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Salazar RM, Duryea JD, Leone AO, Nair SS, Mumme RP, De B, Corrigan KL, Rooney MK, Das P, Holliday EB, Court LE, Niedzielski JS. Random Forest Modeling of Acute Toxicity in Anal Cancer: Effects of Peritoneal Cavity Contouring Approaches on Model Performance. Int J Radiat Oncol Biol Phys 2024; 118:554-564. [PMID: 37619789 DOI: 10.1016/j.ijrobp.2023.08.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 08/04/2023] [Accepted: 08/13/2023] [Indexed: 08/26/2023]
Abstract
PURPOSE Our purpose was to analyze the effect on gastrointestinal (GI) toxicity models when their dose-volume metrics predictors are derived from segmentations of the peritoneal cavity after different contouring approaches. METHODS AND MATERIALS A random forest machine learning approach was used to predict acute grade ≥3 GI toxicity from dose-volume metrics and clinicopathologic factors for 246 patients (toxicity incidence = 9.5%) treated with definitive chemoradiation for squamous cell carcinoma of the anus. Three types of random forest models were constructed based on different bowel bag segmentation approaches: (1) physician-delineated after Radiation Therapy Oncology Group (RTOG) guidelines, (2) autosegmented by a deep learning model (nnU-Net) following RTOG guidelines, and (3) autosegmented but spanning the entire bowel space. Each model type was evaluated using repeated cross-validation (100 iterations; 50%/50% training/test split). The performance of the models was assessed using area under the precision-recall curve (AUPRC) and the receiver operating characteristic curve (AUROCC), as well as optimal F1 score. RESULTS When following RTOG guidelines, the models based on the nnU-Net auto segmentations (mean values: AUROCC, 0.71 ± 0.07; AUPRC, 0.42 ± 0.09; F1 score, 0.46 ± 0.08) significantly outperformed (P < .001) those based on the physician-delineated contours (mean values: AUROCC, 0.67 ± 0.07; AUPRC, 0.34 ± 0.08; F1 score, 0.36 ± 0.07). When spanning the entire bowel space, the performance of the autosegmentation models improved considerably (mean values: AUROCC, 0.87 ± 0.05; AUPRC, 0.70 ± 0.09; F1 score, 0.68 ± 0.09). CONCLUSIONS Random forest models were superior at predicting acute grade ≥3 GI toxicity when based on RTOG-defined bowel bag autosegmentations rather than physician-delineated contours. Models based on autosegmentations spanning the entire bowel space show further considerable improvement in model performance. The results of this study should be further validated using an external data set.
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Affiliation(s)
- Ramon M Salazar
- Department of Radiation Physics, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Jack D Duryea
- Department of Radiation Physics, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Alexandra O Leone
- Department of Radiation Physics, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Saurabh S Nair
- Department of Radiation Physics, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Raymond P Mumme
- Department of Radiation Physics, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Brian De
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Kelsey L Corrigan
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Michael K Rooney
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Emma B Holliday
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Laurence E Court
- Department of Radiation Physics, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Joshua S Niedzielski
- Department of Radiation Physics, The University of Texas, MD Anderson Cancer Center, Houston, Texas.
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Damron EP, Florez M, De B, Huntoon K, Beckham T, Wang C, Li J, Amini B, Briere TM, Tom MC, Tatsui C, Rhines LD, Ghia AJ. Stratifying Response to Stereotactic Radiosurgery for Spinal Metastases by Primary Site Genomic Mutations. Int J Radiat Oncol Biol Phys 2023; 117:e97. [PMID: 37786225 DOI: 10.1016/j.ijrobp.2023.06.862] [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) Spine stereotactic radiosurgery (SSRS) is effective in achieving durable local control (LC) and palliation of pain in patients with spinal metastases. Per institutional standards, SSRS prescription dose is tailored by primary site histology, with radioresistant disease receiving escalated doses. While the association between tumor histology and radioresistance is well studied, the association between specific genotypic mutations and radioresistance to SSRS is not well known. We sought to determine if a relationship exists between primary tumor mutations and clinical outcomes following SSRS. MATERIALS/METHODS We performed a retrospective analysis of 201 patients with available primary site mutation profiles who underwent SSRS to 327 spinal metastases from 2007-2022 at a single institution. Associations with overall survival (OS) and LC were identified using univariate and multivariable Cox proportional hazards modeling adjusted for clinicopathologic and treatment-related factors. RESULTS The median age was 59 years (range: 11-85) at the time of SSRS. One hundred and five patients were male (52%). The median SSRS dose to the gross tumor volume was 24 Gy (range: 12-50) given in a median of 1 fraction (range: 1-5), corresponding to a biologically effective dose (BED10) of 81.6 Gy. The most common primary tumor sites were head and neck (20%), lung (19%), and genitourinary (15%). The most common spine subsites were thoracic (57%) and lumbar (27%). Twenty-four mutated genes were identified in primary tumors with the most common being TP53 (28%), KIT (15%), PIK3CA (15%), and KRAS (10%). Prior to receipt of SSRS, 19% of patients underwent surgical resection and 23% received conventional radiation therapy (RT) to their treated sites. The median follow-up time and OS following SSRS was 97 months (95% confidence interval [CI] 86-128) and 41 months (95% CI 20-31), respectively. The median LC at 1 and 2 years following SSRS was 88% (95% CI 84-92) and 75% (95% CI 70-82), respectively. On multivariable analysis, receipt of prior RT (hazard ratio [HR] 1.86; 95% CI 1.29-2.67; P = 0.0008) and TP53 mutation (HR 1.68; 95% CI 1.20-2.35; P = 0.0024) were associated with shorter OS, whereas STK11 mutation (HR 2.14; 95% CI 0.47-4.70; P = 0.0589) trended towards shorter OS. LC was more durable with increasing BED10 (HR 0.98; 95% CI 0.96-1.00; P = 0.0166) and less durable with mutations in ATM (HR 2.40; 95% CI 1.06-5.44; P = 0.0362), STK11 (HR 4.89; 95% CI 1.40-15.01; P = 0.0119), and CTNNB1 (HR 4.49; 95% CI 1.90-10.62; P = 0.0006). CONCLUSION While favorable outcomes among all patients receiving SSRS were seen, increasing BED10 was associated with more durable LC. Primary site ATM, STK11, and CTNNB1 mutations may be associated with poorer LC following SSRS. Further investigation into the prognostic value of individual mutations and combinations thereof is warranted.
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Affiliation(s)
- E P Damron
- The University of Texas McGovern Medical School, Houston, TX
| | - M Florez
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - B De
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - K Huntoon
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - T Beckham
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, NY
| | - C Wang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - J Li
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - B Amini
- Department of Musculoskeletal Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - T M Briere
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - M C Tom
- Florida International University, Herbert Wertheim College of Medicine, Miami, FL
| | - C Tatsui
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - L D Rhines
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - A J Ghia
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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Grippin A, De B, Florez M, Tom MC, Beckham T, Wang C, Bishop AJ, Shanker MD, Li J, Amini B, Briere TM, Tatsui C, Rhines LD, McGovern SL, McAleer MF, Ghia AJ. Spine Stereotactic Radiosurgery for Primary and Metastatic Osteosarcoma. Int J Radiat Oncol Biol Phys 2023; 117:e299. [PMID: 37785092 DOI: 10.1016/j.ijrobp.2023.06.2312] [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) Osteosarcoma is difficult to control due to its high propensity for metastasis and resistance to local and systemic therapies. High doses of radiation therapy (RT) may confer local control (LC) in some settings but for lesions involving the vertebral bodies, proximity to the spinal cord may limit the ability to deliver an adequate dose. In this analysis, we investigate the role of spine stereotactic radiosurgery (SSRS) to overcome this barrier and enable efficacious treatment of primary or metastatic osteosarcoma of the spine. MATERIALS/METHODS We retrospectively reviewed all patients treated with SSRS for osteosarcoma of the vertebrae between 2006 and 2022 at a single large tertiary cancer center. We utilized the Kaplan-Meier method to estimate overall survival (OS) and LC. RESULTS We identified 18 patients treated with SSRS for 25 lesions of spinal osteosarcoma. Median follow-up was 17.2 months. Two patients and three separate lesions were treated with SSRS for primary osteosarcoma of the vertebrae. The remaining 16 patients and 22 lesions received SSRS to the spine for metastatic disease. Lesions were treated to a dose of 24Gy in one fraction (n = 20) 27Gy in 3 fractions (n = 4) or 50Gy in 5 fractions (n = 1). Treatment sites included the cervical spine alone (n = 4), thoracic spine alone (n = 12), lumbar spine alone (n = 4), sacrum alone (n = 3), or both the thoracic and lumbar spine (n = 2). At latest follow up, local failure was observed in 9/25 (36%) treated lesions and median LC was 22.5 months (95% CI 6-43 months). Per-lesion LC at 1 year was 64% (95% CI 35-83%). Per-patient median OS was 14 months (95% CI 7-68 months) and OS estimates at 1 and 2 years were 60% (95% CI 32-80%) and 35% (11-60%), respectively. Among 15 patients who received 24 Gy in one fraction, at 1 year per-lesion LC was 72% (95% CI 41-88%) and per-patient OS was 60% (95% CI 28-81%). The most common acute treatment related toxicity was pain flare (12%). Four patients (16%) developed compression fractures in the treated vertebrae after radiation, with incidence between 57 and 578 days after radiation. Two of these fractures required intervention and two were incidental findings on imaging. No patients developed CTCAE Grade 3 or higher adverse events including neurological toxicities. CONCLUSION SSRS appears to be safe and effective in the treatment of metastatic or primary osteosarcoma involving spinal bone. Future work should include further investigation of this technique with pooled multi-institutional studies and randomized trials.
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Affiliation(s)
- A Grippin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - B De
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - M Florez
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - M C Tom
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - T Beckham
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - C Wang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - A J Bishop
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - M D Shanker
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - J Li
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - B Amini
- Department of Musculoskeletal Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - T M Briere
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - C Tatsui
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - L D Rhines
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - S L McGovern
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - M F McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - A J Ghia
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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Florez M, De B, Kowalchuk RO, Tang C, Bishop AJ, Kouzy R, Amini B, Briere TM, Beckham T, Wang C, Li J, Tatsui C, Rhines LD, Merrell KW, Ghia AJ. Validation of the Prognostic Index for Spine Metastasis (PRISM) Score for Stratifying Survival in Patients Treated with Spinal Stereotactic Radiosurgery. Int J Radiat Oncol Biol Phys 2023; 117:e103-e104. [PMID: 37784632 DOI: 10.1016/j.ijrobp.2023.06.875] [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) Stereotactic spinal radiosurgery (SSRS) has been increasingly utilized as a first-line treatment for the management of spine metastases due to its ability to prolong survival and improve symptom control. Studies have shown that SSRS is helpful for select patients; however, there is no universal scoring system utilized to predict patient response to treatment. The Prognostic Index for Spinal Metastases (PRISM) score was shown to predict the likelihood of patients benefiting from SSRS. We sought to further demonstrate its generalizability by performing validation with a large dataset from a second high-volume institution. MATERIALS/METHODS We performed a retrospective review from 2017-2019 of 424 patients treated with SSRS at a single institution. Patients were stratified on the previously described PRISM criteria: Female sex (+2), solitary bone disease (+3), performance status (0 through +3.5), prior surgery at the SSRS site (+1), number of other metastatic sites (-N), prior radiation at the SSRS site (-1), and latency to treatment ≥ 5 months (+3). Patients were grouped based on PRISM scores: >7, Group 1; 4-7, Group 2; 1-3, Group 3; <1 Group 4. There were 89, 188, 88, and 59 patients in Groups 1, 2, 3, and 4, respectively. Most patients were male (70%) with a performance status of 0 (53%). The most common tumor histologies were prostate (34%), renal (18%), and lung (11%). The median biological effective dose (BED10) was 60 Gy (interquartile range [IQR], 60-82). We performed Cox proportional hazards analysis on overall survival (OS) based on PRISM score and patient and tumor characteristics. Concordance indices created from PRISM criteria and the multivariate Cox proportional analysis were compared. RESULTS The median follow-up time was 50.5 months (95% confidence interval [CI], 45.8-54.7) with a median overall survival of 30.3 months (95% CI, 27.3-38.4). The median overall survivals for PRISM Groups 1, 2, 3, and 4 were 57.1, 37, 23.7, and 8.8 months, respectively. There were significant differences in overall survival among PRISM groups with hazard ratios of 0.49 (95% CI, 0.35-0.69; P<0.001) for Group 1, 0.71 (95% CI, 0.55-0.91); P<0.007) for Group 2, 1,45 (95% CI, 1.08-1.94); P = 0.010) for Group 3, and 3.47 (95% CI, 2.56-4.70; P<0.001) for Group 4. Multivariable Cox analysis for patient and tumor characteristics revealed only the number of organs involved and performance status as significant clinicopathologic prognostic attributes. However, the C-index using the PRISM criteria was 0.76, which was superior to the C-index when using the significant clinicopathologic attributes by themselves (0.71). CONCLUSION These data demonstrate robust validation of the PRISM score to stratify OS in patients treated with SSRS and may help guide optimal treatment selection in prospective trials and clinical settings.
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Affiliation(s)
- M Florez
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - B De
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - R O Kowalchuk
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - C Tang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - A J Bishop
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - R Kouzy
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - B Amini
- Department of Musculoskeletal Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - T M Briere
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - T Beckham
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - C Wang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - J Li
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - C Tatsui
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - L D Rhines
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - K W Merrell
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - A J Ghia
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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Tadesse F, De B, Vauthey JN, Javle M, Upadhyay R, Kumala T, Shi C, Dodoo G, Corrigan KL, Manzar GS, Marqueen KE, Pagan VB, Lee S, Jaoude JA, Ludmir EB, Koay EJ. Enhancement Patterns of Metastatic Intrahepatic Cholangiocarcinoma and Outcomes after Chemotherapy and Radiation. Int J Radiat Oncol Biol Phys 2023; 117:e341. [PMID: 37785192 DOI: 10.1016/j.ijrobp.2023.06.2403] [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) Patients with metastatic intrahepatic cholangiocarcinoma (M1-iCCA) have a poor prognosis with a 5-year survival rate of less than 20%. Definitive doses of radiation therapy (RT) after upfront chemotherapy (chemo/RT) in this patient population have shown to prolong survival by reducing the risk of tumor-related liver failure compared to chemotherapy alone. Our group has also identified a baseline radiographic feature, the arterial enhancement pattern, which has pathological and prognostic associations for iCCA. We tested the hypothesis that baseline arterial enhancement is independently associated with survival outcomes for patients who receive chemo/RT or chemo alone. MATERIALS/METHODS Patients with M1-iCCA from 2010 to 2021 were included in this retrospective study. Patients were grouped into those who underwent chemo alone and those who underwent chemo/RT. The inclusion criteria included confirmed diagnosis of M1-iCCA, availability of baseline multi-phasic computed tomography (CT), and follow-up for at least six months or until death. Tumor arterial enhancement patterns were categorized as previously described into hypovascular or hypervascular, where the tumors that were hypervascular had either peripheral enhancement or central enhancement. Mean tumor density in Hounsfield units was recorded for each patient. Survival was estimated using the Kaplan Meier method, and Cox proportional models were used to adjust for prognostic variables. RESULTS A total of 281 patients with iCCA were identified and 229 had evaluable CT scans. Demographic and baseline characteristics of patient groups are shown in the Table. On univariate analysis, patient age, ECOG performance status (PS) at diagnosis, treatment type, and arterial enhancement patterns associated with overall survival (OS). On multivariable analysis, the arterial enhancement pattern independently associated with OS after accounting for covariates. Patients with hypervascular tumors had prolonged OS compared to those with hypovascular tumors (HR = 0.72, [0.54 - 0.96], p = 0.02). Prolonged OS was also observed in the chemo/RT group compared to the chemo alone group (HR = 0.37, [0.25-0.54], p< 0.0001). CONCLUSION Baseline enhancement patterns of M1-iCCA were prognostic in the contexts of chemo alone and chemo/RT. This imaging-based biomarker may improve the ability to stratify patients for therapeutic management.
