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Iocolano M, Yegya-Raman N, Friedes C, Wang X, Kegelman T, Lee SH, Duan L, Li B, Levin WP, Cengel KA, Konski A, Langer CJ, Cohen RB, Sun L, Aggarwal C, Doucette A, Xiao Y, Kevin Teo BK, O'Reilly S, Zou W, Bradley JD, Simone CB, Feigenberg SJ. Acute hospitalizations after proton therapy versus intensity-modulated radiotherapy for locally advanced non-small cell lung cancer in the durvalumab era. Cancer 2024; 130:2031-2041. [PMID: 38294959 DOI: 10.1002/cncr.35230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 11/25/2023] [Accepted: 12/05/2023] [Indexed: 02/02/2024]
Abstract
INTRODUCTION It was hypothesized that use of proton beam therapy (PBT) in patients with locally advanced non-small cell lung cancer treated with concurrent chemoradiation and consolidative immune checkpoint inhibition is associated with fewer unplanned hospitalizations compared with intensity-modulated radiotherapy (IMRT). METHODS Patients with locally advanced non-small cell lung cancer treated between October 2017 and December 2021 with concurrent chemoradiation with either IMRT or PBT ± consolidative immune checkpoint inhibition were retrospectively identified. Logistic regression was used to assess the association of radiation therapy technique with 90-day hospitalization and grade 3 (G3+) lymphopenia. Competing risk regression was used to compare G3+ pneumonitis, G3+ esophagitis, and G3+ cardiac events. Kaplan-Meier method was used for progression-free survival and overall survival. Inverse probability treatment weighting was applied to adjust for differences in PBT and IMRT groups. RESULTS Of 316 patients, 117 (37%) received PBT and 199 (63%) received IMRT. The PBT group was older (p < .001) and had higher Charlson Comorbidity Index scores (p = .02). The PBT group received a lower mean heart dose (p < .0001), left anterior descending artery V15 Gy (p = .001), mean lung dose (p = .008), and effective dose to immune circulating cells (p < .001). On inverse probability treatment weighting analysis, PBT was associated with fewer unplanned hospitalizations (adjusted odds ratio, 0.55; 95% CI, 0.38-0.81; p = .002) and less G3+ lymphopenia (adjusted odds ratio, 0.55; 95% CI, 0.37-0.81; p = .003). There was no difference in other G3+ toxicities, progression-free survival, or overall survival. CONCLUSIONS PBT is associated with fewer unplanned hospitalizations, lower effective dose to immune circulating cells and less G3+ lymphopenia compared with IMRT. Minimizing dose to lymphocytes may be warranted, but prospective data are needed.
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Affiliation(s)
- Michelle Iocolano
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Nikhil Yegya-Raman
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Cole Friedes
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Xingmei Wang
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Timothy Kegelman
- Department of Radiation Oncology, Delaware Radiation Oncology Associates, Christiana Care Health Systems, Newark, Delaware, USA
| | - Sang Ho Lee
- Department of Radiation Oncology, Division of Physics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Lian Duan
- Department of Radiation Oncology, Division of Physics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Bolin Li
- Department of Radiation Oncology, Division of Physics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - William P Levin
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Keith A Cengel
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Andre Konski
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Corey J Langer
- Division of Hematology/Oncology University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Roger B Cohen
- Division of Hematology/Oncology University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Lova Sun
- Division of Hematology/Oncology University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Charu Aggarwal
- Division of Hematology/Oncology University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Abigail Doucette
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ying Xiao
- Department of Radiation Oncology, Division of Physics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Boon-Keng Kevin Teo
- Department of Radiation Oncology, Division of Physics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Shannon O'Reilly
- Department of Radiation Oncology, Division of Physics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Wei Zou
- Department of Radiation Oncology, Division of Physics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jeffrey D Bradley
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Steven J Feigenberg
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Hotca A, Sindhu KK, Lehrer EJ, Hartsell WF, Vargas C, Tsai HK, Chang JH, Apisarnthanarax S, Nichols RC, Chhabra AM, Hasan S, Press RH, Lazarev S, Hajj C, Kabarriti R, Rule WG, Simone CB, Choi JI. Reirradiation With Proton Therapy for Recurrent Malignancies of the Esophagus and Gastroesophageal Junction: Results of the Proton Collaborative Group Multi-Institutional Prospective Registry Trial. Adv Radiat Oncol 2024; 9:101459. [PMID: 38596455 PMCID: PMC11002543 DOI: 10.1016/j.adro.2024.101459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 01/21/2024] [Indexed: 04/11/2024] Open
Abstract
Purpose Treatment options for recurrent esophageal cancer (EC) previously treated with radiation therapy (RT) are limited. Reirradiation (reRT) with proton beam therapy (PBT) can offer lower toxicities by limiting doses to surrounding tissues. In this study, we present the first multi-institutional series reporting on toxicities and outcomes after reRT for locoregionally recurrent EC with PBT. Methods and Materials Analysis of the prospective, multicenter, Proton Collaborative Group registry of patients with recurrent EC who had previously received photon-based RT and underwent PBT reRT was performed. Patient/tumor characteristics, treatment details, outcomes, and toxicities were collected. Local control (LC), distant metastasis-free survival (DMFS), and overall survival (OS) were estimated using the Kaplan-Meier method. Event time was determined from reRT start. Results Between 2012 and 2020, 31 patients received reRT via uniform scanning/passive scattering (61.3%) or pencil beam scanning (38.7%) PBT at 7 institutions. Median prior RT, PBT reRT, and cumulative doses were 50.4 Gy (range, 37.5-110.4), 48.6 Gy (relative biological effectiveness) (25.2-72.1), and 99.9 Gy (79.1-182.5), respectively. Of these patients, 12.9% had 2 prior RT courses, and 67.7% received PBT with concurrent chemotherapy. Median follow-up was 7.2 months (0.9-64.7). Post-PBT, there were 16.7% locoregional only, 11.1% distant only, and 16.7% locoregional and distant recurrences. Six-month LC, DMFS, and OS were 80.5%, 83.4%, and 69.1%, respectively. One-year LC, DMFS, and OS were 67.1%, 83.4%, and 27%, respectively. Acute grade ≥3 toxicities occurred in 23% of patients, with 1 acute grade 5 toxicity secondary to esophageal hemorrhage, unclear if related to reRT or disease progression. No grade ≥3 late toxicities were reported. Conclusions In the largest report to date of PBT for reRT in patients with recurrent EC, we observed acceptable acute toxicities and encouraging rates of disease control. However, these findings are limited by the poor prognoses of these patients, who are at high risk of mortality. Further research is needed to better assess the long-term benefits and toxicities of PBT in this specific patient population.
