs 36%, >1 yr, P = .01). On multivariate analysis, older age was the only significant predictor for OS (hazard ratio 1.63, 95% CI 1.16-2.29, P = .005). CONCLUSION SRS plays an important role in the management of brain metastases from SCLC, especially in salvage therapy following WBRT. Ongoing prospective trials will better assess the value of radiosurgery in the primary management of SCLC brain metastases and potentially challenge the standard application of WBRT in SCLC patients.
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Affiliation(s)
- Christopher P Cifarelli
- Department of Neurosurgery, School of Medicine, West Virginia University, Morgantown, West Virginia.,Department of Radiation Oncology, School of Medicine, West Virginia University, Morgantown, West Virginia
| | - John A Vargo
- Department of Neurosurgery, School of Medicine, West Virginia University, Morgantown, West Virginia.,Department of Radiation Oncology, School of Medicine, West Virginia University, Morgantown, West Virginia
| | - Wei Fang
- West Virginia Clinical and Translational Science Institute, School of Medicine, West Virginia University, Morgantown, West Virginia
| | - Roman Liscak
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Khumar Guseynova
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | | | - Cheng-Chia Lee
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | | | - Tonmoy Maiti
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio
| | - Zaid A Siddiqui
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Justin C Yuan
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - David Mathieu
- Division of Neurosurgery, Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, Canada
| | - Charles J Touchette
- Division of Neurosurgery, Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, Canada
| | - Diogo Cordeiro
- Department of Neurosurgery, School of Medicine, University of Virginia, Charlottesville, Virginia
| | - Veronica Chiang
- Department of Neurosurgery, Yale School of Medicine, Yale University, New Haven, Connecticut.,Department of Radiation Oncology, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Judith Hess
- Department of Neurosurgery, Yale School of Medicine, Yale University, New Haven, Connecticut.,Department of Radiation Oncology, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Christopher J Tien
- Department of Neurosurgery, Yale School of Medicine, Yale University, New Haven, Connecticut.,Department of Radiation Oncology, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Andrew Faramand
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Hideyuki Kano
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Gene H Barnett
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio
| | - Jason P Sheehan
- Department of Neurosurgery, School of Medicine, University of Virginia, Charlottesville, Virginia
| | - L Dade Lunsford
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Rusthoven CG, Yamamoto M, Bernhardt D, Smith DE, Gao D, Serizawa T, Yomo S, Aiyama H, Higuchi Y, Shuto T, Akabane A, Sato Y, Niranjan A, Faramand AM, Lunsford LD, McInerney J, Tuanquin LC, Zacharia BE, Chiang V, Singh C, Yu JB, Braunstein S, Mathieu D, Touchette CJ, Lee CC, Yang HC, Aizer AA, Cagney DN, Chan MD, Kondziolka D, Bernstein K, Silverman JS, Grills IS, Siddiqui ZA, Yuan JC, Sheehan JP, Cordeiro D, Nosaki K, Seto T, Deibert CP, Verma V, Day S, Halasz LM, Warnick RE, Trifiletti DM, Palmer JD, Attia A, Li B, Cifarelli CP, Brown PD, Vargo JA, Combs SE, Kessel KA, Rieken S, Patel S, Guckenberger M, Andratschke N, Kavanagh BD, Robin TP. Evaluation of First-line Radiosurgery vs Whole-Brain Radiotherapy for Small Cell Lung Cancer Brain Metastases: The FIRE-SCLC Cohort Study. JAMA Oncol 2021; 6:1028-1037. [PMID: 32496550 DOI: 10.1001/jamaoncol.2020.1271] [Citation(s) in RCA: 100] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance Although stereotactic radiosurgery (SRS) is preferred for limited brain metastases from most histologies, whole-brain radiotherapy (WBRT) has remained the standard of care for patients with small cell lung cancer. Data on SRS are limited. Objective To characterize and compare first-line SRS outcomes (without prior WBRT or prophylactic cranial irradiation) with those of first-line WBRT. Design, Setting, and Participants FIRE-SCLC (First-line Radiosurgery for Small-Cell Lung Cancer) was a multicenter cohort study that analyzed SRS outcomes from 28 centers and a single-arm trial and compared these data with outcomes from a first-line WBRT cohort. Data were collected from October 26, 2017, to August 15, 2019, and analyzed from August 16, 2019, to November 6, 2019. Interventions SRS and WBRT for small cell lung cancer brain metastases. Main Outcomes and Measures Overall survival, time to central nervous system progression (TTCP), and central nervous system (CNS) progression-free survival (PFS) after SRS were evaluated and compared with WBRT outcomes, with adjustment for performance status, number of brain metastases, synchronicity, age, sex, and treatment year in multivariable and propensity score-matched analyses. Results In total, 710 patients (median [interquartile range] age, 68.5 [62-74] years; 531 men [74.8%]) who received SRS between 1994 and 2018 were analyzed. The median overall survival was 8.5 months, the median TTCP was 8.1 months, and the median CNS PFS was 5.0 months. When stratified by the number of brain metastases treated, the median overall survival was 11.0 months (95% CI, 8.9-13.4) for 1 lesion, 8.7 months (95% CI, 7.7-10.4) for 2 to 4 lesions, 8.0 months (95% CI, 6.4-9.6) for 5 to 10 lesions, and 5.5 months (95% CI, 4.3-7.6) for 11 or more lesions. Competing risk estimates were 7.0% (95% CI, 4.9%-9.2%) for local failures at 12 months and 41.6% (95% CI, 37.6%-45.7%) for distant CNS failures at 12 months. Leptomeningeal progression (46 of 425 patients [10.8%] with available data) and neurological mortality (80 of 647 patients [12.4%] with available data) were uncommon. On propensity score-matched analyses comparing SRS with WBRT, WBRT was associated with improved TTCP (hazard ratio, 0.38; 95% CI, 0.26-0.55; P < .001), without an improvement in overall survival (median, 6.5 months [95% CI, 5.5-8.0] for SRS vs 5.2 months [95% CI, 4.4-6.7] for WBRT; P = .003) or CNS PFS (median, 4.0 months for SRS vs 3.8 months for WBRT; P = .79). Multivariable analyses comparing SRS and WBRT, including subset analyses controlling for extracranial metastases and extracranial disease control status, demonstrated similar results. Conclusions and Relevance Results of this study suggest that the primary trade-offs associated with SRS without WBRT, including a shorter TTCP without a decrease in overall survival, are similar to those observed in settings in which SRS is already established.