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Affiliation(s)
- F Tadesse
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - B De
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - J N Vauthey
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - M Javle
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - T Kumala
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - C Shi
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - G Dodoo
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - K L Corrigan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - G S Manzar
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - K E Marqueen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - V Bernard Pagan
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - S Lee
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - J Abi Jaoude
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - E B Ludmir
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - E J Koay
- The University of Texas MD Anderson Cancer Center, Houston, TX
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Sherry AD, Maroongroge S, De B, Amini B, Conley AP, Bishop AJ, Wang C, Beckham T, Tom M, Briere T, Li J, Yeboa DN, McAleer MF, North R, Tatsui CE, Rhines LD, Ghia AJ. Management of chordoma and chondrosarcoma with definitive dose-escalated single-fraction spine stereotactic radiosurgery. J Neurooncol 2023; 164:377-386. [PMID: 37667065 DOI: 10.1007/s11060-023-04432-1] [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: 07/31/2023] [Accepted: 08/19/2023] [Indexed: 09/06/2023]
Abstract
PURPOSE The management of chordoma or chondrosarcoma involving the spine is often challenging due to adjacent critical structures and tumor radioresistance. Spine stereotactic radiosurgery (SSRS) has radiobiologic advantages compared with conventional radiotherapy, though there is limited evidence on SSRS in this population. We sought to characterize the long-term local control (LC) of patients treated with SSRS. METHODS We retrospectively reviewed patients with chordoma or chondrosarcoma treated with dose-escalated SSRS, defined as 24 Gy in 1 fraction to the gross tumor volume. Overall survival (OS) was calculated by Kaplan-Meier functions. Competing risk analysis using the cause-specific hazard function estimated LC time. RESULTS Fifteen patients, including 12 with chordoma and 3 with chondrosarcoma, with 22 lesions were included. SSRS intent was definitive, single-modality in 95% of cases (N = 21) and post-operative in 1 case (5%). After a median censored follow-up time of 5 years (IQR 4 to 8 years), median LC time was not reached (IQR 8 years to not reached), with LC rates of 100%, 100%, and 90% at 1 year, 2 years, and 5 years. The median OS was 8 years (IQR 3 years to not reached). Late grade 3 toxicity occurred after 23% of treatments (N = 5, fracture), all of which were managed successfully with stabilization. CONCLUSION Definitive dose-escalated SSRS to 24 Gy in 1 fraction appears to be a safe and effective treatment for achieving durable local control in chordoma or chondrosarcoma involving the spine, and may hold particular importance as a low-morbidity alternative to surgery in selected cases.
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Affiliation(s)
- Alexander D Sherry
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Sean Maroongroge
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Brian De
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Behrang Amini
- Department of Musculoskeletal Imaging, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anthony P Conley
- Department of Sarcoma Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew J Bishop
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Chenyang Wang
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Thomas Beckham
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Martin Tom
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Tina Briere
- Department of Radiation Physics, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jing Li
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Debra N Yeboa
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Mary Frances McAleer
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA
| | - Robert North
- Department of Neurosurgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Claudio E Tatsui
- Department of Neurosurgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laurence D Rhines
- Department of Neurosurgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amol J Ghia
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bldv, Unit 1202, 77030, Houston, TX, USA.
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7
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De B, Upadhyay R, Liao K, Kumala T, Shi C, Dodoo G, Abi Jaoude J, Corrigan KL, Manzar GS, Marqueen KE, Bernard V, Lee SS, Raghav KPS, Vauthey JN, Tzeng CWD, Tran Cao HS, Lee G, Wo JY, Hong TS, Crane CH, Minsky BD, Smith GL, Holliday EB, Taniguchi CM, Koong AC, Das P, Javle M, Ludmir EB, Koay EJ. Definitive Liver Radiotherapy for Intrahepatic Cholangiocarcinoma with Extrahepatic Metastases. Liver Cancer 2023; 12:198-208. [PMID: 37593365 PMCID: PMC10427952 DOI: 10.1159/000530134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 03/06/2023] [Indexed: 08/19/2023] Open
Abstract
Introduction Tumor-related liver failure (TRLF) is the most common cause of death in patients with intrahepatic cholangiocarcinoma (ICC). Though we previously showed that liver radiotherapy (L-RT) for locally advanced ICC is associated with less frequent TRLF and longer overall survival (OS), the role of L-RT for patients with extrahepatic metastatic disease (M1) remains undefined. We sought to compare outcomes for M1 ICC patients treated with and without L-RT. Methods We reviewed ICC patients that found to have M1 disease at initial diagnosis at a single institution between 2010 and 2021 who received L-RT, matching them with an institutional cohort by propensity score and a National Cancer Database (NCDB) cohort by frequency technique. The median biologically effective dose was 97.5 Gy (interquartile range 80.5-97.9 Gy) for L-RT. Patients treated with other local therapies or supportive care alone were excluded. We analyzed survival with Cox proportional hazard modeling. Results We identified 61 patients who received L-RT and 220 who received chemotherapy alone. At median follow-up of 11 months after diagnosis, median OS was 9 months (95% confidence interval [CI] 8-11) and 21 months (CI: 17-26) for patients receiving chemotherapy alone and L-RT, respectively. TRLF was the cause of death more often in the patients who received chemotherapy alone compared to those who received L-RT (82% vs. 47%; p = 0.001). On multivariable propensity score-matched analysis, associations with lower risk of death included duration of upfront chemotherapy (hazard ratio [HR] 0.82; p = 0.005) and receipt of L-RT (HR: 0.40; p = 0.002). The median OS from diagnosis for NCDB chemotherapy alone cohort was shorter than that of the institutional L-RT cohort (9 vs. 22 months; p < 0.001). Conclusion For M1 ICC, L-RT associated with a lower rate of death due to TRLF and longer OS versus those treated with chemotherapy alone. Prospective studies of L-RT in this setting are warranted.
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Affiliation(s)
- Brian De
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rituraj Upadhyay
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kaiping Liao
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tiffany Kumala
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christopher Shi
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Grace Dodoo
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph Abi Jaoude
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kelsey L Corrigan
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gohar S Manzar
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kathryn E Marqueen
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vincent Bernard
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sunyoung S Lee
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kanwal P S Raghav
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hop S Tran Cao
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Grace Lee
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher H Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Bruce D Minsky
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Grace L Smith
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Emma B Holliday
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cullen M Taniguchi
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Albert C Koong
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Milind Javle
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ethan B Ludmir
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eugene J Koay
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Florez MA, Jaoude JA, Patel RR, Kouzy R, Lin TA, De B, Beck EJ, Taniguchi CM, Minsky BD, Fuller CD, Lee JJ, Kupferman M, Raghav KP, Overman MJ, Thomas CR, Ludmir EB. Incidence of Primary End Point Changes Among Active Cancer Phase 3 Randomized Clinical Trials. JAMA Netw Open 2023; 6:e2313819. [PMID: 37195664 DOI: 10.1001/jamanetworkopen.2023.13819] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023] Open
Abstract
Importance Primary end point (PEP) changes to an active clinical trial raise questions regarding trial quality and the risk of outcome reporting bias. It is unknown how the frequency and transparency of the reported changes depend on reporting method and whether the PEP changes are associated with trial positivity (ie, the trial met the prespecified statistical threshold for PEP positivity). Objectives To assess the frequency of reported PEP changes in oncology randomized clinical trials (RCTs) and whether these changes are associated with trial positivity. Design, Setting, and Participants This cross-sectional study used publicly available data for complete oncology phase 3 RCTs registered in ClinicalTrials.gov from inception through February 2020. Main Outcomes and Measures The main outcome was change between the initial PEP and the final reported PEP, assessed using 3 methods: (1) history of tracked changes on ClinicalTrials.gov, (2) self-reported changes noted in the article, and (3) changes reported within the protocol, including all available protocol documents. Logistic regression analyses were performed to evaluate whether PEP changes were associated with US Food and Drug Administration approval or trial positivity. Results Of 755 included trials, 145 (19.2%) had PEP changes found by at least 1 of the 3 detection methods. Of the 145 trials with PEP changes, 102 (70.3%) did not have PEP changes disclosed within the manuscript. There was significant variability in rates of PEP detection by each method (χ2 = 72.1; P < .001). Across all methods, PEP changes were detected at higher rates when multiple versions of the protocol (47 of 148 [31.8%]) were available compared with 1 version (22 of 134 [16.4%]) or no protocol (76 of 473 [16.1%]) (χ2 = 18.7; P < .001). Multivariable analysis demonstrated that PEP changes were associated with trial positivity (odds ratio, 1.86; 95% CI, 1.25-2.82; P = .003). Conclusions and Relevance This cross-sectional study revealed substantial rates of PEP changes among active RCTs; PEP changes were markedly underreported in published articles and mostly occurred after reported study completion dates. Significant discrepancies in the rate of detected PEP changes call into question the role of increased protocol transparency and completeness in identifying key changes occurring in active trials.
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Affiliation(s)
- Marcus A Florez
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
- Program in Translational Biology and Molecular Medicine, Baylor College of Medicine, Houston, Texas
| | - Joseph Abi Jaoude
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Roshal R Patel
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Ramez Kouzy
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Timothy A Lin
- Department of Radiation Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brian De
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Esther J Beck
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Cullen M Taniguchi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Bruce D Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Clifton D Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - J Jack Lee
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston
| | - Michael Kupferman
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Kanwal P Raghav
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Michael J Overman
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Charles R Thomas
- Department of Radiation Oncology, Dartmouth Geisel School of Medicine, Norris Cotton Cancer Center, Lebanon, New Hampshire
| | - Ethan B Ludmir
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston
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Ly V, Liu L, Cardenas C, Maroongroge S, De B, Basha DE, Court L, Luo X. Parametric delineation uncertainties contouring (PDUC) modeling on CT scans of prostate cancer patients. J Appl Clin Med Phys 2023:e13970. [PMID: 37078392 DOI: 10.1002/acm2.13970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 02/23/2023] [Accepted: 03/01/2023] [Indexed: 04/21/2023] Open
Abstract
PURPOSE Variability in contouring contributes to large variations in radiation therapy planning and treatment outcomes. The development and testing of tools to automatically detect contouring errors require a source of contours that includes well-understood and realistic errors. The purpose of this work was to develop a simulation algorithm that intentionally injects errors of varying magnitudes into clinically accepted contours and produces realistic contours with different levels of variability. METHODS We used a dataset of CT scans from 14 prostate cancer patients with clinician-drawn contours of the regions of interest (ROI) of the prostate, bladder, and rectum. Using our newly developed Parametric Delineation Uncertainties Contouring (PDUC) model, we automatically generated alternative, realistic contours. The PDUC model consists of the contrast-based DU generator and a 3D smoothing layer. The DU generator transforms contours (deformation, contraction, and/or expansion) as a function of image contrast. The generated contours undergo 3D smoothing to obtain a realistic look. After model building, the first batch of auto-generated contours was reviewed. Editing feedback from the reviews was then used in a filtering model for the auto-selection of clinically acceptable (minor-editing) DU contours. RESULTS Overall, C values of 5 and 50 consistently produced high proportions of minor-editing contours across all ROI compared to the other C values (0.936 ± $ \pm \;$ 0.111 and 0.552 ± $ \pm \;$ 0.228, respectively). The model performed best on the bladder, which had the highest proportion of minor-editing contours (0.606) of the three ROI. In addition, the classification AUC for the filtering model across all three ROI is 0.724 ± $ \pm \;$ 0.109. DISCUSSION The proposed methodology and subsequent results are promising and could have a great impact on treatment planning by generating mathematically simulated alternative structures that are clinically relevant and realistic enough (i.e., similar to clinician-drawn contours) to be used in quality control of radiation therapy.
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Affiliation(s)
- Vi Ly
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Biostatistics and Data Science, University of Texas Health Science Center, School of Public Health, Houston, Texas, USA
| | - Lizhong Liu
- Department of Biostatistics and Data Science, University of Texas Health Science Center, School of Public Health, Houston, Texas, USA
| | - Carlos Cardenas
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sean Maroongroge
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Brian De
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Daniel El Basha
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Laurence Court
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Xi Luo
- Department of Biostatistics and Data Science, University of Texas Health Science Center, School of Public Health, Houston, Texas, USA
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Kowalchuk R, Mullikin TC, Breen W, Gits HC, Florez M, De B, Harmsen WS, Rose PS, Siontis BL, Costello BA, Morris JM, Lucido JJ, Olivier KR, Stish B, Laack NN, Park S, Owen D, Ghia AJ, Brown PD, Merrell KW. Development and validation of a unifying pre-treatment decision tool for intracranial and extracranial metastasis-directed radiotherapy. Front Oncol 2023; 13:1095170. [PMID: 37051531 PMCID: PMC10083422 DOI: 10.3389/fonc.2023.1095170] [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: 11/10/2022] [Accepted: 03/15/2023] [Indexed: 03/29/2023] Open
Abstract
BackgroundThough metastasis-directed therapy (MDT) has the potential to improve overall survival (OS), appropriate patient selection remains challenging. We aimed to develop a model predictive of OS to refine patient selection for clinical trials and MDT.Patients and methodsWe assembled a multi-institutional cohort of patients treated with MDT (stereotactic body radiation therapy, radiosurgery, and whole brain radiation therapy). Candidate variables for recursive partitioning analysis were selected per prior studies: ECOG performance status, time from primary diagnosis, number of additional non-target organ systems involved (NOS), and intracranial metastases.ResultsA database of 1,362 patients was assembled with 424 intracranial, 352 lung, and 607 spinal treatments (n=1,383). Treatments were split into training (TC) (70%, n=968) and internal validation (IVC) (30%, n=415) cohorts. The TC had median ECOG of 0 (interquartile range [IQR]: 0-1), NOS of 1 (IQR: 0-1), and OS of 18 months (IQR: 7-35). The resulting model components and weights were: ECOG = 0, 1, and > 1 (0, 1, and 2); 0, 1, and > 1 NOS (0, 1, and 2); and intracranial target (2), with lower scores indicating more favorable OS. The model demonstrated high concordance in the TC (0.72) and IVC (0.72). The score also demonstrated high concordance for each target site (spine, brain, and lung).ConclusionThis pre-treatment decision tool represents a unifying model for both intracranial and extracranial disease and identifies patients with the longest survival after MDT who may benefit most from aggressive local therapy. Carefully selected patients may benefit from MDT even in the presence of intracranial disease, and this model may help guide patient selection for MDT.
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Affiliation(s)
- Roman Kowalchuk
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Trey C. Mullikin
- Department of Radiation Oncology, Duke University, Durham, NC, United States
| | - William Breen
- Department of Radiation Oncology, Duke University, Durham, NC, United States
| | - Hunter C. Gits
- Department of Radiation Oncology, Duke University, Durham, NC, United States
| | - Marcus Florez
- Department of Radiation Oncology, Houston, MD Anderson Cancer Center, Houston, TX, United States
| | - Brian De
- Department of Radiation Oncology, Houston, MD Anderson Cancer Center, Houston, TX, United States
| | | | - Peter Sean Rose
- Mayo Clinic, Department of Orthopedic Surgery, Rochester, MN, United States
| | | | | | - Jonathan M. Morris
- Mayo Clinic, Department of Medical Oncology, Rochester, MN, United States
| | - John J. Lucido
- Mayo Clinic, Department of Medical Physics, Rochester, MN, United States
| | - Kenneth R. Olivier
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Brad Stish
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Nadia N. Laack
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Sean Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Dawn Owen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Amol J. Ghia
- Department of Radiation Oncology, Houston, MD Anderson Cancer Center, Houston, TX, United States
| | - Paul D. Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Kenneth Wing Merrell
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
- *Correspondence: Kenneth Wing Merrell,
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Florez MA, De B, Chapman BV, Prayongrat A, Thomas JG, Beckham TH, Wang C, Yeboa DN, Bishop AJ, Briere T, Amini B, Li J, Tatsui CE, Rhines LD, Ghia AJ. Safety and efficacy of salvage conventional re-irradiation following stereotactic radiosurgery for spine metastases. Radiat Oncol J 2023; 41:12-22. [PMID: 37013414 PMCID: PMC10073838 DOI: 10.3857/roj.2022.00353] [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: 06/26/2022] [Accepted: 12/28/2022] [Indexed: 03/17/2023] Open
Abstract
PURPOSE There has been limited work assessing the use of re-irradiation (re-RT) for local failure following stereotactic spinal radiosurgery (SSRS). We reviewed our institutional experience of conventionally-fractionated external beam radiation (cEBRT) for salvage therapy following SSRS local failure. MATERIALS AND METHODS We performed a retrospective review of 54 patients that underwent salvage conventional re-RT at previously SSRS-treated sites. Local control following re-RT was defined as the absence of progression at the treated site as determined by magnetic resonance imaging. RESULTS Competing risk analysis for local failure was performed using a Fine-Gray model. The median follow-up time was 25 months and median overall survival (OS) was 16 months (95% confidence interval [CI], 10.8-24.9 months) following cEBRT re-RT. Multivariable Cox proportional-hazards analysis revealed Karnofsky performance score prior to re-RT (hazard ratio [HR] = 0.95; 95% CI, 0.93-0.98; p = 0.003) and time to local failure (HR = 0.97; 95% CI, 0.94-1.00; p = 0.04) were associated with longer OS, while male sex (HR = 3.92; 95% CI, 1.64-9.33; p = 0.002) was associated with shorter OS. Local control at 12 months was 81% (95% CI, 69.3-94.0). Competing risk multivariable regression revealed radioresistant tumors (subhazard ratio [subHR] = 0.36; 95% CI, 0.15-0.90; p = 0.028) and epidural disease (subHR = 0.31; 95% CI, 0.12-0.78; p =0.013) were associated with increased risk of local failure. At 12 months, 91% of patients maintained ambulatory function. CONCLUSION Our data suggest that cEBRT following SSRS local failure can be used safely and effectively. Further investigation is needed into optimal patient selection for cEBRT in the retreatment setting.