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Affiliation(s)
| | - Kunal K. Sindhu
- Icahn School of Medicine at Mount Sinai, New York, New York
- New York Proton Center, New York, New York
| | - Eric J. Lehrer
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | | | | | - Smith Apisarnthanarax
- University of Washington, Fred Hutchinson Cancer Center Proton Therapy, Seattle, Washington
| | - Romaine C. Nichols
- University of Florida Health Proton Therapy Institute, Jacksonville, Florida
| | - Arpit M. Chhabra
- Icahn School of Medicine at Mount Sinai, New York, New York
- New York Proton Center, New York, New York
| | - Shaakir Hasan
- New York Proton Center, New York, New York
- Montefiore Medical Center, Bronx, New York
| | | | - Stanislav Lazarev
- Icahn School of Medicine at Mount Sinai, New York, New York
- New York Proton Center, New York, New York
| | - Carla Hajj
- New York Proton Center, New York, New York
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Rafi Kabarriti
- New York Proton Center, New York, New York
- Montefiore Medical Center, Bronx, New York
| | | | - Charles B. Simone
- New York Proton Center, New York, New York
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - J. Isabelle Choi
- New York Proton Center, New York, New York
- Memorial Sloan Kettering Cancer Center, New York, New York
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Lin H, Qi H, Kang M, Simone CB. In Regard to Dupere et al. Int J Radiat Oncol Biol Phys 2024; 119:306-307. [PMID: 38631743 DOI: 10.1016/j.ijrobp.2023.12.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 12/26/2023] [Indexed: 04/19/2024]
Affiliation(s)
- Haibo Lin
- New York Proton Center, New York, New York; Department of Radiation Oncology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York; Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hang Qi
- New York Proton Center, New York, New York
| | | | - Charles B Simone
- New York Proton Center, New York, New York; Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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Yegya-Raman N, Berman AT, Ciunci CA, Friedes C, Berlin E, Iocolano M, Wang X, Lai C, Levin WP, Cengel KA, O'Reilly SE, Cohen RB, Aggarwal C, Marmarelis ME, Singh AP, Sun L, Bradley JD, Plastaras JP, Simone CB, Langer CJ, Feigenberg SJ. Phase 2 Trial of Consolidation Pembrolizumab After Proton Reirradiation for Thoracic Recurrences of Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2024; 119:56-65. [PMID: 37652303 DOI: 10.1016/j.ijrobp.2023.08.047] [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: 04/26/2023] [Revised: 07/08/2023] [Accepted: 08/17/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE Reirradiation (reRT) with proton beam therapy (PBT) may offer a chance of cure while minimizing toxicity for patients with isolated intrathoracic recurrences of non-small cell lung cancer (NSCLC). However, distant failure remains common, necessitating strategies to integrate more effective systemic therapy. METHODS AND MATERIALS This was a phase 2, single-arm trial (NCT03087760) of consolidation pembrolizumab after PBT reRT for locoregional recurrences of NSCLC. Four to 12 weeks after completion of 60 to 70 Gy PBT reRT, patients without progressive disease received pembrolizumab for up to 12 months. Primary endpoint was progression-free survival (PFS), measured from the start of reRT. Secondary endpoints were overall survival (OS) and National Cancer Institute Common Terminology Criteria for Adverse Events, version 5.0 toxicity. RESULTS Between 2017 and 2021, 22 patients received PBT reRT. Median interval from prior radiation end to reRT start was 20 months. Most recurrences (91%) were centrally located. Most patients received concurrent chemotherapy (95%) and pencil beam scanning PBT (77%), and 36% had received prior durvalumab. Fifteen patients (68%) initiated consolidation pembrolizumab on trial and received a median of 3 cycles (range, 2-17). Pembrolizumab was discontinued most commonly due to toxicity (n = 5; 2 were pembrolizumab-related), disease progression (n = 4), and completion of 1 year (n = 3). Median follow-up was 38.7 months. Median PFS and OS were 8.8 months (95% CI, 4.2-23.7) and 22.8 months (95% CI, 6.9-not reached), respectively. There was only one isolated in-field failure after reRT. Grade ≥3 toxicities occurred in 10 patients (45%); 2 were pembrolizumab-related. There were 2 grade 5 toxicities, an aorto-esophageal fistula at 6.9 months and hemoptysis at 46.8 months, both probably from reRT. The trial closed early due to widespread adoption of immunotherapy off-protocol. CONCLUSIONS In the first-ever prospective trial combining PBT reRT with consolidation immunotherapy, PFS was acceptable and OS favorable. Late grade 5 toxicity occurred in 2 of 22 patients. This approach may be considered in selected patients with isolated thoracic recurrences of NSCLC.