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Affiliation(s)
- Chad G Rusthoven
- University of Colorado School of Medicine, Department of Radiation Oncology, Aurora
| | | | - Denise Bernhardt
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Derek E Smith
- University of Colorado Cancer Center, Biostatistics Core, Aurora
| | - Dexiang Gao
- University of Colorado Cancer Center, Biostatistics Core, Aurora
| | - Toru Serizawa
- Tokyo Gamma Unit Center, Tsukiji Neurological Clinic, Tokyo, Japan
| | - Shoji Yomo
- Aizawa Comprehensive Cancer Center, Division of Radiation Oncology, Aizawa Hospital, Matsumoto, Japan
| | | | - Yoshinori Higuchi
- Chiba University Graduate School of Medicine, Department of Neurological Surgery, Chiba, Japan
| | - Takashi Shuto
- Yokohama Rosai Hospital, Department of Neurosurgery, Yokohama, Japan
| | - Atsuya Akabane
- Gamma Knife Center, NTT Medical Center Tokyo, Tokyo, Japan
| | - Yasunori Sato
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, Tokyo, Japan
| | - Ajay Niranjan
- Department of Neurological Surgery and Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Andrew M Faramand
- Department of Neurological Surgery and Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - L Dade Lunsford
- Department of Neurological Surgery and Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - James McInerney
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Leonard C Tuanquin
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Brad E Zacharia
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Veronica Chiang
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - Charu Singh
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - James B Yu
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - Steve Braunstein
- Department of Radiation Oncology, University of California, San Francisco, San Francisco
| | - David Mathieu
- Division of Neurosurgery, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, Quebec, Canada
| | - Charles J Touchette
- Division of Neurosurgery, Université de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, Quebec, Canada
| | - Cheng-Chia Lee
- Taipei Veterans General Hospital, Department of Neurosurgery, Neurological Institute, Taipei, Taiwan
| | - Huai-Che Yang
- Taipei Veterans General Hospital, Department of Neurosurgery, Neurological Institute, Taipei, Taiwan
| | - Ayal A Aizer
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Daniel N Cagney
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Michael D Chan
- Department of Radiation Oncology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Langone Medical Center, New York
| | - Kenneth Bernstein
- Department of Neurosurgery, New York University Langone Medical Center, New York
| | - Joshua S Silverman
- Department of Neurosurgery, New York University Langone Medical Center, New York
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Zaid A Siddiqui
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Justin C Yuan
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville
| | - Diogo Cordeiro
- Department of Neurological Surgery, University of Virginia, Charlottesville
| | - Kename Nosaki
- National Hospital Organization Kyushu Cancer Center, Department of Thoracic Oncology, Fukuoka, Japan
| | - Takahashi Seto
- National Hospital Organization Kyushu Cancer Center, Department of Thoracic Oncology, Fukuoka, Japan
| | | | - Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Samuel Day
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle
| | - Lia M Halasz
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle
| | - Ronald E Warnick
- Department of Neurosurgery, Jewish Hospital-Mercy Health, Cincinnati, Ohio
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic Jacksonville, Jacksonville, Florida
| | - Joshua D Palmer
- Department of Radiation Oncology, Ohio State University, Columbus
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt University, Nashville, Tennessee
| | - Benjamin Li
- Department of Radiation Oncology, Vanderbilt University, Nashville, Tennessee
| | | | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - John A Vargo
- Department of Neurological Surgery and Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Department of Neurosurgery, West Virginia University, Morgantown
| | - Stephanie E Combs
- Department of Radiation Oncology, Technical University of Munich, Munich, Germany
| | - Kerstin A Kessel
- Department of Radiation Oncology, Technical University of Munich, Munich, Germany
| | - Stefan Rieken
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Samir Patel
- Department of Radiation Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, The University of Zurich, Zurich, Switzerland
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital Zurich, The University of Zurich, Zurich, Switzerland
| | - Brian D Kavanagh
- University of Colorado School of Medicine, Department of Radiation Oncology, Aurora
| | - Tyler P Robin
- University of Colorado School of Medicine, Department of Radiation Oncology, Aurora
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11
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Chen CJ, Lee CC, Kano H, Kearns KN, Ding D, Tzeng SW, Atik AF, Joshi K, Huang PP, Kondziolka D, Ironside N, Mathieu D, Iorio-Morin C, Grills IS, Quinn TJ, Siddiqui ZA, Marvin K, Feliciano C, Starke RM, Faramand A, Barnett G, Lunsford LD, Sheehan JP. Radiosurgery for Unruptured Intervention-Naïve Pediatric Brain Arteriovenous Malformations. Neurosurgery 2021; 87:368-376. [PMID: 31942635 DOI: 10.1093/neuros/nyz558] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 11/12/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Long-term data regarding stereotactic radiosurgery (SRS) as a standalone therapy for unruptured pediatric brain arteriovenous malformations (AVMs) are incompletely defined. OBJECTIVE To evaluate, in a multicenter, retrospective cohort study, the outcomes after SRS for unruptured, intervention-naïve pediatric AVMs. METHODS To retrospectively analyze the International Radiosurgery Research Foundation pediatric AVM database from 1987 to 2018. Pediatric patients with unruptured, previously untreated AVMs who underwent SRS were included. The primary endpoint was a composite of hemorrhagic stroke, death, or permanently symptomatic radiation-induced changes. RESULTS The study cohort comprised 101 patients (mean follow-up 80.8 mo). The primary endpoint occurred in 14%, comprising hemorrhagic stroke, death, and permanent radiation-induced changes in 6%, 3%, and 8%, respectively. Estimated probabilities of the primary endpoint were 5.2%, 10.8%, and 23.0% at 2, 5, and 10 yr, respectively. Estimated probabilities of AVM obliteration at 5 and 10 yr were 64% and 82%, respectively. Single SRS treatment (P = .007) and higher margin dose (P = .005) were predictors of obliteration. Subgroup analysis of Spetzler-Martin grade I-III AVMs estimated primary endpoint probabilities of 3.7%, 8.4%, and 18.7% at 2, 5, and 10 yr, respectively. CONCLUSION Treatment of unruptured, intervention-naïve AVMs in the pediatric population with SRS carries an approximately 2% annual risk of morbidity and mortality, which appears to plateau after 10 yr. The poorly described natural history of pediatric AVMs renders any comparison of SRS vs conservative management imperfect.