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Affiliation(s)
- Marcus A. Florez
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian De
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bhavana V. Chapman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anussara Prayongrat
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jonathan G. Thomas
- Department of Neurological Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thomas H. Beckham
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Chenyang Wang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Debra N. Yeboa
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew J. Bishop
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tina Briere
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Behrang Amini
- Department of Musculoskeletal Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jing Li
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Claudio E. Tatsui
- Department of Neurological Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laurence D. Rhines
- Department of Neurological Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amol J. Ghia
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Correspondence: Amol J. Ghia Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1202, Houston, TX 77030, USA. Tel: +1-832-628-7357,
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Maroongroge S, De B, Woodhouse KD, Bassett Jr RL, Lee P, Bloom ES, Smith GL, Frank SJ, Li J, Perkins G, Das P, Koong AC, Smith BD, Wang C. Physician Perspectives on Telemedicine in Radiation Oncology. Adv Radiat Oncol 2023; 8:101005. [PMID: 36311822 PMCID: PMC9598490 DOI: 10.1016/j.adro.2022.101005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 04/16/2022] [Indexed: 11/06/2022] Open
Abstract
Purpose Telemedicine enthusiasm and uptake in radiation oncology rapidly increased during the COVID-19 pandemic, but it is unclear if and how telemedicine should be used after the COVID-19 public health emergency ends is unclear. Herein, we report on our institution's provider experience after the mature adoption of telemedicine. Methods and Materials We distributed a survey to all radiation oncology attending physicians at our institution in October 2021 to assess satisfaction, facilitators, and barriers to telemedicine implementation. We performed quantitative and qualitative analyses to characterize satisfaction and identify influencing factors whether telemedicine is employed. We calculated the average proportion of visits that providers expected to be appropriately performed with telemedicine for each disease site and visit type. Results A total of 60 of the 82 eligible radiation oncologists (73%) responded to the survey, of whom 78% were satisfied with telemedicine in the radiation oncology department and 83% wished to continue offering video visits after the COVID-19 public health emergency ends. Common patient factors influencing whether physicians offer telemedicine include the patient's travel burden, patient preferences, and whether a physical examination is required. Approximately 20% of new consultations and 50% of weekly management visits were estimated to be appropriate for telemedicine. The central nervous system/pediatrics and thoracic faculty considered telemedicine appropriate for the greatest proportion of new consultations, and 93% of respondents felt comfortable determining whether telemedicine was appropriate. Conclusions Surveyed radiation oncologists were satisfied with telemedicine in their practice, and wished to continue offering video visits in the future. Our data suggest that payers should continue to support this patient-centered technology.
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Affiliation(s)
- Sean Maroongroge
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Brian De
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kristina D. Woodhouse
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Roland L. Bassett Jr
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Percy Lee
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elizabeth S. Bloom
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Grace L. Smith
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Steven J. Frank
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jing Li
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - George Perkins
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Prajnan Das
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Albert C. Koong
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Benjamin D. Smith
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Chenyang Wang
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
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Rooney MK, De B, Corrigan K, Smith GL, Taniguchi C, Minsky BD, Ludmir EB, Koay EJ, Das P, Koong AC, Peacock O, Chang G, You YN, Morris VK, Nogueras-González G, Holliday EB. Patient-reported Bowel Function and Bowel-related Quality of Life After Pelvic Radiation for Rectal Adenocarcinoma: The Impact of Radiation Fractionation and Surgical Resection. Clin Colorectal Cancer 2023; 22:211-221. [PMID: 36878805 DOI: 10.1016/j.clcc.2023.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 02/10/2023] [Indexed: 02/17/2023]
Abstract
INTRODUCTION Multimodality treatment for locally advanced rectal cancer (LARC) can include long-course radiotherapy (LCRT) or short course radiotherapy (SCRT). Nonoperative management is increasingly pursued for those achieving a complete clinical response. Data regarding long-term function and quality-of-life (QOL) are limited. METHODS Patients with LARC treated with radiotherapy from 2016 to 2020 completed the Functional Assessment of Cancer Therapy- General (FACT-G7), the Low Anterior Resection Syndrome Score (LARS) and the Fecal Incontinence QOL Scale (FIQOL). Univariate and multivariable linear regression analyses identified associations between clinical variables including radiation fractionation and the use of surgery versus non-operative management. RESULTS Of 204 patients surveyed, 124 (60.8%) responded. Median (interquartile range) time from radiation to survey completion was 30.1 (18.3-43) months. Seventy-nine (63.7%) respondents received LCRT, and 45 (36.3%) received SCRT; 101 (81.5%) respondents underwent surgery, and 23 (18.5%) pursued nonoperative management. There were no differences in LARS, FIQoL or FACT-G7 between patients receiving LCRT versus SCRT. On multivariable analysis, only nonoperative management was associated with lower LARS score signifying less bowel dysfunction. Nonoperative management and female sex were associated with a higher FIQoL score signifying less disruption and distress from fecal incontinence issues. Finally, lower BMI at the time of radiation, female sex, and higher FIQoL score were associated with higher FACT-G7 scores signifying better overall QOL. CONCLUSIONS These results suggest long-term patient-reported bowel function and QOL may be similar for individuals receiving SCRT and LCRT for the treatment of LARC, but nonoperative management may lead to improved bowel function and QOL.
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Affiliation(s)
- Michael K Rooney
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Brian De
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kelsey Corrigan
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Grace L Smith
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Cullen Taniguchi
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Bruce D Minsky
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ethan B Ludmir
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Eugene J Koay
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Prajnan Das
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Albert C Koong
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Oliver Peacock
- Department of Colorectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - George Chang
- Department of Colorectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Y Nancy You
- Department of Colorectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | - Emma B Holliday
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Chamseddine I, Kim Y, De B, Naqa IE, Duda DG, Wolfgang JA, Pursley J, Wo JY, Hong TS, Paganetti H, Koay EJ, Grassberger C. Predictive Model of Liver Toxicity to Aid the Personalized Selection of Proton Versus Photon Therapy in Hepatocellular Carcinoma. Int J Radiat Oncol Biol Phys 2023:S0360-3016(23)00104-9. [PMID: 36739920 DOI: 10.1016/j.ijrobp.2023.01.055] [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: 06/29/2022] [Revised: 12/23/2022] [Accepted: 01/27/2023] [Indexed: 02/05/2023]
Abstract
PURPOSE Our objective was to develop an externally validated model for predicting liver toxicity after radiation therapy in patients with hepatocellular carcinoma (HCC) that can integrate both photon and proton dose distributions with patient-specific characteristics. METHODS AND MATERIALS Training data consisted of all patients with HCC treated between 2008 and 2019 at our institution (n = 117, 60%/40% photon/proton). We developed a shallow convolutional neural network (CNN) to predict posttreatment liver dysfunction from the differential dose-volume histogram (DVH) and baseline liver metrics. To reduce bias and improve robustness, we used ensemble learning (CNNE). After a preregistered study analysis plan, we evaluated stability using internal bootstrap resampling and generalizability using a data set from a different institution (n = 88). Finally, we implemented a class activation map method to characterize the critical DVH subregions and benchmarked the model against logistic regression and XGBoost. The models were evaluated using the area under the receiver operating characteristic curve and area under the precision-recall curve. RESULTS The CNNE model showed similar internal performance and robustness compared with the benchmarks. CNNE exceeded the benchmark models in external validation, with an area under the receiver operating characteristic curve of 0.78 versus 0.55 to 0.70, and an area under the precision-recall curve of 0.6 versus 0.43 to 0.52. The model showed improved predictive power in the photon group, excellent specificity in both modalities, and high sensitivity in the photon high-risk group. Models built solely on DVHs confirm outperformance of the CNNE and indicate that the proposed structure efficiently abstracts features from both proton and photon dose distributions. The activation map method demonstrates the importance of the low-dose bath and its interaction with low liver function at baseline. CONCLUSIONS We developed and externally validated a patient-specific prediction model for hepatic toxicity based on the entire DVH and clinical factors that can integrate both photon and proton therapy cohorts. This model complements the new American Society for Radiation Oncology clinical practice guidelines and could support value-driven integration of proton therapy into the management of HCC.
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Affiliation(s)
- Ibrahim Chamseddine
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Yejin Kim
- Korean Advanced Institute of Science and Technology, Daejeon, South Korea
| | - Brian De
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Issam El Naqa
- Department of Machine Learning, Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Dan G Duda
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - John A Wolfgang
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jennifer Pursley
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Harald Paganetti
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Eugene J Koay
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Clemens Grassberger
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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15
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Shi C, De B, Florez MA, Tran Cao HS, Lee SS, Willis J, Noticewala SS, Minsky BD, Smith GL, Holliday E, Taniguchi CM, Koong AC, Das P, Ludmir EB, Koay EJ. Dose-escalated pancreas radiotherapy for unresected pancreatic adenocarcinoma: Patterns of care and survival in the United States. J Clin Oncol 2023. [DOI: 10.1200/jco.2023.41.4_suppl.676] [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: 01/25/2023] Open
Abstract
676 Background: Randomized trials have not shown an overall survival (OS) benefit to adding radiotherapy (RT) to chemotherapy for patients with locally advanced pancreatic adenocarcinoma (LAPC). However, trials such as LAP07 did not incorporate escalated-dose RT (EDR), which may confer longer survival. The adoption of EDR across the United States and associated outcomes are unknown. Methods: We queried the National Cancer Data Base for non-surgically managed patients with LAPC diagnosed between 2004 and 2019. RT with biologically effective doses (BED10) > 70 and ≤ 200 Gy were labeled EDR and conventional-dose RT (CDR) for 39-70 Gy doses. Associations with receipt of EDR and with OS were identified using multivariate analysis (MVA) logistic and Cox regressions, respectively. Bonferroni corrections were applied. Cochran-Armitage and Mann-Kendall trend tests were performed to assess trends in use of RT. Results: Of 64,303 patients, the most common treatments were chemotherapy alone (CT) (71%), chemoradiation (CRT) (27%), and pancreas RT alone (2%). 18,970 patients received pancreas RT, of which 91% was CDR (median dose 50.4 Gy; median 28 fractions) and 9% was EDR (50 Gy; 5 fractions). Use of pancreas RT increased from 14% in 2004 to a peak of 18% in 2010, decreased to a nadir of 13% in 2016, and subsequently increased to 15% by 2019 ( Ptrend < 0.001). EDR use increased from 7% in 2004 to 22% in 2019 ( Ptrend < 0.0001). Median BED10 increased from 53 to 59 Gy ( Ptrend< 0.001). Of patients receiving pancreas RT, use of intensity-modulated RT (IMRT) and stereotactic body RT (SBRT) respectively increased from 25% and 2% in 2004 to 60% and 27% in 2019, while use of 3-D conformal RT (3D-CRT) decreased from 64% to 9% ( Ptrend < 0.02 for all comparisons). On MVA logistic regression, primary tumor location in the body/tail vs. head (aOR 1.22, 95% CI 1.07-1.40; P = 0.003) associated with greater EDR receipt, whereas T3-4 vs. T2 disease (aOR 0.81, CI 0.71-0.92; P = 0.002) associated with lesser receipt. At a median follow up of 59.1 months (CI 57.5-61.0), median OS estimates for CDR and EDR were 10.2 months (CI 10.1-10.3) and 13.3 months (CI 13.2-13.5; P < 0.0001), respectively. On MVA Cox regression, N1 vs. N0 disease (HR 1.08, CI 1.06-1.10; P < 0.001) correlated with higher risk of death, whereas CRT vs. CT (HR 0.83, CI 0.81-0.85; P < 0.001) correlated with lower risk of death. Subset MVA of 14,634 CRT patients correlated higher RT dose—as both a categorical variable (EDR vs. CDR; HR 0.84, CI 0.79-0.90; P < 0.001) and continuous variable (BED10; HR 0.994, CI 0.992-0.995; P < 0.001)—with lower risk of death. Conclusions: Fewer than 1 in 6 patients with unresected LAPC received pancreas RT, despite a nominal increase in utilization in recent years. Although retrospective, these NCDB data suggest longer OS with the addition of RT for unresected LAPC, suggesting continued unmet need. EDR is associated with longer survival vs. CDR.
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Affiliation(s)
- Christopher Shi
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Brian De
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Marcus A. Florez
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Hop Sanderson Tran Cao
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sunyoung S. Lee
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jason Willis
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sonal S Noticewala
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Bruce D. Minsky
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Grace L. Smith
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Emma Holliday
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Cullen M. Taniguchi
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Albert C. Koong
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Prajnan Das
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ethan B. Ludmir
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Eugene Jon Koay
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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Dodoo GN, De B, Lee SS, Abi Jaoude J, Vauthey JN, Tzeng CWD, Tran Cao HS, Katlowitz KA, Mandel JJ, Beckham TH, Minsky BD, Smith GL, Holliday EB, Koong AC, Das P, Taniguchi CM, Javle M, Koay EJ, Ludmir EB. Brain Metastases from Biliary Tract Cancer: Case Series and Clinicogenomic Analysis. Oncologist 2023; 28:327-332. [PMID: 36715178 PMCID: PMC10078902 DOI: 10.1093/oncolo/oyac273] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 11/17/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Limited data from small series have suggested that brain metastases from biliary tract cancers (BrM-BTC) affect ≤2% of patients with BTC. We sought to review our experience with patients with BrM-BTC and to identify associations of tumor-related molecular alterations with outcomes. MATERIALS AND METHODS A retrospective review of patients with BTC seen at a tertiary referral center from 2005 to 2021 was performed; patients with BrM-BTC were identified, and clinical and molecular data were collected. RESULTS Twenty-one of 823 patients with BTC (2.6%) developed BrM. For patients with BrM-BTC, median follow-up time was 27.9 months after primary BTC diagnosis and 3.1 months after BrM diagnosis. Median time from primary diagnosis to diagnosis of BrM was 14.4 [range, 1.1-66.0] months. Median overall survival (OS) from primary diagnosis was 31.5 [2.9-99.8] months and median OS from BrM diagnosis was 4.2 [0.2-33.8] months. Patients who underwent BrM-directed therapy trended toward longer OS following BrM diagnosis than patients receiving supportive care only (median 6.5 vs 0.8 months, P = .060). The BrM-BTC cohort was enriched for BRAF (30%), PIK3CA (25%), and GNAS (20%) mutations. patients with BrM-BTC with BRAF mutations trended toward longer OS following BrM diagnosis (median 13.1 vs 4.2 months, P = .131). CONCLUSION This is the largest series of patients with BrM-BTC to date and provides molecular characterization of this rare subgroup of patients with BTC. Patients with BrM-BTC may be more likely to have BRAF mutations. With advances in targeted therapy for patients with BTC with actionable mutations, continued examination of shifting patterns of failure, with emphasis on BrM, is warranted.