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Affiliation(s)
- Nikhil Yegya-Raman
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Abigail T Berman
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christine A Ciunci
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Cole Friedes
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eva Berlin
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michelle Iocolano
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Xingmei Wang
- Department of Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ching Lai
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - William P Levin
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Keith A Cengel
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shannon E O'Reilly
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Roger B Cohen
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Charu Aggarwal
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Melina E Marmarelis
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Aditi P Singh
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lova Sun
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey D Bradley
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John P Plastaras
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Charles B Simone
- New York Proton Center, New York, New York; Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Corey J Langer
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Steven J Feigenberg
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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Huang RS, Chow R, Chopade P, Mihalache A, Hasan A, Boldt G, Glicksman R, Simone CB, Lock M, Raman S. Dose-response of localized renal cell carcinoma after stereotactic body radiation therapy: A meta-analysis. Radiother Oncol 2024; 194:110216. [PMID: 38462092 DOI: 10.1016/j.radonc.2024.110216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 03/02/2024] [Accepted: 03/04/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Stereotactic ablative radiation therapy (SBRT) is an emerging treatment option for primary renal cell carcinoma (RCC), particularly in patients who are unsuitable for surgery. The aim of this review is to assess the effect of increasing the biologically equivalent dose (BED) via various radiation fractionation regimens on clinical outcomes. METHODS A literature search was conducted in PubMed (Medline), EMBASE, and the Cochrane Library for studies published up to October 2023. Studies reporting on patients with localized RCC receiving SBRT were included to determine its effectiveness on local control, progression-free survival, and overall survival. A random effects model was used to meta-regress clinical outcomes relative to the BED for each study and heterogeneity was assessed by I2. RESULTS A total of 724 patients with RCC from 22 studies were included, with a mean age of 72.7 years (range: 44.0-81.0). Local control was excellent with an estimate of 99 % (95 %CI: 97-100 %, I2 = 19 %), 98 % (95 %CI: 96-99 %, I2 = 8 %), and 94 % (95 %CI: 90-97 %, I2 = 11 %) at one year, two years, and five years respectively. No definitive association between increasing BED and local control, progression-free survival and overall survival was observed. No publication bias was observed. CONCLUSIONS A significant dose response relationship between oncological outcomes and was not identified, and excellent local control outcomes were observed at the full range of doses. Until new evidence points otherwise, we support current recommendations against routine dose escalation beyond 25-26 Gy in one fraction or 42-48 Gy in three fractions, and to consider de-escalation or compromising target coverage if required to achieve safe organ at risk doses.
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Affiliation(s)
- Ryan S Huang
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ronald Chow
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Princess Margaret Cancer Centre, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada; London Regional Cancer Program, London Health Sciences Centre, Schulich School of Medicine, University of Western Ontario, London, ON, Canada; New York Proton Center, New York, NY, USA
| | - Pradnya Chopade
- Princess Margaret Cancer Centre, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Andrew Mihalache
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Asad Hasan
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Gabriel Boldt
- London Regional Cancer Program, London Health Sciences Centre, Schulich School of Medicine, University of Western Ontario, London, ON, Canada
| | - Rachel Glicksman
- Princess Margaret Cancer Centre, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | | | - Michael Lock
- London Regional Cancer Program, London Health Sciences Centre, Schulich School of Medicine, University of Western Ontario, London, ON, Canada
| | - Srinivas Raman
- Princess Margaret Cancer Centre, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada.
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Valdes G, Scholey J, Nano TF, Gennatas ED, Mohindra P, Mohammed N, Zeng J, Kotecha R, Rosen LR, Chang J, Tsai HK, Urbanic JJ, Vargas CE, Yu NY, Ungar LH, Eaton E, Simone CB. Predicting the Effect of Proton Beam Therapy Technology on Pulmonary Toxicities for Patients With Locally Advanced Lung Cancer Enrolled in the Proton Collaborative Group Prospective Clinical Trial. Int J Radiat Oncol Biol Phys 2024; 119:66-77. [PMID: 38000701 DOI: 10.1016/j.ijrobp.2023.11.026] [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: 10/27/2022] [Revised: 10/27/2023] [Accepted: 11/13/2023] [Indexed: 11/26/2023]
Abstract
PURPOSE This study aimed to predict the probability of grade ≥2 pneumonitis or dyspnea within 12 months of receiving conventionally fractionated or mildly hypofractionated proton beam therapy for locally advanced lung cancer using machine learning. METHODS AND MATERIALS Demographic and treatment characteristics were analyzed for 965 consecutive patients treated for lung cancer with conventionally fractionated or mildly hypofractionated (2.2-3 Gy/fraction) proton beam therapy across 12 institutions. Three machine learning models (gradient boosting, additive tree, and logistic regression with lasso regularization) were implemented to predict Common Terminology Criteria for Adverse Events version 4 grade ≥2 pulmonary toxicities using double 10-fold cross-validation for parameter hyper-tuning without leak of information. Balanced accuracy and area under the curve were calculated, and 95% confidence intervals were obtained using bootstrap sampling. RESULTS The median age of the patients was 70 years (range, 20-97), and they had predominantly stage IIIA or IIIB disease. They received a median dose of 60 Gy in 2 Gy/fraction, and 46.4% received concurrent chemotherapy. In total, 250 (25.9%) had grade ≥2 pulmonary toxicity. The probability of pulmonary toxicity was 0.08 for patients treated with pencil beam scanning and 0.34 for those treated with other techniques (P = 8.97e-13). Use of abdominal compression and breath hold were highly significant predictors of less toxicity (P = 2.88e-08). Higher total radiation delivered dose (P = .0182) and higher average dose to the ipsilateral lung (P = .0035) increased the likelihood of pulmonary toxicities. The gradient boosting model performed the best of the models tested, and when demographic and dosimetric features were combined, the area under the curve and balanced accuracy were 0.75 ± 0.02 and 0.67 ± 0.02, respectively. After analyzing performance versus the number of data points used for training, we observed that accuracy was limited by the number of observations. CONCLUSIONS In the largest analysis of prospectively enrolled patients with lung cancer assessing pulmonary toxicities from proton therapy to date, advanced machine learning methods revealed that pencil beam scanning, abdominal compression, and lower normal lung doses can lead to significantly lower probability of developing grade ≥2 pneumonitis or dyspnea.