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Affiliation(s)
- Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hideyuki Kano
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kathryn N Kearns
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Dale Ding
- Department of Neurosurgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Shih-Wei Tzeng
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ahmet Fatih Atik
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Krishna Joshi
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Paul P Huang
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Natasha Ironside
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - David Mathieu
- Division of Neurosurgery, Centre de recherche du CHUS, University of Sherbrooke, Sherbrooke, Canada
| | - Christian Iorio-Morin
- Division of Neurosurgery, Centre de recherche du CHUS, University of Sherbrooke, Sherbrooke, Canada
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Thomas J Quinn
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Zaid A Siddiqui
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Kim Marvin
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Caleb Feliciano
- Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico
| | - Robert M Starke
- Department of Neurosurgery, University of Miami, Miami, Florida
| | - Andrew Faramand
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Gene Barnett
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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12
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Mankuzhy NP, Almahariq MF, Siddiqui ZA, Thompson AB, Grills IS, Guerrero TM, Lee KC, Stevens CW, Quinn TJ. The Role of Postoperative Radiation Therapy for pN2 Non-small-cell Lung Cancer. Clin Lung Cancer 2020; 22:e5-e17. [PMID: 32873482 DOI: 10.1016/j.cllc.2020.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/24/2020] [Accepted: 07/24/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND The role for postoperative radiation therapy (PORT) for patients with non-small-cell lung cancer (NSCLC) with mediastinal lymph node (LN) involvement (pN2 disease) is controversial. We compared surgery alone with PORT among patients with pN2 NSCLC. We then performed subset analyses to better delineate patients that might benefit from PORT. PATIENTS AND METHODS We conducted a propensity score (PS)-matched, inverse probability of treatment weighting (IPTW) Surveillance, Epidemiology, and End Results (SEER) analysis of patients with pN2 disease from 1989 to 2016 with surgery alone or PORT. Multiple imputation with chained equations was used for missing LN data. RESULTS A total of 8631 patients were included in this analysis; 4579 underwent surgery alone, and 4052 underwent PORT. Following PS matching and IPTW, there was no difference in overall survival (OS) (hazard ratio [HR], 0.99; P = .76). However, PORT improved OS among a subset of patients with a LN positive to sampled ratio ≥ 50% (HR, 0.90; P = .01). Moreover, there was a trend towards improved OS among this subset, even with chemotherapy (HR, 0.91; P = .09). CONCLUSION PORT is not associated with an improvement or detriment in OS for all patients with pN2 NSCLC. However, patients with a positive to sampled LN ratio ≥ 50% may benefit, regardless of chemotherapy status. Nevertheless, PORT will remain the standard of care as we await the results of the ongoing LUNG ART trial.
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Affiliation(s)
- Nikhil P Mankuzhy
- Department of Radiation Oncology, Beaumont Health, Royal Oak, MI; Oakland University William Beaumont School of Medicine, Rochester, MI
| | | | - Zaid A Siddiqui
- Department of Radiation Oncology, Beaumont Health, Royal Oak, MI
| | | | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health, Royal Oak, MI
| | | | - Kuei C Lee
- Department of Radiation Oncology, Beaumont Health, Royal Oak, MI
| | - Craig W Stevens
- Department of Radiation Oncology, Beaumont Health, Royal Oak, MI
| | - Thomas J Quinn
- Department of Radiation Oncology, Beaumont Health, Royal Oak, MI.
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Vu CC, Siddiqui ZA, Zamdborg L, Thompson AB, Quinn TJ, Castillo E, Guerrero TM. Deep convolutional neural networks for automatic segmentation of thoracic organs-at-risk in radiation oncology - use of non-domain transfer learning. J Appl Clin Med Phys 2020; 21:108-113. [PMID: 32602187 PMCID: PMC7324695 DOI: 10.1002/acm2.12871] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 11/11/2019] [Accepted: 02/29/2020] [Indexed: 12/20/2022] Open
Abstract
PURPOSE Segmentation of organs-at-risk (OARs) is an essential component of the radiation oncology workflow. Commonly segmented thoracic OARs include the heart, esophagus, spinal cord, and lungs. This study evaluated a convolutional neural network (CNN) for automatic segmentation of these OARs. METHODS The dataset was created retrospectively from consecutive radiotherapy plans containing all five OARs of interest, including 22,411 CT slices from 168 patients. Patients were divided into training, validation, and test datasets according to a 66%/17%/17% split. We trained a modified U-Net, applying transfer learning from a VGG16 image classification model trained on ImageNet. The Dice coefficient and 95% Hausdorff distance on the test set for each organ was compared to a commercial atlas-based segmentation model using the Wilcoxon signed-rank test. RESULTS On the test dataset, the median Dice coefficients for the CNN model vs. the multi-atlas model were 71% vs. 67% for the spinal cord, 96% vs. 94% for the right lung, 96%vs. 94% for the left lung, 91% vs. 85% for the heart, and 63% vs. 37% for the esophagus. The median 95% Hausdorff distances were 9.5 mm vs. 25.3 mm, 5.1 mm vs. 8.1 mm, 4.0 mm vs. 8.0 mm, 9.8 mm vs. 15.8 mm, and 9.2 mm vs. 20.0 mm for the respective organs. The results all favored the CNN model (P < 0.05). CONCLUSIONS A 2D CNN can achieve superior results to commercial atlas-based software for OAR segmentation utilizing non-domain transfer learning, which has potential utility for quality assurance and expediting patient care.