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Affiliation(s)
- Grace N Dodoo
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian De
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sunyoung S Lee
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph Abi Jaoude
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hop S Tran Cao
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kalman A Katlowitz
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA.,Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jacob J Mandel
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - Thomas H Beckham
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bruce D Minsky
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Grace L Smith
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Emma B Holliday
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Albert C Koong
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cullen M Taniguchi
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Milind Javle
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eugene J Koay
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ethan B Ludmir
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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17
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De B, Farooqi AS, Mitchell KG, Ludmir EB, Lewis J, Rinsurongkawong W, Rinsurongkawong V, Lee JJ, Swisher SG, Gibbons DL, Zhang J, Le X, Elamin YY, Gomez DR, Ning MS, Lin SH, Liao Z, Chang JY, Vaporciyan AA, Heymach JV, Antonoff MB, Gandhi SJ. Benchmarking Outcomes for Molecularly Characterized Synchronous Oligometastatic Non-Small-Cell Lung Cancer Reveals EGFR Mutations to Be Associated With Longer Overall Survival. JCO Precis Oncol 2023; 7:e2200540. [PMID: 36716413 PMCID: PMC9928880 DOI: 10.1200/po.22.00540] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/03/2022] [Accepted: 12/12/2022] [Indexed: 02/01/2023] Open
Abstract
PURPOSE Local consolidative therapy (LCT) for patients with synchronous oligometastatic non-small-cell lung cancer is an evolving treatment strategy, but outcomes following LCT stratified by genetic mutations have not been reported. We sought to identify genomic associations with overall survival (OS) and progression-free survival (PFS) for these patients. METHODS We identified all patients presenting between 2000 and 2017 with stage IV non-small-cell lung cancer and ≤ 3 synchronous metastatic sites. Patients were grouped according to mutational statuses. Primary outcomes included OS and PFS following initial diagnosis. RESULTS Of 194 included patients, 121 received comprehensive LCT to all sites of disease with either surgery or radiation. TP53 mutations were identified in 40 of 78 (55%), KRAS in 32 of 95 (34%), EGFR in 24 of 109 (22%), and STK11 in nine of 77 (12%). At median follow-up of 96 months, median OS and PFS were 26 (95% CI, 23 to 31) months and 11 (95% CI, 9 to 13) months, respectively. On multivariable analysis, patients with EGFR mutations had lower mortality risk (hazard ratio [HR], 0.53; 95% CI, 0.29 to 0.98; P = .044) compared with wild-type patients, and patients with STK11 mutations had higher risk of progression or mortality (HR, 2.32; 95% CI, 1.12 to 4.79; P = .023) compared with wild-type patients. TP53 and KRAS mutations were not associated with OS or PFS. Among 71 patients with known EGFR mutational status who received comprehensive LCT, EGFR mutations were associated with lower mortality compared with wild-type (HR, 0.45; 95% CI, 0.22 to 0.94; P = .032). CONCLUSION When compared with wild-type patients, those with EGFR and STK11 mutations had longer OS and shorter PFS, respectively. EGFR mutations were associated with longer OS among oligometastatic patients treated with comprehensive LCT in addition to systemic therapy.
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Affiliation(s)
- Brian De
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ahsan S. Farooqi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kyle G. Mitchell
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ethan B. Ludmir
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jeff Lewis
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Waree Rinsurongkawong
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - J. Jack Lee
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Stephen G. Swisher
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Don L. Gibbons
- Department of Thoracic/Head & Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jianjun Zhang
- Department of Thoracic/Head & Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Xiuning Le
- Department of Thoracic/Head & Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Yasir Y. Elamin
- Department of Thoracic/Head & Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Daniel R. Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Matthew S. Ning
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Steven H. Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Joe Y. Chang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ara A. Vaporciyan
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - John V. Heymach
- Department of Thoracic/Head & Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mara B. Antonoff
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Saumil J. Gandhi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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Florez MA, De B, Cavazos A, Farooqi A, Beckham TH, Wang C, Yeboa DN, Bishop AJ, McAleer MF, Briere T, Amini B, Li J, Tatsui CE, Rhines LD, Ghia AJ. Safety and Efficacy of Dose-Escalated Radiation Therapy With a Simultaneous Integrated Boost for the Treatment of Spinal Metastases. Pract Radiat Oncol 2023; 13:e7-e13. [PMID: 36604100 DOI: 10.1016/j.prro.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 08/25/2022] [Accepted: 08/28/2022] [Indexed: 12/29/2022]
Abstract
PURPOSE Intensity modulated radiation therapy (RT) for spine metastases using a simultaneous integrated boost (SSIB) was shown as an alternative to the treatment of select osseous metastases that are not amenable to spine stereotactic radiosurgery. We sought to update our clinical experience using SSIB in patients for whom dose escalation was warranted but spine stereotactic radiosurgery was not feasible. METHODS AND MATERIALS A total of 58 patients with 63 spinal metastatic sites treated with SSIB between 2012 and 2021 were retrospectively reviewed. The gross tumor volume and clinical target volume were prescribed 40 and 30 Gy in 10 fractions, respectively. RESULTS The median follow-up time was 31 months. Of 79% of patients who reported pain before RT with SSIB, 82% reported an improvement following treatment. Patient-reported pain scores on a 10-point scale revealed a significant decrease in pain at 1, 3, 6, and 12 months after SSIB (P < .0001). Additionally, there were limited toxicities; only 1 patient suffered grade 3 toxicity (pain) following RT. There were no reports of radiation-induced myelopathy at last follow-up, and 8 patients (13%) experienced a vertebral column fracture post-treatment. Local control was 88% (95% confidence interval [CI], 80%-98%) and 74% (95% CI, 59%-91%) at 1 and 2 years, respectively. Overall survival was 64% (95% CI, 53%-78%) and 45% (95% CI, 34%-61%) at 1 and 2 years, respectively. The median overall survival was 18 months (95% CI, 13-27 months). Multivariable analysis using patient, tumor, and dosimetric characteristics revealed that a higher Karnofsky performance status before RT (hazard ratio, 0.44, 0.22-0.89; P = .02) was associated with longer survival. CONCLUSIONS These data demonstrate excellent pain relief and local control with limited acute toxicities following treatment with RT using SSIB to 40 Gy. Collectively, our data suggest that dose escalation to spine metastases using SSIB can be safe and efficacious for patients, especially those with radioresistant disease. Further investigation is warranted to validate these findings.
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Affiliation(s)
- Marcus A Florez
- Departments of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Brian De
- Departments of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Adriana Cavazos
- Departments of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ahsan Farooqi
- Departments of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Thomas H Beckham
- Departments of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Chenyang Wang
- Departments of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Debra N Yeboa
- Departments of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Andrew J Bishop
- Departments of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mary F McAleer
- Departments of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Tina Briere
- Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Behrang Amini
- Musculoskeletal Imaging, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jing Li
- Departments of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Claudio E Tatsui
- Neurological Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Laurence D Rhines
- Neurological Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amol J Ghia
- Departments of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas.
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De B, Maroongroge S, Smith GL. Letter to the editor regarding "disparities in telemedicine during COVID-19". Cancer Med 2023; 12:1556-1557. [PMID: 35837958 PMCID: PMC9350141 DOI: 10.1002/cam4.5036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 07/06/2022] [Indexed: 02/01/2023] Open
Affiliation(s)
- Brian De
- Department of Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Sean Maroongroge
- Department of Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Grace L. Smith
- Department of Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
- Department of Health Services ResearchThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
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20
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De B, Pasalic D, Barocas DA, Wallis CJ, Huang LC, Zhao Z, Koyama T, Tang C, Conwill R, Goodman M, Hamilton AS, Wu XC, Paddock LE, Stroup A, Cooperberg MR, Hashibe M, O’Neil BB, Kaplan SH, Greenfield S, Penson DF, Hoffman KE. Patient-reported Outcomes After External Beam Radiotherapy With Low Dose Rate Brachytherapy Boost vs Radical Prostatectomy for Localized Prostate Cancer: Five-year Results From a Prospective Comparative Effectiveness Study. J Urol 2022; 208:1226-1239. [PMID: 36006050 PMCID: PMC9933910 DOI: 10.1097/ju.0000000000002902] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 07/21/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Data comparing radical prostatectomy and external beam radiation therapy with low dose rate brachytherapy boost are lacking. To better guide shared decision making regarding treatment, we compared patient reported outcomes through 5 years following radical prostatectomy or external beam radiation therapy with low dose rate brachytherapy boost for localized prostate cancer. MATERIALS AND METHODS From 2011-2012, men aged <80 years with localized prostate adenocarcinoma were enrolled and followed longitudinally. Patient reported outcomes included the Expanded Prostate Index Composite. Regression models adjusted for baseline scores and covariates were constructed. RESULTS The study population included 112 men treated with external beam radiation therapy with low dose rate brachytherapy boost and 1,553 treated with radical prostatectomy. Compared to radical prostatectomy, external beam radiation therapy with low dose rate brachytherapy boost was associated with clinically meaningful worse urinary irritative/obstructive (adjusted mean score difference [95% confidence interval]: 5.0 [-8.7, -1.3]; P = .008 at 5 years) and better urinary incontinence function (13.3 [7.7, 18.9]; P < .001 at 5 years) through 5 years. Urinary function bother was similar between groups (P > .4 at all timepoints). Treatment with external beam radiation therapy with low dose rate brachytherapy boost was associated with worse bowel function (-4.0 [-6.9, -1.1]; P = .006 at 5 years) through 5 years compared to radical prostatectomy. Treatment with external beam radiation therapy with low dose rate brachytherapy boost was associated with better sexual function at 1 year (12.0 [6.5, 17.5]; P < .001 at 1 year) compared to radical prostatectomy, but there was insufficient evidence to reject the supposition that no difference was seen at 3 or 5 years. CONCLUSIONS Compared to radical prostatectomy, external beam radiation therapy with low dose rate brachytherapy boost was associated with clinically meaningful worse urinary irritative/obstructive and bowel functions but better urinary incontinence function through 5 years after treatment. These patient-reported functional outcomes may clarify treatment expectations and help inform treatment choices for localized prostate cancer.
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Affiliation(s)
- Brian De
- The University of Texas MD Anderson Cancer Center, Department of Radiation Oncology, Houston, TX
| | - Dario Pasalic
- The University of Texas MD Anderson Cancer Center, Department of Radiation Oncology, Houston, TX
| | - Daniel A. Barocas
- Vanderbilt University Medical Center, Department of Urology, Nashville, TN
| | - Christopher J.D. Wallis
- Mount Sinai Hospital, Division of Urology, Department of Surgery, University of Toronto, Toronto, ON
| | - Li-Ching Huang
- Vanderbilt University Medical Center, Department of Biostatistics, Nashville, TN
| | - Zhiguo Zhao
- Vanderbilt University Medical Center, Department of Biostatistics, Nashville, TN
| | - Tatsuki Koyama
- Vanderbilt University Medical Center, Department of Biostatistics, Nashville, TN
| | - Chad Tang
- The University of Texas MD Anderson Cancer Center, Department of Radiation Oncology, Houston, TX
| | - Ralph Conwill
- Vanderbilt University Medical Center, Office of Patient and Community Education, Patient Advocacy Program, Vanderbilt Ingram Cancer Center, Nashville, TN
| | - Michael Goodman
- Emory University Rollins School of Public Health, Department of Epidemiology, Atlanta, GA
| | - Ann S. Hamilton
- Keck School of Medicine at the University of Southern California, Department of Preventative Medicine, Los Angeles, CA
| | - Xiao-Cheng Wu
- Louisiana State University New Orleans School of Public Health, Department of Epidemiology, New Orleans, LA
| | - Lisa E. Paddock
- Cancer Institute of New Jersey, Rutgers Health, Department of Epidemiology, New Brunswick, NJ
| | - Antoinette Stroup
- Cancer Institute of New Jersey, Rutgers Health, Department of Epidemiology, New Brunswick, NJ
| | | | - Mia Hashibe
- University of Utah School of Medicine, Department of Family and Preventative Medicine, Salt Lake City, UT
| | - Brock B. O’Neil
- University of Utah Health, Department of Urology, Salt Lake City, UT
| | | | | | - David F. Penson
- Vanderbilt University Medical Center, Department of Urology, Nashville, TN
- Geriatric Research Education and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN
| | - Karen E. Hoffman
- The University of Texas MD Anderson Cancer Center, Department of Radiation Oncology, Houston, TX
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21
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De B, Andres G, Bates C, Staren E, Kutscher E, Brooks DJ, Thaker GH, Buscema J, Gin R, Thaker N. Radiation Therapy Expenditures Through the First 8 Performance Periods of the Oncology Care Model at a Statewide Multispecialty Health System. Int J Radiat Oncol Biol Phys 2022:S0360-3016(22)03557-X. [PMID: 36427644 DOI: 10.1016/j.ijrobp.2022.11.030] [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: 08/19/2022] [Revised: 10/29/2022] [Accepted: 11/13/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE Our purpose was to use real world data to assess trends in radiation therapy (RT) treatment fractionation and cost under the Oncology Care Model (OCM) through the first 8 performance periods (PPs). METHODS We identified 17,157 episodes of care from 9898 patients treated at a statewide multispecialty health system through the first 8 6-month PPs (PP1-8: July 1, 2016, to June 30, 2020) of the OCM. Spending was stratified by 10 expenditure domains (eg, Part B/D drugs, radiation oncology [RO], etc), and 21 disease sites were extracted from claims data, from which an analysis of RO expenditures was performed on 2219 episodes from 2033 patients treated with RT. Expenses are expressed in per-beneficiary, per-episode terms. RESULTS RO expenditures comprised 3% ($14.7M) of total spending over the 8 periods. By primary cancer, the largest RO expenses were for breast ($2.9M; 20%), prostate ($2.9M; 19%), and lung cancer ($2.8M; 13%). For RO, total per-episode average spending remained roughly constant between PP1 ($6314) and PP8 ($6664; Ptrend > .05) and decreased ($6314-$6215) when indexed to the Consumer Price Index for July 2016. Average number of RT fractions per episode decreased from 19.2 in PP1 to 18.6 in PP8; this decrease was most notably seen for breast (-2.1), lung (-2.8), and female genitourinary (-3.5) cancers. Intensity-modulated RT (IMRT) charges accounted for $7.6M (51%) of RT spending and increased 5% from PP1 to 8, whereas conventional external beam RT made up $3.0M (21%) and decreased 8%. Expenses for image guidance ($2.5M; 17%; +2% from PP1-8) and stereotactic RT ($1.3M; 9%; +1%) increased. CONCLUSIONS In inflation-adjusted terms, total RO expenditures have declined despite greater use of IMRT, stereotactic RT, and image guidance. Conversely, oncology costs have risen because of drug spending. Successful payment models must prioritize high-cost spending areas-including novel drug therapies-while accounting for high-value care and patient outcomes.
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Affiliation(s)
- Brian De
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | | | | | | | | | | | | | - Robert Gin
- Arizona Oncology Associates, Tucson, Arizona
| | - Nikhil Thaker
- Arizona Oncology Associates, Tucson, Arizona; Bayta Systems, Tucson, Arizona.
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22
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McGinnis GJ, Holden S, Yu B, Ransom C, Guidarelli C, De B, Diao K, Boyce D, Thomas CR, Winters-Stone K, Raber J. Association of fall rate and functional status by APOE genotype in cancer survivors after exercise intervention. Oncotarget 2022; 13:1259-1270. [PMID: 36441715 DOI: 10.18632/oncotarget.28310] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
PURPOSE/OBJECTIVES Cancer treatment survivors often report impaired functioning and increased falls. Not all survivors experience the same symptom burden, suggesting individual susceptibilities. APOE genotype is a potential genetic risk factor for cancer treatment related side effects. Lifestyle factors such as physical activity can mitigate the effect of APOE genotype on measures of clinical interest in individuals without a history of cancer. We tested the hypothesis that APOE genotype influences cancer treatment related side effects and symptoms as well as response to exercise intervention. MATERIALS AND METHODS Data from a subsample of a study of fall prevention exercise in post-treatment female cancer survivors aged 50-75 years old (https://clinicaltrials.gov NCT01635413) were used to conduct a secondary data analysis. ApoE genotype was determined by serum sampling. Physical functioning, frequency of falls, and symptom burden were assessed using survey instruments. RESULTS Data from 126 female cancer survivors a median of 49 months out from cancer diagnosis were analyzed. ApoE4 carriers trended toward a higher fall rate at baseline (p = 0.059), but after exercise intervention had a fall rate lower than E4 non-carriers both immediately after structured intervention (p = 0.013) and after 6 months of follow up (p = 0.002). E2 carriers did not show improved measures of depressive symptoms and self-report disability after exercise intervention. E3 homozygotes showed increased self report physical activity after the 6 month exercise intervention, but E4 and E2 carriers did not. CONCLUSIONS APOE genotype may modulate cancer treatment related side effects and symptoms and response to exercise intervention.