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Affiliation(s)
- Gilmer Valdes
- Department of Radiation Oncology, University of California, San Francisco, California
| | - Jessica Scholey
- Department of Radiation Oncology, University of California, San Francisco, California
| | - Tomi F Nano
- Department of Radiation Oncology, University of California, San Francisco, California.
| | - Efstathios D Gennatas
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Pranshu Mohindra
- University of Maryland School of Medicine and Maryland Proton Treatment Center, Baltimore, Maryland
| | - Nasir Mohammed
- Northwestern Medicine Chicago Proton Center, Warrenville, Illinois
| | - Jing Zeng
- University of Washington and Seattle Cancer Care Alliance Proton Therapy Center, Seattle, Washington
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - Lane R Rosen
- Willis-Knighton Medical Center, Shreveport, Louisiana
| | - John Chang
- Oklahoma Proton Center, Oklahoma City, Oklahoma
| | - Henry K Tsai
- New Jersey Procure Proton Therapy Center, Somerset, New Jersey
| | - James J Urbanic
- Department of Radiation Oncology, California Protons Therapy Center, San Diego, California
| | - Carlos E Vargas
- Department of Radiation Oncology, Mayo Clinic Proton Center, Phoenix, Arizona
| | - Nathan Y Yu
- Department of Radiation Oncology, Mayo Clinic Proton Center, Phoenix, Arizona
| | - Lyle H Ungar
- Department of Computer and Information Science, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eric Eaton
- Department of Computer and Information Science, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Charles B Simone
- Department of Radiation Oncology, New York Proton Center, New York, New York
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7
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Meng YJ, Mankuzhy NP, Chawla M, Lee RP, Yorke ED, Zhang Z, Gelb E, Lim SB, Cuaron JJ, Wu AJ, Simone CB, Gelblum DY, Lovelock DM, Harris W, Rimner A. A Prospective Study on Deep Inspiration Breath Hold Thoracic Radiation Therapy Guided by Bronchoscopically Implanted Electromagnetic Transponders. Cancers (Basel) 2024; 16:1534. [PMID: 38672616 PMCID: PMC11048337 DOI: 10.3390/cancers16081534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/03/2024] [Accepted: 04/13/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Electromagnetic transponders bronchoscopically implanted near the tumor can be used to monitor deep inspiration breath hold (DIBH) for thoracic radiation therapy (RT). The feasibility and safety of this approach require further study. METHODS We enrolled patients with primary lung cancer or lung metastases. Three transponders were implanted near the tumor, followed by simulation with DIBH, free breathing, and 4D-CT as backup. The initial gating window for treatment was ±5 mm; in a second cohort, the window was incrementally reduced to determine the smallest feasible gating window. The primary endpoint was feasibility, defined as completion of RT using transponder-guided DIBH. Patients were followed for assessment of transponder- and RT-related toxicity. RESULTS We enrolled 48 patients (35 with primary lung cancer and 13 with lung metastases). The median distance of transponders to tumor was 1.6 cm (IQR 0.6-2.8 cm). RT delivery ranged from 3 to 35 fractions. Transponder-guided DIBH was feasible in all but two patients (96% feasible), where it failed because the distance between the transponders and the antenna was >19 cm. Among the remaining 46 patients, 6 were treated prone to keep the transponders within 19 cm of the antenna, and 40 were treated supine. The smallest feasible gating window was identified as ±3 mm. Thirty-nine (85%) patients completed one year of follow-up. Toxicities at least possibly related to transponders or the implantation procedure were grade 2 in six patients (six incidences, cough and hemoptysis), grade 3 in three patients (five incidences, cough, dyspnea, pneumonia, and supraventricular tachycardia), and grade 4 pneumonia in one patient (occurring a few days after implantation but recovered fully and completed RT). Toxicities at least possibly related to RT were grade 2 in 18 patients (41 incidences, most commonly cough, fatigue, and pneumonitis) and grade 3 in four patients (seven incidences, most commonly pneumonia), and no patients had grade 4 or higher toxicity. CONCLUSIONS Bronchoscopically implanted electromagnetic transponder-guided DIBH lung RT is feasible and safe, allowing for precise tumor targeting and reduced normal tissue exposure. Transponder-antenna distance was the most common challenge due to a limited antenna range, which could sometimes be circumvented by prone positioning.
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Affiliation(s)
- Yuzhong Jeff Meng
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA; (Y.J.M.); (N.P.M.); (E.G.); (J.J.C.); (A.J.W.); (C.B.S.II)
| | - Nikhil P. Mankuzhy
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA; (Y.J.M.); (N.P.M.); (E.G.); (J.J.C.); (A.J.W.); (C.B.S.II)
| | - Mohit Chawla
- Department of Medicine, Pulmonary Service, Section of Interventional Pulmonology, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA; (M.C.); (R.P.L.)
| | - Robert P. Lee
- Department of Medicine, Pulmonary Service, Section of Interventional Pulmonology, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA; (M.C.); (R.P.L.)
| | - Ellen D. Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA; (E.D.Y.); (S.B.L.); (D.M.L.)
| | - Zhigang Zhang
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA;
| | - Emily Gelb
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA; (Y.J.M.); (N.P.M.); (E.G.); (J.J.C.); (A.J.W.); (C.B.S.II)
| | - Seng Boh Lim
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA; (E.D.Y.); (S.B.L.); (D.M.L.)
| | - John J. Cuaron
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA; (Y.J.M.); (N.P.M.); (E.G.); (J.J.C.); (A.J.W.); (C.B.S.II)
| | - Abraham J. Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA; (Y.J.M.); (N.P.M.); (E.G.); (J.J.C.); (A.J.W.); (C.B.S.II)
| | - Charles B. Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA; (Y.J.M.); (N.P.M.); (E.G.); (J.J.C.); (A.J.W.); (C.B.S.II)
- New York Proton Center, New York, NY 10035, USA
| | - Daphna Y. Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA; (Y.J.M.); (N.P.M.); (E.G.); (J.J.C.); (A.J.W.); (C.B.S.II)
| | - Dale Michael Lovelock
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA; (E.D.Y.); (S.B.L.); (D.M.L.)
| | - Wendy Harris
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA; (E.D.Y.); (S.B.L.); (D.M.L.)