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Affiliation(s)
- Charles C. Vu
- Beaumont Artificial Intelligence Research LaboratoryBeaumont Health System, Royal OakMIUSA
- Department of Radiation OncologyBeaumont Health System, Royal OakMIUSA
| | - Zaid A. Siddiqui
- Beaumont Artificial Intelligence Research LaboratoryBeaumont Health System, Royal OakMIUSA
- Department of Radiation OncologyBeaumont Health System, Royal OakMIUSA
| | - Leonid Zamdborg
- Beaumont Artificial Intelligence Research LaboratoryBeaumont Health System, Royal OakMIUSA
- Department of Radiation OncologyBeaumont Health System, Royal OakMIUSA
| | - Andrew B. Thompson
- Beaumont Artificial Intelligence Research LaboratoryBeaumont Health System, Royal OakMIUSA
- Department of Radiation OncologyBeaumont Health System, Royal OakMIUSA
| | - Thomas J. Quinn
- Beaumont Artificial Intelligence Research LaboratoryBeaumont Health System, Royal OakMIUSA
- Department of Radiation OncologyBeaumont Health System, Royal OakMIUSA
| | - Edward Castillo
- Department of Radiation OncologyBeaumont Health System, Royal OakMIUSA
| | - Thomas M. Guerrero
- Beaumont Artificial Intelligence Research LaboratoryBeaumont Health System, Royal OakMIUSA
- Department of Radiation OncologyBeaumont Health System, Royal OakMIUSA
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14
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Thompson AB, Quinn TJ, Siddiqui ZA, Almahariq MF, Grills IS, Stevens CW. Addition of radiotherapy to surgery and chemotherapy improves survival in localized malignant pleural mesothelioma: A Surveillance, Epidemiology, and End Results (SEER) study. Lung Cancer 2020; 146:120-126. [PMID: 32531717 DOI: 10.1016/j.lungcan.2020.05.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 04/23/2020] [Accepted: 05/22/2020] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Malignant pleural mesothelioma (MPM) is a devastating disease with poor survival outcomes for most patients. Optimizing therapeutic approaches is thus vital, but has been hampered by a dearth of randomized trials to guide decision making. We used a population-level database to evaluate the impact of radiotherapy as a component of trimodality therapy on overall survival (OS) in MPM. METHODS We retrospectively reviewed the SEER Radiation/Chemotherapy database for patients with MPM who received surgery and chemotherapy, with or without radiotherapy. A propensity score-matched analysis with inverse probability of treatment weighting (IPTW) was performed. Weight-adjusted univariate KM analysis was performed and doubly robust, IPTW-adjusted multivariable cox proportional hazards regression modeling was also performed to quantify the effect of radiotherapy on OS in trimodality therapy for MPM. RESULTS 1015 patients were identified. 678 patients received surgery and chemotherapy, and 337 patients received trimodality therapy. For patients with localized disease, OS was significantly improved with trimodality therapy (HR 0.56, CI 0.4 - 0.8, p = 0.001), which persisted with IPTW adjustment (HR 0.65, CI 0.49 - 0.95, p = 0.0248). No significant benefit was seen for patients with regional or distant disease. On multivariate analysis, positive predictors of survival after IPTW adjustment were female sex, diagnosis after 2005, and left-sided disease. CONCLUSIONS These findings support a significant benefit to OS by incorporating radiotherapy as a component of trimodality therapy for patients with localized MPM compared to only surgery and chemotherapy. It does not provide a significant overall survival benefit for patients with regional or metastatic disease.
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Affiliation(s)
- Andrew B Thompson
- Department of Radiation Oncology, Beaumont Health, 3601 W 13 Mile Rd, Royal Oak, MI 48073, United States
| | - Thomas J Quinn
- Department of Radiation Oncology, Beaumont Health, 3601 W 13 Mile Rd, Royal Oak, MI 48073, United States
| | - Zaid A Siddiqui
- Department of Radiation Oncology, Beaumont Health, 3601 W 13 Mile Rd, Royal Oak, MI 48073, United States
| | - Muayad F Almahariq
- Department of Radiation Oncology, Beaumont Health, 3601 W 13 Mile Rd, Royal Oak, MI 48073, United States
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health, 3601 W 13 Mile Rd, Royal Oak, MI 48073, United States
| | - Craig W Stevens
- Department of Radiation Oncology, Beaumont Health, 3601 W 13 Mile Rd, Royal Oak, MI 48073, United States.
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15
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Almahariq MF, Quinn TJ, Siddiqui ZA, Thompson AB, Jawad MS, Chen PY, Gustafson GS, Dilworth JT. Post-mastectomy radiotherapy is associated with improved overall survival in T3N0 patients who do not receive chemotherapy. Radiother Oncol 2020; 145:229-237. [PMID: 32065903 DOI: 10.1016/j.radonc.2020.01.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [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: 11/18/2019] [Revised: 01/22/2020] [Accepted: 01/26/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND PURPOSE There is limited retrospective evidence addressing the utility of post-mastectomy radiotherapy (PMRT) in patients with T3N0 breast cancer. We performed a retrospective analysis of the National Cancer Database (NCDB) comparing overall survival (OS) in T3N0 patients treated with mastectomy alone (MTX) or with PMRT. MATERIALS AND METHODS We performed a matched-cohort analysis of NCDB breast cancer patients with pT3N0 disease who did not receive NAC, or cT3N0 patients who received NAC treated between 2006 and 2014. Patients were matched for all available baseline characteristics using propensity scores with inverse probability of treatment weighting (IPTW) with stabilized weights. RESULTS We identified 13,901 eligible patients. In the pT3N0 cohort, median follow-up was 47 months for the MTX group and 50 months for the PMRT group. In the cT3N0 cohort, median follow-up was 44 months for the MTX group and 46 months for the PMRT group. OS was higher in pT3N0 patients treated with PMRT compared to MTX: 7-year OS of 74% vs. 65% (P < 0.001). Doubly robust multivariable analysis showed an association between PMRT and improved OS (HR 0.78, 95% CI 0.68-0.89, P < 0.001). There was no benefit to PMRT in patients who received adjuvant chemotherapy (AC). In the NAC cohort, PMRT did not change OS, with 7-year OS of 78% with MTX and 79% with PMRT. There was a trend of improved OS with PMRT in patients with residual disease in the breast and lymph nodes (HR 0.70, 95% CI 0.46-1.07). CONCLUSION PMRT improves OS in patients with pT3N0 disease, but the benefit appears limited to those who do not receive AC. PMRT does not improve OS in patients with cT3N0 disease who receive NAC, but there might be a benefit in patients with a poor response to chemotherapy. However, longer follow-up may be needed to make a definitive conclusion about the benefit of PMRT in patients who receive chemotherapy.