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Affiliation(s)
- Gwendolyn J McGinnis
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Sarah Holden
- Department of Behavioral Neuroscience, Oregon Health and Science University, Portland, OR 97239, USA
| | - Betty Yu
- Department of Behavioral Neuroscience, Oregon Health and Science University, Portland, OR 97239, USA
| | - Charlton Ransom
- Department of Behavioral Neuroscience, Oregon Health and Science University, Portland, OR 97239, USA
| | - Carolyn Guidarelli
- School of Nursing, Oregon Health and Science University, Portland, OR 97239, USA
| | - Brian De
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Kevin Diao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - David Boyce
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Charles R Thomas
- Department of Radiation Medicine, Oregon Health and Science University, Portland, OR 97239, USA.,Department of Radiation Oncology, Dartmouth-Hitchcock's Dartmouth Cancer Center, Lebanon, NH 03756, USA
| | - Kerri Winters-Stone
- School of Nursing, Oregon Health and Science University, Portland, OR 97239, USA.,Knight Cancer Institute, Oregon Health and Science University, Portland, OR 97239, USA.,Joint last authors
| | - Jacob Raber
- Department of Behavioral Neuroscience, Oregon Health and Science University, Portland, OR 97239, USA.,Department of Radiation Medicine, Oregon Health and Science University, Portland, OR 97239, USA.,Department of Neurology and Division of Neuroscience, ONPRC, Oregon Health and Science University, Portland, OR 97239, USA.,Joint last authors
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23
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McCulloch MM, Cazoulat G, Svensson S, Gryshkevych S, Rigaud B, Anderson BM, Kirimli E, De B, Mathew RT, Zaid M, Elganainy D, Peterson CB, Balter P, Koay EJ, Brock KK. Leveraging deep learning-based segmentation and contours-driven deformable registration for dose accumulation in abdominal structures. Front Oncol 2022; 12:1015608. [PMID: 36408172 PMCID: PMC9666494 DOI: 10.3389/fonc.2022.1015608] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/10/2022] [Indexed: 12/29/2023] Open
Abstract
PURPOSE Discrepancies between planned and delivered dose to GI structures during radiation therapy (RT) of liver cancer may hamper the prediction of treatment outcomes. The purpose of this study is to develop a streamlined workflow for dose accumulation in a treatment planning system (TPS) during liver image-guided RT and to assess its accuracy when using different deformable image registration (DIR) algorithms. MATERIALS AND METHODS Fifty-six patients with primary and metastatic liver cancer treated with external beam radiotherapy guided by daily CT-on-rails (CTOR) were retrospectively analyzed. The liver, stomach and duodenum contours were auto-segmented on all planning CTs and daily CTORs using deep-learning methods. Dose accumulation was performed for each patient using scripting functionalities of the TPS and considering three available DIR algorithms based on: (i) image intensities only; (ii) intensities + contours; (iii) a biomechanical model (contours only). Planned and accumulated doses were converted to equivalent dose in 2Gy (EQD2) and normal tissue complication probabilities (NTCP) were calculated for the stomach and duodenum. Dosimetric indexes for the normal liver, GTV, stomach and duodenum and the NTCP values were exported from the TPS for analysis of the discrepancies between planned and the different accumulated doses. RESULTS Deep learning segmentation of the stomach and duodenum enabled considerable acceleration of the dose accumulation process for the 56 patients. Differences between accumulated and planned doses were analyzed considering the 3 DIR methods. For the normal liver, stomach and duodenum, the distribution of the 56 differences in maximum doses (D2%) presented a significantly higher variance when a contour-driven DIR method was used instead of the intensity only-based method. Comparing the two contour-driven DIR methods, differences in accumulated minimum doses (D98%) in the GTV were >2Gy for 15 (27%) of the patients. Considering accumulated dose instead of planned dose in standard NTCP models of the duodenum demonstrated a high sensitivity of the duodenum toxicity risk to these dose discrepancies, whereas smaller variations were observed for the stomach. CONCLUSION This study demonstrated a successful implementation of an automatic workflow for dose accumulation during liver cancer RT in a commercial TPS. The use of contour-driven DIR methods led to larger discrepancies between planned and accumulated doses in comparison to using an intensity only based DIR method, suggesting a better capability of these approaches in estimating complex deformations of the GI organs.
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Affiliation(s)
- Molly M. McCulloch
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Guillaume Cazoulat
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | | | | | - Bastien Rigaud
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Brian M. Anderson
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Ezgi Kirimli
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Brian De
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Ryan T. Mathew
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Mohamed Zaid
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Dalia Elganainy
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Christine B. Peterson
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Peter Balter
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Eugene J. Koay
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Kristy K. Brock
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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24
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Chamseddine I, Kim Y, De B, Naqa IE, Duda G, Wolfgang J, Pursley J, Paganetti H, Wo J, Hong T, Koay E, Grassberger C. Prediction of Hepatic Toxicity after Radiotherapy Using a Neural Network Including Blood Biomarkers and Liver Dose Distributions. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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25
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Kowalchuk R, Mullikin T, Florez M, De B, Harmsen W, Rose P, Siontis B, Costello B, Morris J, Marion J, Johnson-Tesch B, Lucido J, Olivier K, Owen D, Stish B, Laack N, Park S, Brown P, Ghia A, Merrell K. An Externally Validated RPA-Based Pre-Treatment Decision-Making Tool Identifying Ideal Candidates for Spine SBRT. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.1639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Rooney M, De B, Corrigan K, Smith G, Taniguchi C, Minsky B, Ludmir E, Koay E, Das P, Koong A, Peacock O, Chang G, You Y, Nogueras-Gonzalez G, Holliday E. Patient-Reported Bowel Function and Quality of Life Following Short and Long Course Radiotherapy for Locally Advanced Rectal Cancer. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.1002] [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: 11/28/2022]
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27
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De B, Andres G, Bates C, Staren E, Kutscher E, Brooks D, Buscema J, Gin R, Thaker N. Total Cost of Cancer Care: Evaluating Health System Expenditures through Eight Performance Periods of the Oncology Care Model. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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28
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Sperduto PW, De B, Li J, Carpenter D, Kirkpatrick J, Milligan M, Shih HA, Kutuk T, Kotecha R, Higaki H, Otsuka M, Aoyama H, Bourgoin M, Roberge D, Dajani S, Sachdev S, Gainey J, Buatti JM, Breen W, Brown PD, Ni L, Braunstein S, Gallitto M, Wang TJC, Shanley R, Lou E, Shiao J, Gaspar LE, Tanabe S, Nakano T, An Y, Chiang V, Zeng L, Soliman H, Elhalawani H, Cagney D, Thomas E, Boggs DH, Ahluwalia MS, Mehta MP. Graded Prognostic Assessment (GPA) for Patients With Lung Cancer and Brain Metastases: Initial Report of the Small Cell Lung Cancer GPA and Update of the Non-Small Cell Lung Cancer GPA Including the Effect of Programmed Death Ligand 1 and Other Prognostic Factors. Int J Radiat Oncol Biol Phys 2022; 114:60-74. [PMID: 35331827 PMCID: PMC9378572 DOI: 10.1016/j.ijrobp.2022.03.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/02/2022] [Accepted: 03/14/2022] [Indexed: 11/23/2022]
Abstract
PURPOSE Patients with lung cancer and brain metastases represent a markedly heterogeneous population. Accurate prognosis is essential to optimally individualize care. In prior publications, we described the graded prognostic assessment (GPA), but a GPA for patients with small cell lung cancer (SCLC) has never been reported, and in non-small cell lung cancer (NSCLC), the effect of programmed death ligand 1 (PD-L1) was unknown. The 3-fold purpose of this work is to provide the initial report of an SCLC GPA, to evaluate the effect of PD-L1 on survival in patients with NSCLC, and to update the Lung GPA accordingly. METHODS AND MATERIALS A multivariable analysis of prognostic factors and treatments associated with survival was performed on 4183 patients with lung cancer (3002 adenocarcinoma, 611 nonadenocarcinoma, 570 SCLC) with newly diagnosed brain metastases between January 1, 2015, and December 31, 2020, using a multi-institutional retrospective database. Significant variables were used to update the Lung GPA. RESULTS Overall median survival for lung adenocarcinoma, SCLC, and nonadenocarcinoma was 17, 10, and 8 months, respectively, but varied widely by GPA from 2 to 52 months. In SCLC, the significant prognostic factors were age, performance status, extracranial metastases, and number of brain metastases. In NSCLC, the distribution of molecular markers among patients with lung adenocarcinoma and known primary tumor molecular status revealed alterations/expression in PD-L1 50% to 100%, PD-L1 1% to 49%, epidermal growth factor receptor, and anaplastic lymphoma kinase in 32%, 31%, 30%, and 7%, respectively. Median survival of patients with lung adenocarcinoma and brain metastases with 0, 1% to 49%, and ≥50% PD-L1 expression was 17, 19, and 24 months, respectively (P < .01), confirming PD-L1 is a prognostic factor. Previously identified prognostic factors for NSCLC (epidermal growth factor receptor and anaplastic lymphoma kinase status, performance status, age, number of brain metastases, and extracranial metastases) were reaffirmed. These factors were incorporated into the updated Lung GPA with robust separation between subgroups for all histologies. CONCLUSIONS Survival for patients with lung cancer and brain metastases has improved but varies widely. The initial report of a GPA for SCLC is presented. For patients with NSCLC-adenocarcinoma and brain metastases, PD-L1 is a newly identified significant prognostic factor, and the previously identified factors were reaffirmed. The updated indices establish unique criteria for SCLC, NSCLC-nonadenocarcinoma, and NSCLC-adenocarcinoma (incorporating PD-L1). The updated Lung GPA, available for free at brainmetgpa.com, provides an accurate tool to estimate survival, individualize treatment, and stratify clinical trials.
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Affiliation(s)
| | - Brian De
- MD Anderson Cancer Center, Houston, Texas
| | - Jing Li
- MD Anderson Cancer Center, Houston, Texas
| | | | | | | | - Helen A Shih
- Massachusetts General Hospital, Boston, Massachusetts
| | - Tugce Kutuk
- Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - Rupesh Kotecha
- Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | | | | | - Hidefumi Aoyama
- Hokkaido Cancer Center, Hokkaido, Japan; Hokkaido University, Sapporo, Japan
| | - Malie Bourgoin
- Centre Hospitalier de l' Université de Montreal, Montreal, Quebec, Canada
| | - David Roberge
- Centre Hospitalier de l' Université de Montreal, Montreal, Quebec, Canada
| | | | | | | | | | | | | | - Lisa Ni
- University of California, San Francisco, California
| | | | | | | | | | - Emil Lou
- University of Minnesota, Minneapolis, Minnesota
| | - Jay Shiao
- University of Colorado Denver, Denver, Colorado
| | - Laurie E Gaspar
- University of Colorado Denver, Denver, Colorado; Banner MD Anderson Cancer Center, Loveland, Colorado
| | | | | | - Yi An
- Yale University, New Haven, Connecticut
| | | | - Liang Zeng
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Hany Soliman
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Evan Thomas
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - Minesh P Mehta
- Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
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De B, Tran Cao HS, Vauthey JN, Manzar GS, Corrigan KL, Raghav KP, Lee SS, Tzeng CWD, Minsky BD, Smith GL, Holliday EB, Taniguchi CM, Koong AC, Das P, Javle M, Ludmir EB, Koay EJ. Ablative liver radiotherapy for unresected intrahepatic cholangiocarcinoma: Patterns of care and survival in the United States. Cancer 2022; 128:2529-2539. [PMID: 35417569 PMCID: PMC9177808 DOI: 10.1002/cncr.34223] [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: 01/19/2022] [Revised: 03/01/2022] [Accepted: 03/22/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Single-institution studies have shown the oncologic benefit of ablative liver radiotherapy (A-RT) for patients with unresectable intrahepatic cholangiocarcinoma (ICC). However, adoption of A-RT across the United States and its associated outcomes are unknown. METHODS We queried the National Cancer Data Base for nonsurgically managed patients with ICC diagnosed between 2004 and 2018. Patients were labeled A-RT for receipt of biologically effective doses (BED10 ) ≥ 80.5 Gy and conventional RT (Conv-RT) for lower doses. Associations with A-RT use and overall survival were identified using logistic and Cox regressions, respectively. RESULTS Of 27,571 patients, the most common treatments were chemotherapy without liver RT (45%), no chemotherapy or liver RT (42%), and liver RT ± chemotherapy (13%). Use of liver RT remained constant over time. Of 1112 patients receiving liver RT with known doses, RT was 73% Conv-RT (median BED10 , 53 Gy; median, 20 fractions) and 27% A-RT (median BED10 , 100 Gy; median, 5 fractions). Use of A-RT increased from 5% in 2004 to 48% in 2018 (Ptrend < .001). With a median follow-up of 52.3 months, median survival estimates for Conv-RT and A-RT were 12.8 and 23.7 months (P < .001), respectively. On multivariable analysis, stage III and IV disease correlated with a higher risk of death, whereas chemotherapy and A-RT correlated with a lower risk. CONCLUSIONS Although A-RT has been increasingly used, use of liver RT as a whole in the United States remained constant despite growing evidence supporting its use, suggesting continued unmet need. A-RT is associated with longer survival versus Conv-RT. LAY SUMMARY Bile duct cancer is a rare, deadly disease that often presents at advanced stages. Single-institution retrospective studies have demonstrated that use of high-dose radiotherapy may be associated with longer survival, but larger studies have not been conducted. We used a large, national cancer registry of patients diagnosed between 2004 and 2018 to show that liver radiotherapy use remains low in the United States, despite growing evidence that patients who receive it live longer. Furthermore, we showed that patients who received high-dose radiotherapy lived longer than those who received lower doses. Greater awareness of the benefits of liver radiotherapy is needed to improve patient outcomes.
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Affiliation(s)
- Brian De
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hop S. Tran Cao
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gohar S. Manzar
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kelsey L. Corrigan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kanwal P.S. Raghav
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sunyoung S. Lee
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ching-Wei D. Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bruce D. Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Grace L. Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Emma B. Holliday
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cullen M. Taniguchi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Albert C. Koong
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Milind Javle
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ethan B. Ludmir
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eugene J. Koay
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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De B, Lowenstein LM, Corrigan KL, Andring LM, Kuban DA, Cantor SB, Volk RJ, Hoffman KE. Patients’ Preferences for Androgen Deprivation Therapy in the Treatment of Intermediate-Risk Prostate Cancer. MDM Policy Pract 2022; 7:23814683221137752. [PMID: 36405544 PMCID: PMC9669695 DOI: 10.1177/23814683221137752] [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: 07/18/2022] [Accepted: 10/18/2022] [Indexed: 11/16/2022] Open
Abstract
Background. For men with intermediate-risk prostate cancer (IRPC), adding short-term androgen deprivation therapy (ADT) to external beam radiation therapy (EBRT) has shown efficacy, but men are often reluctant to accept it because of its impact on quality of life. Methods. We conducted time tradeoffs (score of 1 = perfect health and 0 = death) and probability tradeoffs with patients aged 51 to 78 y who had received EBRT for IRPC within the past 2 y. Of 40 patients, 20 had received 6 mo of ADT and 20 had declined. Utility assessments explored 4 ADT-related side effects: hot flashes, fatigue, loss of libido/erectile dysfunction, and weight gain. Results. The most commonly reported “worst” treatment-related complication of ADT was fatigue (50% in both cohorts) followed by reduced libido/erectile dysfunction (40% in both cohorts). The utilities for fatigue were mean = 0.71 and median = 0.92 and for reduced libido/erectile dysfunction were mean = 0.81 and median = 0.92. Utilities did not differ significantly between cohorts. Assuming a 6-mo course of ADT, men reported being willing to trade 3 mo of life expectancy to avoid fatigue due to ADT and 1.8 mo to avoid sexual side effects. Patients in the ADT cohort were willing to accept the side effects of ADT in exchange for a mean 8% absolute increase in survival, whereas patients in the no ADT cohort required a 16% increase ( P < 0.001). Conclusions. When considering treatment with ADT, men with IRPC identified fatigue and sexual dysfunction as the most bothersome side effects. Patients who declined ADT expected a larger survival benefit than those who opted for treatment. Both groups expected a survival benefit exceeding that shown by recent trials, suggesting some men may be selecting treatments inconsistent with their preferences. Highlights This study demonstrates that prostate cancer patients receiving radiation therapy are reluctant to receive androgen deprivation therapy (ADT) most commonly due to anticipated fatigue and loss of libido/erectile dysfunction. Men who had received ADT reported they would require an average 8% absolute increase in survival to tolerate its side effects, whereas those who declined ADT would require an average 16% increase. Required thresholds are well above the estimated absolute survival benefit for ADT demonstrated in recent clinical trials, suggesting an unmet need for improved patient education regarding the risks and benefits of ADT.