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA; (Y.J.M.); (N.P.M.); (E.G.); (J.J.C.); (A.J.W.); (C.B.S.II)
- Department of Radiation Oncology, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, German Cancer Consortium (DKTK), Partner Site DKTK-Freiburg, Robert-Koch-Strasse 3, 79106 Freiburg, Germany
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8
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Rodrigues G, Higgins KA, Rimner A, Amini A, Chang JY, Chun SG, Donington J, Edelman MJ, Gubens MA, Iyengar P, Movsas B, Ning MS, Park HS, Wolf A, Simone CB. American Radium Society Appropriate Use Criteria for Unresectable Locally Advanced Non-Small Cell Lung Cancer. JAMA Oncol 2024:2817451. [PMID: 38602670 DOI: 10.1001/jamaoncol.2024.0294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
Importance The treatment of locally advanced non-small cell lung cancer (LA-NSCLC) has been informed by more than 5 decades of clinical trials and other relevant literature. However, controversies remain regarding the application of various radiation and systemic therapies in commonly encountered clinical scenarios. Objective To develop case-referenced consensus and evidence-based guidelines to inform clinical practice in unresectable LA-NSCLC. Evidence Review The American Radium Society (ARS) Appropriate Use Criteria (AUC) Thoracic Committee guideline is an evidence-based consensus document assessing various clinical scenarios associated with LA-NSCLC. A systematic review of the literature with evidence ratings was conducted to inform the appropriateness of treatment recommendations by the ARS AUC Thoracic Committee for the management of unresectable LA-NSCLC. Findings Treatment appropriateness of a variety of LA-NSCLC scenarios was assessed by a consensus-based modified Delphi approach using a range of 3 points to 9 points to denote consensus agreement. Committee recommendations were vetted by the ARS AUC Executive Committee and a 2-week public comment period before official approval and adoption. Standard of care management of good prognosis LA-NSCLC consists of combined concurrent radical (60-70 Gy) platinum-based chemoradiation followed by consolidation durvalumab immunotherapy (for patients without progression). Planning and delivery of locally advanced lung cancer radiotherapy usually should be performed using intensity-modulated radiotherapy techniques. A variety of palliative and radical fractionation schedules are available to treat patients with poor performance and/or pulmonary status. The salvage therapy for a local recurrence after successful primary management is complex and likely requires both multidisciplinary input and shared decision-making with the patient. Conclusions and Relevance Evidence-based guidance on the management of various unresectable LA-NSCLC scenarios is provided by the ARS AUC to optimize multidisciplinary patient care for this challenging patient population.
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Affiliation(s)
- George Rodrigues
- Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada
| | | | - Andreas Rimner
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Arya Amini
- City of Hope National Medical Center, Duarte, California
| | - Joe Y Chang
- The University of Texas, MD Anderson Cancer Center, Houston
| | - Stephen G Chun
- The University of Texas, MD Anderson Cancer Center, Houston
| | | | - Martin J Edelman
- Fox Chase Comprehensive Cancer Center, Philadelphia, Pennsylvania
| | - Matthew A Gubens
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco
| | - Puneeth Iyengar
- The University of Texas at Southwestern Medical Center, Dallas
| | | | - Matthew S Ning
- The University of Texas, MD Anderson Cancer Center, Houston
| | | | - Andrea Wolf
- Mount Sinai Health System, New York, New York
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9
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Chan AW, Simone CB, van der Linden Y, Hoskin P, Detsky J, Choi JI, Lee SF, Wong HC, Martin EJ, Raman S, Rades D, Rembielak A, Kazmierska J, Vassiliou V, Alcorn S, Bonomo P, Oldenburger E. Prophylactic Radiation Therapy for High-Risk Asymptomatic Bone Metastases: A New Standard of Care or Need for More Data? J Clin Oncol 2024; 42:1326-1327. [PMID: 38320224 DOI: 10.1200/jco.23.02391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 12/06/2023] [Indexed: 02/08/2024] Open
Affiliation(s)
- Adrian Wai Chan
- Adrian Wai Chan, MBBS, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; Charles B. Simone II, MD, Department of Radiation Oncology, New York Proton Center, New York, NY; Yvette van der Linden, MD, PhD, Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands, Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands; Peter Hoskin, MD, Mount Vernon Cancer Centre, Northwood, United Kingdom, Division of Cancer Sciences, University of Manchester, United Kingdom; Jay Detsky, MD, PhD, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; J. Isabelle Choi, MD, Department of Radiation Oncology, New York Proton Center, New York, NY, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; S.F. Lee, MD, , Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore; Henry CY Wong, MBBS, Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China, Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China; Henry CY Wong, MBBS, Department of Medicine, UCLA Health, Los Angeles, CA; Srinivas Raman, MD, Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada; Dirk Rades, MD, Department of Radiation Oncology, University of Lübeck, Germany; Agata Rembielak, MD, PhD, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Joanna Kazmierska, MD, PhD, Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland, Electroradiology Department, University of Medical Sciences, Poznan, Poland; Vassilios Vassiliou, MD, PhD, Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Strovolos, Cyprus; Sara Alcorn, MD, PhD, Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN; Pierluigi Bonomo, MD, Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; and Eva Oldenburger, MD, Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Charles B Simone
- Adrian Wai Chan, MBBS, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; Charles B. Simone II, MD, Department of Radiation Oncology, New York Proton Center, New York, NY; Yvette van der Linden, MD, PhD, Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands, Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands; Peter Hoskin, MD, Mount Vernon Cancer Centre, Northwood, United Kingdom, Division of Cancer Sciences, University of Manchester, United Kingdom; Jay Detsky, MD, PhD, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; J. Isabelle Choi, MD, Department of Radiation Oncology, New York Proton Center, New York, NY, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; S.F. Lee, MD, , Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore; Henry CY Wong, MBBS, Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China, Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China; Henry CY Wong, MBBS, Department of Medicine, UCLA Health, Los Angeles, CA; Srinivas Raman, MD, Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada; Dirk Rades, MD, Department of Radiation Oncology, University of Lübeck, Germany; Agata Rembielak, MD, PhD, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Joanna Kazmierska, MD, PhD, Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland, Electroradiology Department, University of Medical Sciences, Poznan, Poland; Vassilios Vassiliou, MD, PhD, Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Strovolos, Cyprus; Sara Alcorn, MD, PhD, Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN; Pierluigi Bonomo, MD, Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; and Eva Oldenburger, MD, Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Yvette van der Linden