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Affiliation(s)
- Muayad F Almahariq
- Department of Radiation Oncology, Beaumont Health, Royal Oak, MI, United States
| | - Thomas J Quinn
- Department of Radiation Oncology, Beaumont Health, Royal Oak, MI, United States
| | - Zaid A Siddiqui
- Department of Radiation Oncology, Beaumont Health, Royal Oak, MI, United States
| | - Andrew B Thompson
- Department of Radiation Oncology, Beaumont Health, Royal Oak, MI, United States
| | - Maha S Jawad
- Department of Radiation Oncology, Beaumont Health, Royal Oak, MI, United States
| | - Peter Y Chen
- Department of Radiation Oncology, Beaumont Health, Royal Oak, MI, United States
| | - Gregory S Gustafson
- Department of Radiation Oncology, Beaumont Health, Royal Oak, MI, United States
| | - Joshua T Dilworth
- Department of Radiation Oncology, Beaumont Health, Royal Oak, MI, United States.
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16
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Chen CJ, Lee CC, Kano H, Kearns KN, Ding D, Tzeng SW, Atik A, Joshi K, Barnett GH, Huang PP, Kondziolka D, Mathieu D, Iorio-Morin C, Grills IS, Quinn TJ, Siddiqui ZA, Marvin K, Feliciano C, Faramand A, Lunsford LD, Sheehan JP. Stereotactic radiosurgery for pediatric brain arteriovenous malformations: long-term outcomes. J Neurosurg Pediatr 2020; 25:1-9. [PMID: 32032957 DOI: 10.3171/2019.12.peds19595] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 10/07/2019] [Accepted: 12/12/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Contrary to the better described obliteration- and hemorrhage-related data after stereotactic radiosurgery (SRS) of brain arteriovenous malformations (AVMs) in pediatric patients, estimates of the rarer complications, including cyst and tumor formation, are limited in the literature. The aim of the present study was to assess the long-term outcomes and risks of SRS for AVMs in pediatric patients (age < 18 years). METHODS The authors retrospectively analyzed the International Radiosurgery Research Foundation pediatric AVM database for the years 1987 to 2018. AVM obliteration, post-SRS hemorrhage, cyst formation, and tumor formation were assessed. Cumulative probabilities, adjusted for the competing risk of death, were calculated. RESULTS The study cohort comprised 539 pediatric AVM patients (mean follow-up 85.8 months). AVM obliteration was observed in 64.3% of patients, with cumulative probabilities of 63.6% (95% CI 58.8%-68.0%), 77.1% (95% CI 72.1%-81.3%), and 88.1% (95% CI 82.5%-92.0%) over 5, 10, and 15 years, respectively. Post-SRS hemorrhage was observed in 8.4% of patients, with cumulative probabilities of 4.9% (95% CI 3.1%-7.2%), 9.7% (95% CI 6.4%-13.7%), and 14.5% (95% CI 9.5%-20.5%) over 5, 10, and 15 years, respectively. Cyst formation was observed in 2.1% of patients, with cumulative probabilities of 5.5% (95% CI 2.3%-10.7%) and 6.9% (95% CI 3.1%-12.9%) over 10 and 15 years, respectively. Meningiomas were observed in 2 patients (0.4%) at 10 and 12 years after SRS, with a cumulative probability of 3.1% (95% CI 0.6%-9.7%) over 15 years. CONCLUSIONS AVM obliteration can be expected after SRS in the majority of the pediatric population, with a relatively low risk of hemorrhage during the latency period. Cyst and benign tumor formation after SRS can be observed in 7% and 3% of patients over 15 years, respectively. Longitudinal surveillance for delayed neoplasia is prudent despite its low incidence.
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Affiliation(s)
- Ching-Jen Chen
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Cheng-Chia Lee
- 2Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital
- 3School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hideyuki Kano
- 4Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kathryn N Kearns
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Dale Ding
- 5Department of Neurosurgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Shih-Wei Tzeng
- 2Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital
| | - Ahmet Atik
- 6Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Krishna Joshi
- 6Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Gene H Barnett
- 6Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Paul P Huang
- 7Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Douglas Kondziolka
- 7Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - David Mathieu
- 8Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Christian Iorio-Morin
- 8Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Inga S Grills
- 9Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan; and
| | - Thomas J Quinn
- 9Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan; and
| | - Zaid A Siddiqui
- 9Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan; and
| | - Kim Marvin
- 9Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan; and
| | - Caleb Feliciano
- 10Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico
| | - Andrew Faramand
- 4Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - L Dade Lunsford
- 4Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jason P Sheehan
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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Siddiqui ZA, Squires BS, Johnson MD, Baschnagel AM, Chen PY, Krauss DJ, Olson RE, Meyer KD, Grills IS. Predictors of radiation necrosis in long-term survivors after Gamma Knife stereotactic radiosurgery for brain metastases. Neurooncol Pract 2019; 7:400-408. [PMID: 32765891 DOI: 10.1093/nop/npz067] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background The long-term risk of necrosis after radiosurgery for brain metastases is uncertain. We aimed to investigate incidence and predictors of radiation necrosis for individuals with more than 1 year of survival after radiosurgery for brain metastases. Methods Patients who had a diagnosis of brain metastases treated between December 2006 and December 2014, who had at least 1 year of survival after first radiosurgery were retrospectively reviewed. Survival was analyzed using the Kaplan-Meier estimator, and the incidence of radiation necrosis was estimated with death or surgical resection as competing risks. Patient and treatment factors associated with radiation necrosis were also analyzed. Results A total of 198 patients with 732 lesions were analyzed. Thirty-four lesions required salvage radiosurgery and 10 required salvage surgical resection. Median follow-up was 24 months. The estimated median survival for this population was 25.4 months. The estimated per-lesion incidence of radiation necrosis at 4 years was 6.8%. Medical or surgical therapy was required for 60% of necrosis events. Tumor volume and male sex were significant factors associated with radiation necrosis. The per-lesions incidence of necrosis for patients undergoing repeat radiosurgery was 33.3% at 4 years. Conclusions In this large series of patients undergoing radiosurgery for brain metastases, patients continued to be at risk for radiation necrosis throughout their first 4 years of survival. Repeat radiosurgery of recurrent lesions greatly exacerbates the risk of radiation necrosis, whereas treatment of larger target volumes increases the risk modestly.