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Affiliation(s)
- Brian De
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lisa M. Lowenstein
- Departments of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kelsey L. Corrigan
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lauren M. Andring
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Deborah A. Kuban
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Scott B. Cantor
- Departments of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Robert J. Volk
- Departments of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Karen E. Hoffman
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Jan I, De B, Kwon YS, Freeman R, Larkin K, Subramanian S, Pandu P, Song A, Young M, Sayan M, Ludmir EB, Haffty BG, Mattes MD. Race- and sex-based variation in industry research and general payments to medical oncologists in the United States. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.11050] [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
11050 Background: Industry partnerships offer financial incentives, prestige, and can facilitate career advancement in oncology. However, not all physicians may have equal access to these opportunities. We hypothesized that physicians who are underrepresented in the medical oncology workforce based on race, ethnicity, and gender receive less industry funding. Methods: All US medical oncologists (MOs) who received ≥1 industry research payment between 2016 and 2020 according to the Open Payments database were included in this retrospective study. Information extracted from Open Payments included MO’s name, institution, research payments (i.e. funding for a research project where the physician is a Principle Investigator), and general payments (i.e. fees not associated with research, such as consulting and travel fees). Additional web searches were conducted using institutional websites, NPPES NPI registry, LinkedIn, Doximity, Scopus, and NIH RePORTER to determine each MO’s race, ethnicity, sex, academic rank, degrees, h-index, institutional NIH research funding rank, and individual receipt of NIH funding. Log-linear regression was performed to identify associations of both industry and general payment data. Results: Of 7,542 physicians meeting inclusion criteria, 69% were male, 65% White, 29% Asian, 2% Black, and 4% Hispanic, which is comparable to the American Medical Association Physician Masterfile figures for MO. The median sum research payment and general payment was $134,857 and $11,537 per physician respectively. Significantly higher mean research payments were associated with an MS (+72%; P = 0.003) or PhD degree (+30%; P = 0.009), h-index (+3%; P < 0.001), top 50 institution rank by NIH funding (+44%; P < 0.001), and associate professor rank (+95%; P < 0.001). Significantly lower mean research payment were observed for Black physicians (-36%; P = 0.022) and those with non-academic affiliation (-47%; P < 0.001). No significant association was observed between sex and research payment. Significantly higher mean general payments were associated with male sex (+46%; P < 0.001), MS degree (+171%; P < 0.001), h-index (+2%; P < 0.001), and Asian race (+72%; P < 0.001). Significantly lower mean general payments were associated with an affiliation with a non-academic practice (-31%; P = 0.012). Conclusions: Black physicians received smaller sums of industry research payments compared to White physicians. Female sex was associated with decreased general payments compared to male sex. Further exploring the underlying mechanisms determining access to industry payments may help facilitate greater equity and inclusivity in oncology.
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Affiliation(s)
- Imraan Jan
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Brian De
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Young Suk Kwon
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Robert Freeman
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Kelsey Larkin
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | | | | | - Amy Song
- Rutgers New Jersey Medical School, Newark, NJ
| | | | - Mutlay Sayan
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Ethan B. Ludmir
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Bruce George Haffty
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Malcolm David Mattes
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
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Upadhyay R, Ludmir EB, De B, Holliday E, Smith GL, Taniguchi CM, Das P, Minsky BD, Koong AC, Javle MM, Lee SS, Vauthey JN, Tzeng CWD, Tran Cao H, Koay EJ. Preservation of liver function with local radiation therapy in patients with metastatic intrahepatic cholangiocarcinoma with extrahepatic disease. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.4080] [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
4080 Background: Tumor related liver failure (TRLF) is the most common cause of death in patients with metastatic intrahepatic cholangiocarcinoma (mICC) accounting for up to 72% deaths in patients treated with systemic therapy alone. We present our institutional experience of treating mICC patients with local liver-directed radiation therapy (RT). Methods: ICC patients with extrahepatic metastatic disease who received radiation therapy at our center with a biologically equivalent dose (BED) of at least 50 Gy from January 1, 2011 to March 31, 2021 were included in our study. Patient, tumor and treatment characteristics as well as the survival outcomes were recorded. TRLF was considered the cause of death if the patient died due to liver failure; and freedom from TRLF (FFTRLF) at 1 year and 2 years after RT was calculated. Results: Sixty-seven patients were included in the study. The median age was 63 years (range 29-83 years) and median RT dose was 60 Gy (range, 40-100 Gy). 73.1% patients received a BED > 80.5 Gy. All except 1 patient were treated with upfront induction chemotherapy, followed by RT to the primary lesion in liver with (71.6%) or without (28.4%) concurrent chemotherapy. The most common induction chemotherapy regimen used was gemcitabine and cisplatin (65.7%) followed by gemcitabine, cisplatin and paclitaxel (22.4%), while the most common concurrent systemic therapy was capecitabine. Out of 43 patients with satellitosis, 29 were treated with RT to the dominant liver lesion while 14 received RT to the primary as well as one or more satellites. Overall, 15 patients (22.4%) had local progression of the radiated lesion, 42 patients (62.7%) progressed elsewhere in liver, and 52 patients (77.6%) had a distant progression. TRLF was the cause of death in 28.4% of patients. Median OS from diagnosis was 25 months while median OS after RT was 11.9 months. The 1- and 2-year rates of FFTRLF were 73.1% and 58.2% respectively, which were significantly higher than 1- and 2-year OS after RT (47.1% and 24.7% respectively, p < 0.005). Univariate analysis did not identify significant association of FFTRLF or OS with age, sex, performance status, size of liver lesions, T or N stage, satellitosis, vascular thrombosis, TRLF, timing of metastasis, site of metastasis, RT technique and dose and chemotherapy. Conclusions: Liver directed radiation therapy in patients with mICC with extrahepatic disease appears to have favorable rates of TRLF and survival times, compared to historical data. Future prospective studies are warranted to define the survival benefit in these patients attributable to radiation therapy.
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Affiliation(s)
| | - Ethan B. Ludmir
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Brian De
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Emma Holliday
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Grace L. Smith
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Prajnan Das
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Albert C. Koong
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Sunyoung S. Lee
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | - Hop Tran Cao
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Eugene Jon Koay
- The University of Texas MD Anderson Cancer Center, Houston, TX
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Corrigan KL, Rooney MK, De B, Ludmir ED, Das P, Smith GL, Taniguchi C, Minsky BD, Koay EJ, Koong A, Morris VK, Messick CA, Nogueras-Gonzalez G, Holliday EB. Patient-reported sexual function in long-term survivors of anal cancer treated with definitive intensity-modulated radiotherapy and concurrent chemotherapy. Pract Radiat Oncol 2022; 12:e397-e405. [DOI: 10.1016/j.prro.2022.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 03/15/2022] [Accepted: 05/17/2022] [Indexed: 11/25/2022]
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De B, Fu S, Chen Y, Das P, Ku K, Maroongroge S, Woodhouse KD, Hoffman KE, Nguyen Q, Reed VK, Chen AB, Koong AC, Smith BD, Smith GL. Patient, physician, and policy factors underlying variation in use of telemedicine for radiation oncology cancer care. Cancer Med 2022; 11:2096-2105. [PMID: 35297210 PMCID: PMC9119354 DOI: 10.1002/cam4.4555] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/10/2021] [Accepted: 12/17/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Oncology telemedicine was implemented rapidly after COVID-19. We examined multilevel correlates and outcomes of telemedicine use for patients undergoing radiotherapy (RT) for cancer. METHODS Upon implementation of a telemedicine platform at a comprehensive cancer center, we analyzed 468 consecutive patient RT courses from March 16, 2020 to June 1, 2020. Patients were categorized as using telemedicine during ≥1 weekly oncologist visits versus in-person oncologist management only. Temporal trends were evaluated with Cochran-Armitage tests; chi-squared test and multilevel multivariable logistic models identified correlates of use and outcomes. RESULTS Overall, 33% used telemedicine versus 67% in-person only oncologist management. Temporal trends (ptrend < 0.001) correlated with policy changes: uptake was rapid after local social-distancing restrictions, reaching peak use (35% of visits) within 4 weeks of implementation. Use declined to 15% after national "Opening Up America Again" guidelines. In the multilevel model, patients more likely to use telemedicine were White non-Hispanic versus Black or Hispanic (odds ratio [OR] = 2.20, 95% confidence interval [CI] 1.03-4.72; p = 0.04) or receiving ≥6 fractions of RT versus 1-5 fractions (OR = 4.49, 95% CI 2.29-8.80; p < 0.001). Model intraclass correlation coefficient demonstrated 43% utilization variation was physician-level driven. Treatment toxicities and 30-day emergency visits or unplanned hospitalizations did not differ for patients using versus not using telemedicine (p > 0.05, all comparisons). CONCLUSION Though toxicities were similar with telemedicine oncology management, there remained lower uptake among non-White patients. Continuing strategies for oncology telemedicine implementation should address multilevel patient, physician, and policy factors to optimize telemedicine's potential to surmount-and not exacerbate-barriers to quality cancer care.
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Affiliation(s)
- Brian De
- Department of Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Shuangshuang Fu
- Department of Health Services ResearchThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Ying‐Shiuan Chen
- Department of Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Prajnan Das
- Department of Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Kimberly Ku
- Department of Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Sean Maroongroge
- Department of Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Kristina D. Woodhouse
- Department of Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Karen E. Hoffman
- Department of Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Quynh‐Nhu Nguyen
- Department of Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Valerie K. Reed
- Department of Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Aileen B. Chen
- Department of Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
- Department of Health Services ResearchThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Albert C. Koong
- Department of Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Benjamin D. Smith
- Department of Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
- Department of Health Services ResearchThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Grace L. Smith
- Department of Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
- Department of Health Services ResearchThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
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Corrigan KL, De B, Rooney MK, Ludmir EB, Das P, Smith GL, Taniguchi CM, Minsky BD, Koay EJ, Koong AC, Holliday EB. Patient-Reported Outcomes Following Chemoradiation in Patients with Anal Cancer: A Qualitative Analysis. Adv Radiat Oncol 2022; 7:100986. [PMID: 35662810 PMCID: PMC9157211 DOI: 10.1016/j.adro.2022.100986] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 04/21/2022] [Indexed: 11/29/2022] Open
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Abi Jaoude J, De B, Nieves Jiménez HR, Upadhyay R, Taniguchi CM, Koay EJ, Ludmir EB. “Super massive” intrahepatic cholangiocarcinoma: Potential role of radiation therapy. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.4_suppl.567] [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
567 Background: Intrahepatic cholangiocarcinoma (ICC) is a cancer of the bile ducts within the liver. Most patients have unresectable disease and die of tumor-related liver failure (TRLF); prior data suggest that radiation therapy (RT) may play an important role in decreasing TRLF and improving survival. However, for patients with exceptionally large liver tumors, the role of RT is uncertain. Here, we present our experience using hypofractionated RT for so-called “super-massive” ICC (gross tumor volume > 800cc). Methods: We retrospectively collected data from ICC patients treated at the University of Texas MD Anderson Cancer Center. We included inoperable patients (both M0 and M1) who were treated with RT, identified those with a gross tumor volume of 800cc or more (median: 1,300cc IQR: 900-1,900). We analyzed overall survival (OS), local and distant recurrence, tumor-related liver failure (TRLF), and treatment toxicity. Results: A total of 12 patients were included. The median age was 60 (IQR: 55-67). The average maximal tumor diameter was 14.1cm (IQR: 12.6-15.8). All but 1 patient received pre-RT systemic therapy. Eight patients (67%) were treated with IMRT, and 4 patients (33%) with proton RT. RT was delivered to a median of 67.5Gy (IQR: 60-73.1) over 15 fractions. At a median follow up of 17.4 months, 5 patients were still alive (2-year OS: 41.7%). Median OS, local recurrence, and distant metastasis from RT were 20.0, 20, and 11.3 months, respectively. Two patients (16.7%) died from TRLF. No grade 2 or higher toxicities were noted. No radiation-induced liver toxicity was present. Conclusions: Hypofractionated RT was safe and showed promising clinical outcomes for patients with “super massive” inoperable ICC, compared to historical data. Future studies are still needed to better assess the role of RT in this patient population.