- Adrian Wai Chan, MBBS, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; Charles B. Simone II, MD, Department of Radiation Oncology, New York Proton Center, New York, NY; Yvette van der Linden, MD, PhD, Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands, Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands; Peter Hoskin, MD, Mount Vernon Cancer Centre, Northwood, United Kingdom, Division of Cancer Sciences, University of Manchester, United Kingdom; Jay Detsky, MD, PhD, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; J. Isabelle Choi, MD, Department of Radiation Oncology, New York Proton Center, New York, NY, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; S.F. Lee, MD, , Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore; Henry CY Wong, MBBS, Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China, Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China; Henry CY Wong, MBBS, Department of Medicine, UCLA Health, Los Angeles, CA; Srinivas Raman, MD, Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada; Dirk Rades, MD, Department of Radiation Oncology, University of Lübeck, Germany; Agata Rembielak, MD, PhD, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Joanna Kazmierska, MD, PhD, Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland, Electroradiology Department, University of Medical Sciences, Poznan, Poland; Vassilios Vassiliou, MD, PhD, Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Strovolos, Cyprus; Sara Alcorn, MD, PhD, Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN; Pierluigi Bonomo, MD, Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; and Eva Oldenburger, MD, Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Peter Hoskin
- Adrian Wai Chan, MBBS, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; Charles B. Simone II, MD, Department of Radiation Oncology, New York Proton Center, New York, NY; Yvette van der Linden, MD, PhD, Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands, Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands; Peter Hoskin, MD, Mount Vernon Cancer Centre, Northwood, United Kingdom, Division of Cancer Sciences, University of Manchester, United Kingdom; Jay Detsky, MD, PhD, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; J. Isabelle Choi, MD, Department of Radiation Oncology, New York Proton Center, New York, NY, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; S.F. Lee, MD, , Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore; Henry CY Wong, MBBS, Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China, Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China; Henry CY Wong, MBBS, Department of Medicine, UCLA Health, Los Angeles, CA; Srinivas Raman, MD, Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada; Dirk Rades, MD, Department of Radiation Oncology, University of Lübeck, Germany; Agata Rembielak, MD, PhD, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Joanna Kazmierska, MD, PhD, Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland, Electroradiology Department, University of Medical Sciences, Poznan, Poland; Vassilios Vassiliou, MD, PhD, Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Strovolos, Cyprus; Sara Alcorn, MD, PhD, Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN; Pierluigi Bonomo, MD, Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; and Eva Oldenburger, MD, Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Jay Detsky
- Adrian Wai Chan, MBBS, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; Charles B. Simone II, MD, Department of Radiation Oncology, New York Proton Center, New York, NY; Yvette van der Linden, MD, PhD, Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands, Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands; Peter Hoskin, MD, Mount Vernon Cancer Centre, Northwood, United Kingdom, Division of Cancer Sciences, University of Manchester, United Kingdom; Jay Detsky, MD, PhD, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; J. Isabelle Choi, MD, Department of Radiation Oncology, New York Proton Center, New York, NY, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; S.F. Lee, MD, , Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore; Henry CY Wong, MBBS, Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China, Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China; Henry CY Wong, MBBS, Department of Medicine, UCLA Health, Los Angeles, CA; Srinivas Raman, MD, Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada; Dirk Rades, MD, Department of Radiation Oncology, University of Lübeck, Germany; Agata Rembielak, MD, PhD, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Joanna Kazmierska, MD, PhD, Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland, Electroradiology Department, University of Medical Sciences, Poznan, Poland; Vassilios Vassiliou, MD, PhD, Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Strovolos, Cyprus; Sara Alcorn, MD, PhD, Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN; Pierluigi Bonomo, MD, Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; and Eva Oldenburger, MD, Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - J Isabelle Choi
- Adrian Wai Chan, MBBS, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; Charles B. Simone II, MD, Department of Radiation Oncology, New York Proton Center, New York, NY; Yvette van der Linden, MD, PhD, Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands, Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands; Peter Hoskin, MD, Mount Vernon Cancer Centre, Northwood, United Kingdom, Division of Cancer Sciences, University of Manchester, United Kingdom; Jay Detsky, MD, PhD, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; J. Isabelle Choi, MD, Department of Radiation Oncology, New York Proton Center, New York, NY, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; S.F. Lee, MD, , Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore; Henry CY Wong, MBBS, Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China, Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China; Henry CY Wong, MBBS, Department of Medicine, UCLA Health, Los Angeles, CA; Srinivas Raman, MD, Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada; Dirk Rades, MD, Department of Radiation Oncology, University of Lübeck, Germany; Agata Rembielak, MD, PhD, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Joanna Kazmierska, MD, PhD, Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland, Electroradiology Department, University of Medical Sciences, Poznan, Poland; Vassilios Vassiliou, MD, PhD, Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Strovolos, Cyprus; Sara Alcorn, MD, PhD, Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN; Pierluigi Bonomo, MD, Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; and Eva Oldenburger, MD, Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - S F Lee
- Adrian Wai Chan, MBBS, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; Charles B. Simone II, MD, Department of Radiation Oncology, New York Proton Center, New York, NY; Yvette van der Linden, MD, PhD, Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands, Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands; Peter Hoskin, MD, Mount Vernon Cancer Centre, Northwood, United Kingdom, Division of Cancer Sciences, University of Manchester, United Kingdom; Jay Detsky, MD, PhD, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; J. Isabelle Choi, MD, Department of Radiation Oncology, New York Proton Center, New York, NY, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; S.F. Lee, MD, , Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore; Henry CY Wong, MBBS, Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China, Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China; Henry CY Wong, MBBS, Department of Medicine, UCLA Health, Los Angeles, CA; Srinivas Raman, MD, Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada; Dirk Rades, MD, Department of Radiation Oncology, University of Lübeck, Germany; Agata Rembielak, MD, PhD, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Joanna Kazmierska, MD, PhD, Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland, Electroradiology Department, University of Medical Sciences, Poznan, Poland; Vassilios Vassiliou, MD, PhD, Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Strovolos, Cyprus; Sara Alcorn, MD, PhD, Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN; Pierluigi Bonomo, MD, Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; and Eva Oldenburger, MD, Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Henry Cy Wong