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Affiliation(s)
- Zaid A Siddiqui
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Bryan S Squires
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Matt D Johnson
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Andrew M Baschnagel
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Peter Y Chen
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Daniel J Krauss
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Ricky E Olson
- Department of Neurological Surgery, Beaumont Health System, Royal Oak, Michigan
| | - Kurt D Meyer
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
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Quinn TJ, Almahariq MF, Siddiqui ZA, Thompson AB, Hamstra DA, Kabolizadeh P, Gowans KL, Chen PY. Trimodality therapy for atypical teratoid/rhabdoid tumor is associated with improved overall survival: A surveillance, epidemiology, and end results analysis. Pediatr Blood Cancer 2019; 66:e27969. [PMID: 31464041 DOI: 10.1002/pbc.27969] [Citation(s) in RCA: 10] [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: 07/01/2019] [Revised: 07/29/2019] [Accepted: 07/31/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Atypical teratoid/rhabdoid tumors (AT/RTs) are rare aggressive central nervous system tumors. The use of radiation therapy (RT) remains controversial, especially for patients younger than three years of age. The purpose of the current investigation is to robustly analyze the impact of RT among pediatric AT/RT patients using the Surveillance, Epidemiology, and End Results (SEER) database. METHODS SEER 18 Custom Data registries were queried for AT/RT (ICD-0-3 9508/3). A total of 190 pediatric AT/RT patients were identified, of whom 102 underwent surgery + chemotherapy and 88 underwent trimodality therapy. Univariate and multivariable analyses using Kaplan-Meier and Cox proportional hazards regression modeling were performed. Propensity-score matched analysis with inverse probability of treatment weighting was performed to account for indication bias. The landmark method was used to account for immortal time bias. RESULTS The majority of patients were <3 years old (75.8%). Patients <3 were more likely to be treated without RT as compared with older patients (62% vs 38%). Doubly robust MVA identified distant disease as a negative prognostic factor (HR 2.1, P = 0.003), whereas trimodality therapy was strongly protective (HR 0.39, P < 0.001). Infants (<1), toddlers (1-2), and older children (3+) all benefited from trimodality therapy, with largest benefit for infants (HR 0.34, P = 0.02) and toddlers (HR 0.31, P < 0.001). CONCLUSION The current study provides further evidence that trimodality therapy improves clinical outcomes among patients with AT/RT. This finding was most pronounced for younger patients; therefore, further studies are needed to confirm this finding in this vulnerable population.
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Affiliation(s)
- Thomas J Quinn
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | | | - Zaid A Siddiqui
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Andrew B Thompson
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Daniel A Hamstra
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | | | - Kate L Gowans
- Department of Pediatric Hematology/Oncology, Beaumont Health, Royal Oak, Michigan
| | - Peter Y Chen
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
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Siddiqui ZA, Gustafson GS, Ye H, Martinez AA, Mitchell B, Sebastian E, Limbacher A, Krauss DJ. Five-Year Outcomes of a Single-Institution Prospective Trial of 19-Gy Single-Fraction High-Dose-Rate Brachytherapy for Low- and Intermediate-Risk Prostate Cancer. Int J Radiat Oncol Biol Phys 2019; 104:1038-1044. [PMID: 30771408 DOI: 10.1016/j.ijrobp.2019.02.010] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 01/31/2019] [Accepted: 02/03/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE To update outcome and toxicity results of a prospective trial of 19-Gy single-fraction high-dose-rate (HDR) brachytherapy for men with low- and intermediate-risk prostate cancer. METHODS AND MATERIALS Patients were treated on a prospective study of single-fraction HDR brachytherapy. All patients had low- or intermediate-risk prostate cancer. Patients with prostate volumes >50 cm3, taking alpha-blockers for urinary symptoms, or with baseline American Urologic Association symptom scores >12 were ineligible. Patients underwent transrectal ultrasound-guided interstitial implant of the prostate followed by single-fraction HDR brachytherapy to a prescription dose of 19 Gy. RESULTS Sixty-eight patients were enrolled with a median follow-up of 3.9 years. Median age was 62 years. Median gland volume at the time of treatment was 35 cm3, 92.6% of patients had T1 disease, 63.2% had a Gleason score of 6, and median pretreatment prostate-specific antigen was 5.0 ng/mL. Chronic grade 2 genitourinary toxicity was 14.7%. No grade 3 urinary toxicity occurred. A single patient experienced grade 2+ rectal toxicity (grade 3 diarrhea) that was transient and resolved with medical management. The 5-year estimated disease-free survival was 77.2% with no significant difference between low- and intermediate-risk patients. A single patient developed distant metastases during the follow-up period. Biopsy-proven local failure at 5 years was 18.8%, occurring at a median interval of 4.0 years posttreatment. No deaths occurred during follow-up. CONCLUSIONS With extended follow-up, toxicity rates after single-fraction 19-Gy HDR brachytherapy remain low. Higher-than-expected rates of biochemical and local failure, however, raise concerns regarding the adequacy of this dose. Additional investigation to define the optimal single-fraction HDR brachytherapy dose is warranted, and single-fraction treatment currently should not be offered outside the context of a clinical trial.
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Affiliation(s)
- Zaid A Siddiqui
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Gary S Gustafson
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Hong Ye
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Alvaro A Martinez
- Michigan HealthCare Professionals/21st Century Oncology, Farmington Hills, Michigan
| | - Beth Mitchell
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Evelyn Sebastian
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Amy Limbacher
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Daniel J Krauss
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan.