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Affiliation(s)
| | - Brian De
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | - Eugene Jon Koay
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ethan B. Ludmir
- The University of Texas MD Anderson Cancer Center, Houston, TX
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Zucchelli A, Manzoni F, Morandi A, Di Santo S, Rossi E, Valsecchi MG, Inzitari M, Cherubini A, Bo M, Mossello E, Marengoni A, Bellelli G, Tarasconi A, Sella M, Auriemma S, Paternò G, Faggian G, Lucarelli C, De Grazia N, Alberto C, Margola A, Porcella L, Nardiello I, Chimenti E, Zeni M, Giani A, Famularo S, Romairone E, Minaglia C, Ceccotti C, Guerra G, Mantovani G, Monacelli F, Minaglia C, Candiani T, Ballestrero A, Minaglia C, Santolini F, Minaglia C, Rosso M, Bono V, Sibilla S, Dal Santo P, Ceci M, Barone P, Schirinzi T, Formenti A, Nastasi G, Isaia G, Gonella D, Battuello A, Casson S, Calvani D, Boni F, Ciaccio A, Rosa R, Sanna G, Manfredini S, Cortese L, Rizzo M, Prestano R, Greco A, Lauriola M, Gelosa G, Piras V, Arena M, Cosenza D, Bellomo A, LaMontagna M, Gabbani L, Lambertucci L, Perego S, Parati G, Basile G, Gallina V, Pilone G, Giudice C, De F, Pietrogrande L, De B, Mosca M, Corazzin I, Rossi P, Nunziata V, D‘Amico F, Grippa A, Giardini S, Barucci R, Cossu A, Fiorin L, Arena M, Distefano M, Lunardelli M, Brunori M, Ruffini I, Abraham E, Varutti A, Fabbro E, Catalano A, Martino G, Leotta D, Marchet A, Dell‘Aquila G, Scrimieri A, Davoli M, Casella M, Cartei A, Polidori G, Basile G, Brischetto D, Motta S, Saponara R, Perrone P, Russo G, Del D, Car C, Pirina T, Franzoni S, Cotroneo A, Ghiggia F, Volpi G, Menichetti C, Bo M, Panico A, Calogero P, Corvalli G, Mauri M, Lupia E, Manfredini R, Fabbian F, March A, Pedrotti M, Veronesi M, Strocchi E, Bianchetti A, Crucitti A, Di Francesco V, Fontana G, Bonanni L, Barbone F, Serrati C, Ballardini G, Simoncelli M, Ceschia G, Scarpa C, Brugiolo R, Fusco S, Ciarambino T, Biagini C, Tonon E, Porta M, Venuti D, DelSette M, Poeta M, Barbagallo G, Trovato G, Delitala A, Arosio P, Reggiani F, Zuliani G, Ortolani B, Mussio E, Girardi A, Coin A, Ruotolo G, Castagna A, Masina M, Cimino R, Pinciaroli A, Tripodi G, Cannistrà U, Cassadonte F, Vatrano M, Cassandonte F, Scaglione L, Fogliacco P, Muzzuilini C, Romano F, Padovani A, Rozzini L, Cagnin A, Fragiacomo F, Desideri G, Liberatore E, Bruni A, Orsitto G, Franco M, Bonfrate L, Bonetto M, Pizio N, Magnani G, Cecchetti G, Longo A, Bubba V, Marinan L, Cotelli M, Turla M, Brunori M, Sessa M, Abruzzi L, Castoldi G, LoVetere D, Musacchio C, Novello M, Cavarape A, Bini A, Leonardi A, Seneci F, Grimaldi W, Fimognari F, Bambara V, Saitta A, Corica F, Braga M, Ettorre E, Camellini C, Marengoni A, Bruni A, Crescenzo A, Noro G, Turco R, Ponzetto M, Giuseppe L, Mazzei B, Maiuri G, Costaggiu D, Damato R, Fabbro E, Patrizia G, Santuari L, Gallucci M, Minaglia C, Paragona M, Bini P, Modica D, Abati C, Clerici M, Barbera I, NigroImperiale F, Manni A, Votino C, Castiglioni C, Di M, Degl‘Innocenti M, Moscatelli G, Guerini S, Casini C, Dini D, DeNotariis S, Bonometti F, Paolillo C, Riccardi A, Tiozzo A, SamySalamaFahmy A, Riccardi A, Paolillo C, DiBari M, Vanni S, Scarpa A, Zara D, Ranieri P, Calogero P, Corvalli G, Pezzoni D, Gentile S, Morandi A, Platto C, D‘Ambrosio V, Faraci B, Ivaldi C, Milia P, DeSalvo F, Solaro C, Strazzacappa M, Bo M, Panico A, Cazzadori M, Confente S, Bonetto M, Magnani G, Cecchetti G, Guerini V, Bernardini B, Corsini C, Boffelli S, Filippi A, Delpin K, Bertoletti E, Vannucci M, Tesi F, Crippa P, Malighetti A, Caltagirone C, DiSant S, Bettini D, Maltese F, Formilan M, Abruzzese G, Minaglia C, Cosimo D, Azzini M, Cazzadori M, Colombo M, Procino G, Fascendini S, Barocco F, Del P, D‘Amico F, Grippa A, Mazzone A, Riva E, Dell‘Acqua D, Cottino M, Vezzadini G, Avanzi S, Orini S, Sgrilli F, Mello A, Lombardi L, Muti E, Dijk B, Fenu S, Pes C, Gareri P, Castagna A, Passamonte M, De F, Rigo R, Locusta L, Caser L, Rosso G, Cesarini S, Cozzi R, Santini C, Carbone P, Cazzaniga I, Lovati R, Cantoni A, Ranzani P, Barra D, Pompilio G, Dimori S, Cernesi S, Riccò C, Piazzolla F, Capittini E, Rota C, Gottardi F, Merla L, Barelli A, Millul A, De G, Morrone G, Bigolari M, Minaglia C, Macchi M, Zambon F, D‘Amico F, D‘Amico F, Pizzorni C, DiCasaleto G, Menculini G, Marcacci M, Catanese G, Sprini D, DiCasalet T, Bocci M, Borga S, Caironi P, Cat C, Cingolani E, Avalli L, Greco G, Citerio G, Gandini L, Cornara G, Lerda R, Brazzi L, Simeone F, Caciorgna M, Alampi D, Francesconi S, Beck E, Antonini B, Vettoretto K, Meggiolaro M, Garofalo E, Bruni A, Notaro S, Varutti R, Bassi F, Mistraletti G, Marino A, Rona R, Rondelli E, Riva I, Scapigliati A, Cortegiani A, Vitale F, Pistidda L, D‘Andrea R, Querci L, Gnesin P, Todeschini M, Lugano M, Castelli G, Ortolani M, Cotoia A, Maggiore S, DiTizio L, Graziani R, Testa I, Ferretti E, Castioni C, Lombardi F, Caserta R, Pasqua M, Simoncini S, Baccarini F, Rispoli M, Grossi F, Cancelliere L, Carnelli M, Puccini F, Biancofiore G, Siniscalchi A, Laici C, Mossello E, Torrini M, Pasetti G, Palmese S, Oggioni R, Mangani V, Pini S, Martelli M, Rigo E, Zuccalà F, Cherri A, Spina R, Calamai I, Petrucci N, Caicedo A, Ferri F, Gritti P, Brienza N, Fonnesu R, Dessena M, Fullin G, Saggioro D. The association between low skeletal muscle mass and delirium: results from the nationwide multi-centre Italian Delirium Day 2017. Aging Clin Exp Res 2022; 34:349-357. [PMID: 34417734 PMCID: PMC8847195 DOI: 10.1007/s40520-021-01950-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 07/31/2021] [Indexed: 01/22/2023]
Abstract
Introduction Delirium and sarcopenia are common, although underdiagnosed, geriatric
syndromes. Several pathological mechanisms can link delirium and low skeletal muscle mass, but few studies have investigated their association. We aimed to investigate (1) the association between delirium and low skeletal muscle mass and (2) the possible role of calf circumference mass in finding cases with delirium. Methods The analyses were conducted employing the cross-sectional “Delirium Day” initiative, on patient 65 years and older admitted to acute hospital medical wards, emergency departments, rehabilitation wards, nursing homes and hospices in Italy in 2017. Delirium was diagnosed as a 4 + score at the 4-AT scale. Low skeletal muscle mass was operationally defined as calf circumference ≤ 34 cm in males and ≤ 33 cm in females. Logistic regression models were used to investigate the association between low skeletal muscle mass and delirium. The discriminative ability of calf circumference was evaluated using non-parametric ROC analyses. Results A sample of 1675 patients was analyzed. In total, 73.6% of participants had low skeletal muscle mass and 24.1% exhibited delirium. Low skeletal muscle mass and delirium showed an independent association (OR: 1.50; 95% CI 1.09–2.08). In the subsample of patients without a diagnosis of dementia, the inclusion of calf circumference in a model based on age and sex significantly improved its discriminative accuracy [area under the curve (AUC) 0.69 vs 0.57, p < 0.001]. Discussion and conclusion Low muscle mass is independently associated with delirium. In patients without a previous diagnosis of dementia, calf circumference may help to better identify those who develop delirium. Supplementary Information The online version contains supplementary material available at 10.1007/s40520-021-01950-8.
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Chamseddine I, Kim Y, De B, El Naqa I, Duda DG, Wolfgang J, Pursley J, Paganetti H, Wo J, Hong T, Koay EJ, Grassberger C. Predictive Modeling of Survival and Toxicity in Patients With Hepatocellular Carcinoma After Radiotherapy. JCO Clin Cancer Inform 2022; 6:e2100169. [PMID: 35192402 PMCID: PMC8863122 DOI: 10.1200/cci.21.00169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 12/20/2021] [Accepted: 01/06/2022] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To stratify patients and aid clinical decision making, we developed machine learning models to predict treatment failure and radiation-induced toxicities after radiotherapy (RT) in patients with hepatocellular carcinoma across institutions. MATERIALS AND METHODS The models were developed using linear and nonlinear algorithms, predicting survival, nonlocal failure, radiation-induced liver disease, and lymphopenia from baseline patient and treatment parameters. The models were trained on 207 patients from Massachusetts General Hospital. Performance was quantified using Harrell's c-index, area under the curve (AUC), and accuracy in high-risk populations. Models' structures were optimized in a nested cross-validation approach to prevent overfitting. A study analysis plan was registered before external validation using 143 patients from MD Anderson Cancer Center. Clinical utility was assessed using net-benefit analysis. RESULTS The survival model stratified high-risk versus low-risk patients well in the external validation cohort (c-index = 0.75), better than existing risk scores. Predictions of 1-year survival and nonlocal failure were excellent (external AUC = 0.74 and 0.80, respectively), especially in the high-risk group (accuracy > 90%). Cause-of-death analysis showed differential modes of treatment failure in these cohorts and indicated that these models could be used to stratify RT patients for liver-sparing treatment regimen or combination approaches with systemic agents. Predictions of liver disease and lymphopenia were good but less robust (external AUC = 0.68 and 0.7, respectively), suggesting the need for more comprehensive consideration of dosimetry and better predictive biomarkers. The liver disease model showed excellent accuracy in the high-risk group (92%) and revealed possible interactions of platelet count with initial liver function. CONCLUSION Machine learning approaches can provide reliable outcome predictions in patients with hepatocellular carcinoma after RT in diverse cohorts across institutions. The excellent performance, particularly in high-risk patients, suggests novel strategies for patient stratification and treatment selection.
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Affiliation(s)
- Ibrahim Chamseddine
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Yejin Kim
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Korean Advanced Institute of Science and Technology, Daejeon, South Korea
| | - Brian De
- Department of Radiation Oncology, University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Issam El Naqa
- Department of Machine Learning, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Dan G. Duda
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - John Wolfgang
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jennifer Pursley
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Harald Paganetti
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jennifer Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Theodore Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Eugene J. Koay
- Department of Radiation Oncology, University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Clemens Grassberger
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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De B, Abu-Gheida I, Patel A, Ng SSW, Zaid M, Thunshelle CP, Elganainy D, Corrigan KL, Rooney MK, Javle M, Raghav K, Lee SS, Vauthey JN, Tzeng CWD, Tran Cao HS, Ludmir EB, Minsky BD, Smith GL, Holliday EB, Taniguchi CM, Koong AC, Das P, Koay EJ. Benchmarking Outcomes after Ablative Radiotherapy for Molecularly Characterized Intrahepatic Cholangiocarcinoma. J Pers Med 2021; 11:1270. [PMID: 34945742 PMCID: PMC8703854 DOI: 10.3390/jpm11121270] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 11/25/2021] [Accepted: 11/26/2021] [Indexed: 02/06/2023] Open
Abstract
We have previously shown that ablative radiotherapy (A-RT) with a biologically effective dose (BED10) ≥ 80.5 Gy for patients with unresectable intrahepatic cholangiocarcinoma (ICC) is associated with longer survival. Despite recent large-scale sequencing efforts in ICC, outcomes following RT based on genetic alterations have not been described. We reviewed records of 156 consecutive patients treated with A-RT for unresectable ICC from 2008 to 2020. For 114 patients (73%), next-generation sequencing provided molecular profiles. The overall survival (OS), local control (LC), and distant metastasis-free survival (DMFS) were estimated using the Kaplan-Meier method. Univariate and multivariable Cox analyses were used to determine the associations with the outcomes. The median tumor size was 7.3 (range: 2.2-18.2) cm. The portal vein thrombus (PVT) was present in 10%. The RT median BED10 was 98 Gy (range: 81-144 Gy). The median (95% confidence interval) follow-up was 58 (42-104) months from diagnosis and 39 (33-74) months from RT. The median OS was 32 (29-35) months after diagnosis and 20 (16-24) months after RT. The one-year OS, LC, and intrahepatic DMFS were 73% (65-80%), 81% (73-87%), and 34% (26-42%). The most common mutations were in IDH1 (25%), TP53 (22%), ARID1A (19%), and FGFR2 (13%). Upon multivariable analysis, the factors associated with death included worse performance status, larger tumor, metastatic disease, higher CA 19-9, PVT, satellitosis, and IDH1 and PIK3CA mutations. TP53 mutation was associated with local failure. Further investigation into the prognostic value of individual mutations and combinations thereof is warranted.
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Affiliation(s)
- Brian De
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (I.A.-G.); (A.P.); (S.S.W.N.); (M.Z.); (C.P.T.); (D.E.); (K.L.C.); (M.K.R.); (E.B.L.); (B.D.M.); (G.L.S.); (E.B.H.); (C.M.T.); (A.C.K.); (P.D.)
| | - Ibrahim Abu-Gheida
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (I.A.-G.); (A.P.); (S.S.W.N.); (M.Z.); (C.P.T.); (D.E.); (K.L.C.); (M.K.R.); (E.B.L.); (B.D.M.); (G.L.S.); (E.B.H.); (C.M.T.); (A.C.K.); (P.D.)
| | - Aashini Patel
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (I.A.-G.); (A.P.); (S.S.W.N.); (M.Z.); (C.P.T.); (D.E.); (K.L.C.); (M.K.R.); (E.B.L.); (B.D.M.); (G.L.S.); (E.B.H.); (C.M.T.); (A.C.K.); (P.D.)
| | - Sylvia S. W. Ng
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (I.A.-G.); (A.P.); (S.S.W.N.); (M.Z.); (C.P.T.); (D.E.); (K.L.C.); (M.K.R.); (E.B.L.); (B.D.M.); (G.L.S.); (E.B.H.); (C.M.T.); (A.C.K.); (P.D.)
| | - Mohamed Zaid
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (I.A.-G.); (A.P.); (S.S.W.N.); (M.Z.); (C.P.T.); (D.E.); (K.L.C.); (M.K.R.); (E.B.L.); (B.D.M.); (G.L.S.); (E.B.H.); (C.M.T.); (A.C.K.); (P.D.)
| | - Connor P. Thunshelle
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (I.A.-G.); (A.P.); (S.S.W.N.); (M.Z.); (C.P.T.); (D.E.); (K.L.C.); (M.K.R.); (E.B.L.); (B.D.M.); (G.L.S.); (E.B.H.); (C.M.T.); (A.C.K.); (P.D.)
| | - Dalia Elganainy
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (I.A.-G.); (A.P.); (S.S.W.N.); (M.Z.); (C.P.T.); (D.E.); (K.L.C.); (M.K.R.); (E.B.L.); (B.D.M.); (G.L.S.); (E.B.H.); (C.M.T.); (A.C.K.); (P.D.)
| | - Kelsey L. Corrigan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (I.A.-G.); (A.P.); (S.S.W.N.); (M.Z.); (C.P.T.); (D.E.); (K.L.C.); (M.K.R.); (E.B.L.); (B.D.M.); (G.L.S.); (E.B.H.); (C.M.T.); (A.C.K.); (P.D.)
| | - Michael K. Rooney
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (I.A.-G.); (A.P.); (S.S.W.N.); (M.Z.); (C.P.T.); (D.E.); (K.L.C.); (M.K.R.); (E.B.L.); (B.D.M.); (G.L.S.); (E.B.H.); (C.M.T.); (A.C.K.); (P.D.)
| | - Milind Javle
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (M.J.); (K.R.); (S.S.L.)
| | - Kanwal Raghav
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (M.J.); (K.R.); (S.S.L.)
| | - Sunyoung S. Lee
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (M.J.); (K.R.); (S.S.L.)
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (J.-N.V.); (C.-W.D.T.); (H.S.T.C.)
| | - Ching-Wei D. Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (J.-N.V.); (C.-W.D.T.); (H.S.T.C.)
| | - Hop S. Tran Cao
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (J.-N.V.); (C.-W.D.T.); (H.S.T.C.)
| | - Ethan B. Ludmir
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (I.A.-G.); (A.P.); (S.S.W.N.); (M.Z.); (C.P.T.); (D.E.); (K.L.C.); (M.K.R.); (E.B.L.); (B.D.M.); (G.L.S.); (E.B.H.); (C.M.T.); (A.C.K.); (P.D.)
| | - Bruce D. Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (I.A.-G.); (A.P.); (S.S.W.N.); (M.Z.); (C.P.T.); (D.E.); (K.L.C.); (M.K.R.); (E.B.L.); (B.D.M.); (G.L.S.); (E.B.H.); (C.M.T.); (A.C.K.); (P.D.)
| | - Grace L. Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (I.A.-G.); (A.P.); (S.S.W.N.); (M.Z.); (C.P.T.); (D.E.); (K.L.C.); (M.K.R.); (E.B.L.); (B.D.M.); (G.L.S.); (E.B.H.); (C.M.T.); (A.C.K.); (P.D.)
| | - Emma B. Holliday
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (I.A.-G.); (A.P.); (S.S.W.N.); (M.Z.); (C.P.T.); (D.E.); (K.L.C.); (M.K.R.); (E.B.L.); (B.D.M.); (G.L.S.); (E.B.H.); (C.M.T.); (A.C.K.); (P.D.)
| | - Cullen M. Taniguchi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (I.A.-G.); (A.P.); (S.S.W.N.); (M.Z.); (C.P.T.); (D.E.); (K.L.C.); (M.K.R.); (E.B.L.); (B.D.M.); (G.L.S.); (E.B.H.); (C.M.T.); (A.C.K.); (P.D.)
| | - Albert C. Koong
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (I.A.-G.); (A.P.); (S.S.W.N.); (M.Z.); (C.P.T.); (D.E.); (K.L.C.); (M.K.R.); (E.B.L.); (B.D.M.); (G.L.S.); (E.B.H.); (C.M.T.); (A.C.K.); (P.D.)
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (I.A.-G.); (A.P.); (S.S.W.N.); (M.Z.); (C.P.T.); (D.E.); (K.L.C.); (M.K.R.); (E.B.L.); (B.D.M.); (G.L.S.); (E.B.H.); (C.M.T.); (A.C.K.); (P.D.)
| | - Eugene J. Koay
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (I.A.-G.); (A.P.); (S.S.W.N.); (M.Z.); (C.P.T.); (D.E.); (K.L.C.); (M.K.R.); (E.B.L.); (B.D.M.); (G.L.S.); (E.B.H.); (C.M.T.); (A.C.K.); (P.D.)