- Adrian Wai Chan, MBBS, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; Charles B. Simone II, MD, Department of Radiation Oncology, New York Proton Center, New York, NY; Yvette van der Linden, MD, PhD, Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands, Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands; Peter Hoskin, MD, Mount Vernon Cancer Centre, Northwood, United Kingdom, Division of Cancer Sciences, University of Manchester, United Kingdom; Jay Detsky, MD, PhD, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; J. Isabelle Choi, MD, Department of Radiation Oncology, New York Proton Center, New York, NY, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; S.F. Lee, MD, , Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore; Henry CY Wong, MBBS, Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China, Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China; Henry CY Wong, MBBS, Department of Medicine, UCLA Health, Los Angeles, CA; Srinivas Raman, MD, Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada; Dirk Rades, MD, Department of Radiation Oncology, University of Lübeck, Germany; Agata Rembielak, MD, PhD, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Joanna Kazmierska, MD, PhD, Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland, Electroradiology Department, University of Medical Sciences, Poznan, Poland; Vassilios Vassiliou, MD, PhD, Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Strovolos, Cyprus; Sara Alcorn, MD, PhD, Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN; Pierluigi Bonomo, MD, Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; and Eva Oldenburger, MD, Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Emily J Martin
- Adrian Wai Chan, MBBS, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; Charles B. Simone II, MD, Department of Radiation Oncology, New York Proton Center, New York, NY; Yvette van der Linden, MD, PhD, Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands, Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands; Peter Hoskin, MD, Mount Vernon Cancer Centre, Northwood, United Kingdom, Division of Cancer Sciences, University of Manchester, United Kingdom; Jay Detsky, MD, PhD, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; J. Isabelle Choi, MD, Department of Radiation Oncology, New York Proton Center, New York, NY, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; S.F. Lee, MD, , Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore; Henry CY Wong, MBBS, Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China, Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China; Henry CY Wong, MBBS, Department of Medicine, UCLA Health, Los Angeles, CA; Srinivas Raman, MD, Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada; Dirk Rades, MD, Department of Radiation Oncology, University of Lübeck, Germany; Agata Rembielak, MD, PhD, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Joanna Kazmierska, MD, PhD, Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland, Electroradiology Department, University of Medical Sciences, Poznan, Poland; Vassilios Vassiliou, MD, PhD, Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Strovolos, Cyprus; Sara Alcorn, MD, PhD, Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN; Pierluigi Bonomo, MD, Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; and Eva Oldenburger, MD, Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Srinivas Raman
- Adrian Wai Chan, MBBS, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; Charles B. Simone II, MD, Department of Radiation Oncology, New York Proton Center, New York, NY; Yvette van der Linden, MD, PhD, Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands, Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands; Peter Hoskin, MD, Mount Vernon Cancer Centre, Northwood, United Kingdom, Division of Cancer Sciences, University of Manchester, United Kingdom; Jay Detsky, MD, PhD, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; J. Isabelle Choi, MD, Department of Radiation Oncology, New York Proton Center, New York, NY, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; S.F. Lee, MD, , Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore; Henry CY Wong, MBBS, Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China, Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China; Henry CY Wong, MBBS, Department of Medicine, UCLA Health, Los Angeles, CA; Srinivas Raman, MD, Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada; Dirk Rades, MD, Department of Radiation Oncology, University of Lübeck, Germany; Agata Rembielak, MD, PhD, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Joanna Kazmierska, MD, PhD, Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland, Electroradiology Department, University of Medical Sciences, Poznan, Poland; Vassilios Vassiliou, MD, PhD, Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Strovolos, Cyprus; Sara Alcorn, MD, PhD, Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN; Pierluigi Bonomo, MD, Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; and Eva Oldenburger, MD, Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Dirk Rades
- Adrian Wai Chan, MBBS, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; Charles B. Simone II, MD, Department of Radiation Oncology, New York Proton Center, New York, NY; Yvette van der Linden, MD, PhD, Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands, Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands; Peter Hoskin, MD, Mount Vernon Cancer Centre, Northwood, United Kingdom, Division of Cancer Sciences, University of Manchester, United Kingdom; Jay Detsky, MD, PhD, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; J. Isabelle Choi, MD, Department of Radiation Oncology, New York Proton Center, New York, NY, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; S.F. Lee, MD, , Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore; Henry CY Wong, MBBS, Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China, Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China; Henry CY Wong, MBBS, Department of Medicine, UCLA Health, Los Angeles, CA; Srinivas Raman, MD, Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada; Dirk Rades, MD, Department of Radiation Oncology, University of Lübeck, Germany; Agata Rembielak, MD, PhD, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Joanna Kazmierska, MD, PhD, Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland, Electroradiology Department, University of Medical Sciences, Poznan, Poland; Vassilios Vassiliou, MD, PhD, Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Strovolos, Cyprus; Sara Alcorn, MD, PhD, Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN; Pierluigi Bonomo, MD, Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; and Eva Oldenburger, MD, Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Agata Rembielak
- Adrian Wai Chan, MBBS, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; Charles B. Simone II, MD, Department of Radiation Oncology, New York Proton Center, New York, NY; Yvette van der Linden, MD, PhD, Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands, Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands; Peter Hoskin, MD, Mount Vernon Cancer Centre, Northwood, United Kingdom, Division of Cancer Sciences, University of Manchester, United Kingdom; Jay Detsky, MD, PhD, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; J. Isabelle Choi, MD, Department of Radiation Oncology, New York Proton Center, New York, NY, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; S.F. Lee, MD, , Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore; Henry CY Wong, MBBS, Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China, Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China; Henry CY Wong, MBBS, Department of Medicine, UCLA Health, Los Angeles, CA; Srinivas Raman, MD, Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada; Dirk Rades, MD, Department of Radiation Oncology, University of Lübeck, Germany; Agata Rembielak, MD, PhD, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Joanna Kazmierska, MD, PhD, Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland, Electroradiology Department, University of Medical Sciences, Poznan, Poland; Vassilios Vassiliou, MD, PhD, Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Strovolos, Cyprus; Sara Alcorn, MD, PhD, Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN; Pierluigi Bonomo, MD, Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; and Eva Oldenburger, MD, Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Joanna Kazmierska