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Abstract
Radiation therapy is a commonly used curative modality for prostate cancer. The addition of androgen deprivation therapy (ADT) increases the curative potential of prostate radiotherapy (RT) in multiple subsets of patients. In addition to having an independent cytotoxic effect, current evidence suggests that androgen deprivation synergistically works with radiation therapy by preventing DNA repair. Given the wide-ranging toxicities of this therapy, clinicians must judiciously choose which patients may benefit from ADT and also consider the appropriate length of treatment. With recent advances in RT delivery, higher doses of radiation are currently used when compared with the dose used in historic trials, leading to the unanswered question of how RT dose interacts with ADT. Current and future clinical studies are attempting to further define the appropriate indications and patient populations for which ADT represents a clinically appropriate addition to prostate RT.
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Affiliation(s)
- Zaid A Siddiqui
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan, USA
| | - Daniel J Krauss
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan, USA
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21
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Pomeraniec IJ, Kano H, Xu Z, Nguyen B, Siddiqui ZA, Silva D, Sharma M, Radwan H, Cohen JA, Dallapiazza RF, Iorio-Morin C, Wolf A, Jane JA, Grills IS, Mathieu D, Kondziolka D, Lee CC, Wu CC, Cifarelli CP, Chytka T, Barnett GH, Lunsford LD, Sheehan JP. Early versus late Gamma Knife radiosurgery following transsphenoidal surgery for nonfunctioning pituitary macroadenomas: a multicenter matched-cohort study. J Neurosurg 2017; 129:648-657. [PMID: 29076785 DOI: 10.3171/2017.5.jns163069] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Gamma Knife radiosurgery (GKRS) is frequently used to treat residual or recurrent nonfunctioning pituitary macroadenomas. There is no consensus as to whether GKRS should be used early after surgery or if radiosurgery should be withheld until there is evidence of imaging-defined progression of tumor. Given the high incidence of adenoma progression after subtotal resection over time, the present study intended to evaluate the effect of timing of radiosurgery on outcome. METHODS This is a multicenter retrospective review of patients with nonfunctioning pituitary macroadenomas who underwent transsphenoidal surgery followed by GKRS from 1987 to 2015 at 9 institutions affiliated with the International Gamma Knife Research Foundation. Patients were matched by adenoma and radiosurgical parameters and stratified based on the interval between last resection and radiosurgery. Operative results, imaging data, and clinical outcomes were compared across groups following early (≤ 6 months after resection) or late (> 6 months after resection) radiosurgery. RESULTS After matching, 222 patients met the authors' study criteria (from an initial collection of 496 patients) and were grouped based on early (n = 111) or late (n = 111) GKRS following transsphenoidal surgery. There was a greater risk of tumor progression after GKRS (p = 0.013) and residual tumor (p = 0.038) in the late radiosurgical group over a median imaging follow-up period of 68.5 months. No significant difference in the occurrence of post-GKRS endocrinopathy was observed (p = 0.68). Thirty percent of patients without endocrinopathy in the early cohort developed new endocrinopathies during the follow-up period versus 27% in the late cohort (p = 0.84). Fourteen percent of the patients in the early group and 25% of the patients in the late group experienced the resolution of endocrine dysfunction after original presentation (p = 0.32). CONCLUSIONS In this study, early GKRS was associated with a lower risk of radiological progression of subtotally resected nonfunctioning pituitary macroadenomas compared with expectant management followed by late radiosurgery. Delaying radiosurgery may increase patient risk for long-term adenoma progression. The timing of radiosurgery does not appear to significantly affect the rate of delayed endocrinopathy.
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Affiliation(s)
- I Jonathan Pomeraniec
- 1Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Hideyuki Kano
- 8Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
| | - Zhiyuan Xu
- 1Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Brandon Nguyen
- 2Department of Radiation Oncology, William Beaumont Hospital-Royal Oak, Michigan
| | - Zaid A Siddiqui
- 2Department of Radiation Oncology, William Beaumont Hospital-Royal Oak, Michigan
| | - Danilo Silva
- 3Cleveland Clinic Foundation, Center for Neurological Restoration, Cleveland, Ohio
| | - Mayur Sharma
- 3Cleveland Clinic Foundation, Center for Neurological Restoration, Cleveland, Ohio
| | - Hesham Radwan
- 3Cleveland Clinic Foundation, Center for Neurological Restoration, Cleveland, Ohio
| | - Jonathan A Cohen
- 8Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
| | - Robert F Dallapiazza
- 1Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Christian Iorio-Morin
- 6Department of Neurosurgery, Centre Hospitalier Universitaire de Sherbrooke, Quebec, Canada
| | - Amparo Wolf
- 4Department of Neurosurgery, NYU Langone Medical Center, New York, New York
| | - John A Jane
- 1Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Inga S Grills
- 2Department of Radiation Oncology, William Beaumont Hospital-Royal Oak, Michigan
| | - David Mathieu
- 6Department of Neurosurgery, Centre Hospitalier Universitaire de Sherbrooke, Quebec, Canada
| | - Douglas Kondziolka
- 4Department of Neurosurgery, NYU Langone Medical Center, New York, New York
| | - Cheng-Chia Lee
- 7Department of Neurosurgery, Taipei Veterans General Hospital, Taipei City, Taiwan
| | - Chih-Chun Wu
- 7Department of Neurosurgery, Taipei Veterans General Hospital, Taipei City, Taiwan
| | - Christopher P Cifarelli
- 9Department of Neurosurgery, West Virginia University Medical Center, Morgantown, West Virginia
| | - Tomas Chytka
- 5Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Gene H Barnett
- 3Cleveland Clinic Foundation, Center for Neurological Restoration, Cleveland, Ohio
| | - L Dade Lunsford
- 8Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
| | - Jason P Sheehan
- 1Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
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Siddiqui ZA, Melian E, Sethi A, Prabhu VC, Rusu I, Emami B, Leonetti JP, Anderson DE. Stereotactic Radiation for Palliation of Skull Base Recurrences of Salivary Gland Carcinomas: Implications for Tumor Targeting. J Neurol Surg B Skull Base 2016; 78:82-88. [PMID: 28180048 DOI: 10.1055/s-0036-1584884] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 05/25/2016] [Indexed: 10/21/2022] Open
Abstract
Background Approximately 3 to 13% of salivary carcinomas recur at the skull base. We report our experience treating these recurrences with stereotactic radiation. Methods In total, 14 patients with skull base recurrence of salivary gland carcinoma were identified. Patient characteristics, treatment parameters, response to treatment, local recurrence-free/overall survival, and patterns of failure were studied. Results All 12 symptomatic patients experienced palliation of symptoms. Two grade 3 toxicities were observed. Local recurrence-free survival after skull base treatment was 28 months (74 months after allowing for additional course of salvage radiotherapy). Overall survival was 153 months from primary diagnosis and 67 months from first skull base failure. Of 13 treatment failures, 8 occurred at margins; the rest were infield. All intracranial failures occurred along meningeal surfaces. Conclusions Stereotactic radiation provides well-tolerated palliation for the majority of patients, but with a high rate of local failure. Due to the propensity for meningeal failures, we suggest increasing margins along the meningeal surfaces when treating these patients.