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De B, Ludmir EB, Messick CA, Cagley MC, Morris VK, Das P, Minsky BD, Taniguchi CM, Smith GL, Koay EJ, Koong AC, Mohan R, Holliday EB. Prognostic impact of lymphopenia and neutrophil-lymphocyte ratio for patients with anal squamous cell carcinoma. J Gastrointest Oncol 2021; 12:2412-2422. [PMID: 34790402 DOI: 10.21037/jgo-21-323] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 08/23/2021] [Indexed: 12/31/2022] Open
Abstract
Background Outcomes after definitive chemoradiation for squamous cell carcinoma are generally favorable. However, biomarkers to further yield prognostic information are desired. Treatment-related lymphopenia as well as an elevated baseline neutrophil-lymphocyte ratio have been associated with worse survival in several cancer types. We evaluated absolute lymphocyte count and neutrophil-lymphocyte ratio at baseline and at treatment-related nadir in patients with anal cancer for associations with oncologic endpoints. Methods We conducted a retrospective analysis of 428 consecutive patients with non-metastatic anal cancer treated with definitive, intensity-modulated radiation therapy-based chemoradiation. We analyzed absolute neutrophil and lymphocyte counts at several timepoints: pretreatment, weekly during treatment, and in the six weeks following treatment completion. Neutrophil-lymphocyte ratio was calculated at baseline and treatment-related nadir. We estimated oncologic endpoints using life tables and compared them using the log-rank test. We conducted univariate and multivariable time-to-event analyses using Cox proportional hazards. Results Median absolute lymphocyte count at baseline and nadir were 1.80 [interquartile range (IQR), 1.45-2.32] k/µL and 0.26 (IQR, 0.18-0.36) k/µL, respectively, and 31% developed treatment-related grade 4 lymphopenia. Median neutrophil-lymphocyte ratio at baseline and nadir were 2.34 (IQR, 1.68-3.30) and 8.80 (IQR, 5.86-12.68), respectively. Estimates of overall survival, local failure-free survival, distant metastasis-free survival (DMFS), and freedom from colostomy at 5 years were 87%, 86%, 82%, and 88%, respectively. Baseline and nadir absolute lymphocyte count were not associated with selected outcomes on univariate analysis. On multivariable analysis, factors independently associated with death included T3-T4 disease, HIV-positive status, treatment break, and baseline neutrophil-lymphocyte ratio >3. Baseline neutrophil-lymphocyte ratio showed a trend toward association with distant progression or death (P=0.07). The 5-year overall survival estimates for patients with baseline neutrophil-lymphocyte ratios ≤3 and >3 were 92.3% and 80.6%, respectively. Conclusions Lymphopenia during and after chemoradiation for anal cancer is common but does not appear to be associated with worse survival, recurrence, or metastases. However, elevated baseline neutrophil-lymphocyte ratio was independently associated with overall survival, local recurrence-free survival, and DMFS. Further studies are needed to determine the clinical utility of baseline neutrophil-lymphocyte ratio to guide treatment and follow-up.
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Affiliation(s)
- Brian De
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ethan B Ludmir
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Craig A Messick
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew C Cagley
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Van K Morris
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bruce D Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cullen M Taniguchi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Grace L Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eugene J Koay
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Albert C Koong
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Radhe Mohan
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Emma B Holliday
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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De B, Corrigan K, Das P, Taniguchi C, Smith G, Minsky B, Koong A, Koay E, Ludmir E, Messick C, You Y, Chang G, Westney O, Morris V, Holliday E. Long-Term Patient-Reported Quality of Life and Functional Outcomes After Chemoradiation Using Intensity Modulated Radiotherapy for Anal Cancer. Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.110] [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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Chamseddine I, Kim Y, De B, Naqa IE, Wolfgang J, Pursley J, Paganetti H, Wo J, Hong T, Koay E, Grassberger C. Prediction of Outcomes after Radiotherapy for Hepatocellular Carcinoma Independently Validated Using Multi-Institutional Data. Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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De B, Kuban DA, Tang C. Multidisciplinary clinics in prostate cancer. Oncotarget 2021; 12:1553-1554. [PMID: 34316333 PMCID: PMC8310670 DOI: 10.18632/oncotarget.27984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Indexed: 11/25/2022] Open
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De B, Venkatesan AM, Msaouel P, Ghia AJ, Li J, Yeboa DN, Nguyen QN, Bishop AJ, Jonasch E, Shah AY, Campbell MT, Wang J, Zurita-Saavedra AJ, Karam JA, Wood CG, Matin SF, Tannir NM, Tang C. Definitive radiotherapy for extracranial oligoprogressive metastatic renal cell carcinoma as a strategy to defer systemic therapy escalation. BJU Int 2021; 129:610-620. [PMID: 34228889 PMCID: PMC10097479 DOI: 10.1111/bju.15541] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [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: 02/10/2021] [Revised: 06/10/2021] [Accepted: 07/01/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To study whether delivering definitive radiotherapy (RT) to sites of oligoprogression in metastatic renal cell carcinoma (mRCC) enabled deferral of systemic therapy (ST) changes without compromising disease control or survival. PATIENTS AND METHODS We identified patients with mRCC who received RT to three or fewer sites of extracranial progressive disease between 2014 and 2019 at a large tertiary cancer centre. Inclusion criteria were: (1) controlled disease for ≥3 months before oligoprogression, (2) all oligoprogression sites treated with a biologically effective dose of ≥100 Gy, and (3) availability of follow-up imaging. Time-to-event end-points were calculated from the start of RT. RESULTS A total of 72 patients were identified (median follow-up 22 months, 95% confidence interval [CI] 19-32 months), with oligoprogressive lesions in lung/mediastinum (n = 35), spine (n = 30), and non-spine bone (n = 5). The most common systemic therapies before oligoprogression were none (n = 33), tyrosine kinase inhibitor (n = 23), and immunotherapy (n = 13). At 1 year, the local control rate was 96% (95% CI 87-99%); progression-free survival (PFS), 52% (95% CI 40-63%); and overall survival, 91% (95% CI 82-96%). At oligoprogression, ST was escalated (n = 16), maintained (n = 49), or discontinued (n = 7), with corresponding median (95% CI) PFS intervals of 19.7 (8.2-27.2) months, 10.1 (6.9-13.2) months, and 9.8 (2.4-28.9) months, respectively. Of the 49 patients maintained on the same ST at oligoprogression, 21 did not subsequently have ST escalation. CONCLUSION Patients with oligoprogressive mRCC treated with RT had comparable PFS regardless of ST strategy, suggesting that RT may be a viable approach for delaying ST escalation. Randomised controlled trials comparing treatment of oligoprogression with RT vs ST alone are needed.
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Affiliation(s)
- Brian De
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Aradhana M Venkatesan
- Department of Abdominal Imaging, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pavlos Msaouel
- Department of Genitourinary Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Translational Molecular Pathology, Division of Pathology and Laboratory Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amol J Ghia
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jing Li
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Debra N Yeboa
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Quynh-Nhu Nguyen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew J Bishop
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eric Jonasch
- Department of Genitourinary Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amishi Y Shah
- Department of Genitourinary Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew T Campbell
- Department of Genitourinary Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jennifer Wang
- Department of Genitourinary Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amado J Zurita-Saavedra
- Department of Genitourinary Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jose A Karam
- Department of Translational Molecular Pathology, Division of Pathology and Laboratory Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Urology, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christopher G Wood
- Department of Urology, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Surena F Matin
- Department of Urology, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nizar M Tannir
- Department of Genitourinary Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Chad Tang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Yeboa DN, Akinfenwa CA, Nguyen J, Amaya D, de Gracia B, Ning M, Cox V, De B, Smith BD, Lin L, Beddar S, Hoang H, Koong A, Liao Z. Effectively Conducting Oncology Clinical Trials During the COVID-19 Pandemic. Adv Radiat Oncol 2021; 6:100676. [PMID: 33686374 PMCID: PMC7927592 DOI: 10.1016/j.adro.2021.100676] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 02/11/2021] [Indexed: 12/28/2022] Open
Abstract
Purpose Clinical trial enrollment has declined globally as a result of the coronavirus disease 2019 (COVID-19) pandemic. This underscores the importance of structured methods to continue critical medical research safely and efficiently. Methods and Materials We report the effect of a phased trial reopening strategy, remote research staffing, and telemedicine on cancer trial enrollment at one of the largest radiation oncology academic cancer centers. In phase 1, trials investigating definitive therapeutic benefit were opened, followed by trials not increasing patient exposure or pulmonary toxicity risk in phase 2. During phase 2.5, multicenter trials reopened and limited research staff were allowed on site. Results Despite initial enrollment declines during the early pandemic, the percentage of new patients enrolling in clinical trials from March to August 2020 was 8.8%, and represented a 10.5% relative increase from 2019. Monthly accrual enrollment from March to August 2019 ranged from 42 to 71, compared with enrollment during COVID-19 from 23 to 73 patients (P < .001). Conclusions Through a phased approach to trial reopening and adaptive techniques, the division of radiation oncology maintained cancer trial accrual during the COVID-19 pandemic. The experience may help centers maintain accrual, preserve clinical trial integrity, and minimize risk to patients and staff.
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Affiliation(s)
- Debra Nana Yeboa
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Jonathan Nguyen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Diana Amaya
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Beth de Gracia
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matthew Ning
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Victoria Cox
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Brian De
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Benjamin D Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lili Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sam Beddar
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hanh Hoang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Albert Koong
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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De B, Ng SP, Liu AY, Avila S, Tao R, Holliday EB, Brownlee Z, Kaseb A, Lee S, Raghav K, Vauthey JN, Minsky BD, Herman JM, Das P, Smith GL, Taniguchi CM, Krishnan S, Crane CH, Grassberger C, Hong TS, Lin SH, Koong AC, Mohan R, Koay EJ. Radiation-Associated Lymphopenia and Outcomes of Patients with Unresectable Hepatocellular Carcinoma Treated with Radiotherapy. J Hepatocell Carcinoma 2021; 8:57-69. [PMID: 33688489 PMCID: PMC7937383 DOI: 10.2147/jhc.s282062] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 02/11/2021] [Indexed: 12/14/2022] Open
Abstract
Background The immune system plays a crucial role in cancer surveillance. Previous studies have shown that lymphopenia associated with radiotherapy (RT) portends a poor prognosis. We sought to differentiate the effects of proton and photon RT on changes in absolute lymphocyte count (ALC) for patients with hepatocellular carcinoma (HCC). Patients and Methods Patients with HCC treated with definitive RT from 2006 to 2016 were studied. Serial ALCs were graded according to CTCAE v4.0. Overall survival (OS), disease-free survival, and distant metastasis-free survival were analyzed using the Kaplan-Meier method. Univariable and multivariable Cox-proportional hazards analyses were used to identify predictors of OS. A cohort analysis matched for treatment volume was performed to investigate differences in ALC dynamics between photon and proton therapy. Results Of 143 patients identified, the median age was 66 (range, 19-90) years. The treatment modality was photon in 103 (72%) and proton in 40 (28%). Median follow-up was 17 months (95% confidence interval, 13-25 months). The median time to ALC nadir after initiation of RT was 17 days with a median relative decrease of 67%. Those who received proton RT had a higher median ALC nadir (0.41 vs 0.32 k/µL, p=0.002) and longer median OS (33 vs 13 months, p=0.002) than those who received photon RT. Matched cohort analyses revealed a larger low-dose liver volume in the photon group, which correlated with lower ALC. On multivariable Cox analysis, Grade 3 or higher lymphopenia prior to or after RT, portal venous tumor thrombus, larger planning target volumes, Child-Pugh (CP) Class B, and increased CP score after RT were associated with a higher risk of death, whereas the use of proton therapy was associated with lower risk. Conclusion Grade 3 or higher lymphopenia may be associated with poorer outcomes in patients receiving RT for HCC. Protons may mitigate lymphopenia compared with photons, potentially due to reduced dose exposure of sites of lymphopoiesis.
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Affiliation(s)
- Brian De
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sweet Ping Ng
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Radiation Oncology, Austin Health, Melbourne, Victoria, Australia
| | - Amy Y Liu
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Santiago Avila
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Randa Tao
- Department of Radiation Oncology, University of Utah, Huntsman Cancer Institute, Salt Lake City, UT, USA
| | - Emma B Holliday
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zachary Brownlee
- Department of Radiation Oncology, Tufts Medical Center, Boston, MA, USA
| | - Ahmed Kaseb
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sunyoung Lee
- Department of Radiation Oncology, University of Utah, Huntsman Cancer Institute, Salt Lake City, UT, USA
| | - Kanwal Raghav
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bruce D Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph M Herman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Grace L Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cullen M Taniguchi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sunil Krishnan
- Department of Radiation Oncology, Mayo Clinic Jacksonville, Jacksonville, FL, USA
| | - Christopher H Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Clemens Grassberger
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Steven H Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Albert C Koong
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Radhe Mohan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eugene J Koay
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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De B, Kaiser KW, Ludmir EB, Yeboa DN, Tang C, Hoffman KE, Liao Z, Koong AC, Smith BD. Radiotherapy clinical trial enrollment during the COVID-19 pandemic. Acta Oncol 2021; 60:312-315. [PMID: 33356801 DOI: 10.1080/0284186x.2020.1865564] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Brian De
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kelsey W. Kaiser
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ethan B. Ludmir
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Debra N. Yeboa
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Chad Tang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Karen E. Hoffman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Albert C. Koong
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Benjamin D. Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Boyce-Fappiano D, Nguyen QN, Chapman BV, Allen PK, Gjyshi O, Pezzi TA, De B, Gomez D, Lin SH, Chang JY, Liao Z, Lee P, Gandhi SJ. Single Institution Experience of Proton and Photon-based Postoperative Radiation Therapy for Non-small-cell Lung Cancer. Clin Lung Cancer 2021; 22:e745-e755. [PMID: 33707003 DOI: 10.1016/j.cllc.2021.02.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [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: 11/05/2020] [Revised: 01/20/2021] [Accepted: 02/01/2021] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Postoperative radiation therapy (PORT) for non-small-cell lung cancer remains controversial with studies showing no overall survival (OS) benefit in the setting of excessive cardiopulmonary toxicity. Proton beam therapy (PBT) can potentially reduce toxicity with improved organ-at-risk sparing. We evaluated outcomes of PORT patients treated with PBT and intensity-modulated radiation therapy (IMRT). MATERIALS AND METHODS This is a retrospective review of 136 PORT patients (61 PBT, 75 IMRT) treated from 2003 to 2016. A Kaplan-Meier analysis was performed to assess oncologic outcomes. A Cox regression was conducted to identify associated factors. Total toxicity burden (TTB) was defined as grade ≥ 2 pneumonitis, cardiac, or esophageal toxicity. RESULTS Median OS was 76 and 46 months for PBT and IMRT with corresponding 1- and 5-year OS of 85.3%, 50.9% and 89.3%, 37.2% (P = .38), respectively. V30 Gy heart (odds ratio [OR], 144.9; 95% confidence interval [CI], 2.91-7214; P = .013) and V5 Gy lung (OR, 15.8; 95% CI, 1.22-202.7; P = .03) were predictive of OS. Organ-at-risk sparing was improved with PBT versus IMRT; mean heart 2.0 versus 7.4 Gy (P < .01), V30 Gy heart 2.6% versus 10.7% (P < .01), mean lung 7.9 versus 10.4 Gy (P = .042), V5 Gy lung 23.4% versus 42.1% (P < .01), and V10 Gy lung 20.4% versus 29.6% (P < .01). TTB was reduced with PBT (OR, 0.35; 95% CI, 0.15-0.83; P = .017). Rates of cardiac toxicity were 14.7% IMRT and 4.9% PBT (P = .09). Rates of ≥ grade 2 pneumonitis were 17.0% IMRT and 4.9% PBT (P = .104). CONCLUSION PBT improved cardiac and lung sparing and reduced toxicity compared with IMRT. Considering the impact of cardiopulmonary toxicity on PORT outcomes, PBT warrants prospective evaluation.
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Affiliation(s)
- David Boyce-Fappiano
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Quynh-Nhu Nguyen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Bhavana V Chapman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Pamela K Allen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Olsi Gjyshi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Todd A Pezzi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Brian De
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Daniel Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Steven H Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Joe Y Chang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Percy Lee
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Saumil J Gandhi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
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De B, Venkatesan A, Msaouel P, Ghia A, Li J, Yeboa D, Nguyen Q, Bishop A, Jonasch E, Shah A, Campbell M, Wang J, Zurita-Saavedra A, Karam J, Wood C, Matin S, Tannir N, Tang C. Definitive Radiotherapy for Oligoprogressive Metastatic Renal Cell Carcinoma as a Strategy to Defer Systemic Therapy Escalation. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.450] [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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50
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Brooks E, Zhang X, De B, Chang J. Dose-Toxicity Relationship Algorithm for Reirradiation: A Novel Tool for ‘How to Treat in a ‘No-Treatment’ Zone’. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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