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Affiliation(s)
- Zaid A Siddiqui
- Department of Radiation Oncology, Loyola University Medical Center, Maywood, Illinois, United States
| | - Edward Melian
- Department of Radiation Oncology, Loyola University Medical Center, Maywood, Illinois, United States; Department of Neurological Surgery, Loyola University Medical Center Maywood, Illinois, United States
| | - Anil Sethi
- Department of Radiation Oncology, Loyola University Medical Center, Maywood, Illinois, United States
| | - Vikram C Prabhu
- Department of Radiation Oncology, Loyola University Medical Center, Maywood, Illinois, United States; Department of Neurological Surgery, Loyola University Medical Center Maywood, Illinois, United States
| | - Iris Rusu
- Department of Radiation Oncology, Loyola University Medical Center, Maywood, Illinois, United States
| | - Bahman Emami
- Department of Radiation Oncology, Loyola University Medical Center, Maywood, Illinois, United States
| | - John P Leonetti
- Department of Otolaryngology, Loyola University Medical Center Maywood, Illinois, United States
| | - Douglas E Anderson
- Department of Neurological Surgery, Loyola University Medical Center Maywood, Illinois, United States
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Harkenrider MM, Block AM, Siddiqui ZA, Small W. The role of vaginal cuff brachytherapy in endometrial cancer. Gynecol Oncol 2015; 136:365-72. [DOI: 10.1016/j.ygyno.2014.12.036] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Revised: 12/23/2014] [Accepted: 12/26/2014] [Indexed: 11/15/2022]
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Siddiqui MN, Siddiqui ZA. Systematic review and meta-analysis of intraoperative versus preoperative endoscopic sphincterotomy in patients with gallbladder and suspected common bile duct stones (Br J Surg 2011; 98: 908-916). Br J Surg 2012; 99:144; author reply 144. [PMID: 22135176 DOI: 10.1002/bjs.7826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Deshpande JM, Nadkarni SS, Siddiqui ZA. Detection of MEF-1 laboratory reference strain of poliovirus type 2 in children with poliomyelitis in India in 2002 & 2003. Indian J Med Res 2003; 118:217-23. [PMID: 14870793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND & OBJECTIVES Significant progress has been made towards eradication of poliomyelitis in India. Surveillance for acute flaccid paralysis (AFP) has reached high standards. Among the 3 types of polioviruses, type 2 had been eliminated in India and eradicated globally as of October 1999. However, we isolated wild poliovirus type 2 from a small number of polio cases in northern India in 2000 and again during December 2002 to February 2003. Using molecular tools the origin, of the wild type 2 poliovirus was investigated. METHODS Polioviruses isolated from stool samples collected from patients with AFP were differentiated as wild virus or Sabin vaccine-like by ELISA and probe hybridization assays. Complete VP1 gene nucleotide sequences of the wild type 2 poliovirus isolates were determined by reverse transcriptase polymerase chain reaction (RT-PCR), followed by cycle sequencing. VP1 nucleotide sequences were compared with those of wild type 2 polioviruses that were indigenous in India in the past as well as prototype/laboratory strains and the GenBank database. RESULTS Wild poliovirus type 2 was detected in stool samples from 6 patients with AFP in western Uttar Pradesh and 1 in Gujarat. In addition, the virus was isolated from one healthy contact child and from environmental sewage sample in Moradabad where three of these patients were reported. These isolates were identified as genetically closely related to laboratory reference strain MEF-1. Molecular characterization of the isolates confirmed that there was no evidence of extensive person-to-person transmission of the virus in the community. INTERPRETATION & CONCLUSION Laboratory reference strain (MEF-1) of poliovirus type 2 caused paralytic poliomyelitis in 10 patients in September 2000 and November 2002 to February 2003. The origin of the virus was some laboratory as yet not identified. This episode highlights the urgent need for stringent containment of wild poliovirus containing materials in the laboratories across the country in order to prevent recurrence of such incidents.
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Affiliation(s)
- J M Deshpande
- Haffkine Institute Compound, Enterovirus Research Centre, (ICMR), Parel, Mumbai, India
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Siddiqui ZA, Mahmood I. Effects of rhizobacteria and root symbionts on the reproduction of Meloidogyne javanica and growth of chickpea. Bioresour Technol 2001; 79:41-45. [PMID: 11396906 DOI: 10.1016/s0960-8524(01)00036-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
The effects of rhizobacteria, i.e. Pseudomonas fluorescens, Azotobacter chyroococcum and Azospirillum brasilense, alone and in combination with root symbionts, Rhizobium sp. and Glomus mosseae, on the growth of chickpea, Cicer arietinum, and reproduction of Meloidogyne jaranica were studied. When added alone G. mosseae was better at improving plant growth and reducing galling and nematode reproduction than any other tested organism. Application of P. fluorescens caused an almost similar increase in plant growth to that caused by Rhizobium sp., while use of A. chroococcum was better than A. brasilense in improving growth of nematode --infected plants. Combined use of P. fluorescens with G. mosseae was better at improving plant growth and reducing galling and nematode multiplication than any other combined treatment.
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Affiliation(s)
- Z A Siddiqui
- Department of Botany, Aligarh Muslim University, India
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