- Adrian Wai Chan, MBBS, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; Charles B. Simone II, MD, Department of Radiation Oncology, New York Proton Center, New York, NY; Yvette van der Linden, MD, PhD, Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands, Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands; Peter Hoskin, MD, Mount Vernon Cancer Centre, Northwood, United Kingdom, Division of Cancer Sciences, University of Manchester, United Kingdom; Jay Detsky, MD, PhD, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; J. Isabelle Choi, MD, Department of Radiation Oncology, New York Proton Center, New York, NY, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; S.F. Lee, MD, , Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore; Henry CY Wong, MBBS, Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China, Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China; Henry CY Wong, MBBS, Department of Medicine, UCLA Health, Los Angeles, CA; Srinivas Raman, MD, Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada; Dirk Rades, MD, Department of Radiation Oncology, University of Lübeck, Germany; Agata Rembielak, MD, PhD, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Joanna Kazmierska, MD, PhD, Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland, Electroradiology Department, University of Medical Sciences, Poznan, Poland; Vassilios Vassiliou, MD, PhD, Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Strovolos, Cyprus; Sara Alcorn, MD, PhD, Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN; Pierluigi Bonomo, MD, Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; and Eva Oldenburger, MD, Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Vassilios Vassiliou
- Adrian Wai Chan, MBBS, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; Charles B. Simone II, MD, Department of Radiation Oncology, New York Proton Center, New York, NY; Yvette van der Linden, MD, PhD, Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands, Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands; Peter Hoskin, MD, Mount Vernon Cancer Centre, Northwood, United Kingdom, Division of Cancer Sciences, University of Manchester, United Kingdom; Jay Detsky, MD, PhD, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; J. Isabelle Choi, MD, Department of Radiation Oncology, New York Proton Center, New York, NY, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; S.F. Lee, MD, , Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore; Henry CY Wong, MBBS, Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China, Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China; Henry CY Wong, MBBS, Department of Medicine, UCLA Health, Los Angeles, CA; Srinivas Raman, MD, Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada; Dirk Rades, MD, Department of Radiation Oncology, University of Lübeck, Germany; Agata Rembielak, MD, PhD, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Joanna Kazmierska, MD, PhD, Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland, Electroradiology Department, University of Medical Sciences, Poznan, Poland; Vassilios Vassiliou, MD, PhD, Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Strovolos, Cyprus; Sara Alcorn, MD, PhD, Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN; Pierluigi Bonomo, MD, Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; and Eva Oldenburger, MD, Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Sara Alcorn
- Adrian Wai Chan, MBBS, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; Charles B. Simone II, MD, Department of Radiation Oncology, New York Proton Center, New York, NY; Yvette van der Linden, MD, PhD, Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands, Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands; Peter Hoskin, MD, Mount Vernon Cancer Centre, Northwood, United Kingdom, Division of Cancer Sciences, University of Manchester, United Kingdom; Jay Detsky, MD, PhD, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; J. Isabelle Choi, MD, Department of Radiation Oncology, New York Proton Center, New York, NY, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; S.F. Lee, MD, , Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore; Henry CY Wong, MBBS, Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China, Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China; Henry CY Wong, MBBS, Department of Medicine, UCLA Health, Los Angeles, CA; Srinivas Raman, MD, Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada; Dirk Rades, MD, Department of Radiation Oncology, University of Lübeck, Germany; Agata Rembielak, MD, PhD, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Joanna Kazmierska, MD, PhD, Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland, Electroradiology Department, University of Medical Sciences, Poznan, Poland; Vassilios Vassiliou, MD, PhD, Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Strovolos, Cyprus; Sara Alcorn, MD, PhD, Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN; Pierluigi Bonomo, MD, Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; and Eva Oldenburger, MD, Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Pierluigi Bonomo
- Adrian Wai Chan, MBBS, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; Charles B. Simone II, MD, Department of Radiation Oncology, New York Proton Center, New York, NY; Yvette van der Linden, MD, PhD, Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands, Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands; Peter Hoskin, MD, Mount Vernon Cancer Centre, Northwood, United Kingdom, Division of Cancer Sciences, University of Manchester, United Kingdom; Jay Detsky, MD, PhD, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; J. Isabelle Choi, MD, Department of Radiation Oncology, New York Proton Center, New York, NY, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; S.F. Lee, MD, , Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore; Henry CY Wong, MBBS, Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China, Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China; Henry CY Wong, MBBS, Department of Medicine, UCLA Health, Los Angeles, CA; Srinivas Raman, MD, Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada; Dirk Rades, MD, Department of Radiation Oncology, University of Lübeck, Germany; Agata Rembielak, MD, PhD, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Joanna Kazmierska, MD, PhD, Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland, Electroradiology Department, University of Medical Sciences, Poznan, Poland; Vassilios Vassiliou, MD, PhD, Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Strovolos, Cyprus; Sara Alcorn, MD, PhD, Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN; Pierluigi Bonomo, MD, Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; and Eva Oldenburger, MD, Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Eva Oldenburger
- Adrian Wai Chan, MBBS, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; Charles B. Simone II, MD, Department of Radiation Oncology, New York Proton Center, New York, NY; Yvette van der Linden, MD, PhD, Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands, Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands; Peter Hoskin, MD, Mount Vernon Cancer Centre, Northwood, United Kingdom, Division of Cancer Sciences, University of Manchester, United Kingdom; Jay Detsky, MD, PhD, Department of Radiation Oncology, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Canada; J. Isabelle Choi, MD, Department of Radiation Oncology, New York Proton Center, New York, NY, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; S.F. Lee, MD, , Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore; Henry CY Wong, MBBS, Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China, Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China; Henry CY Wong, MBBS, Department of Medicine, UCLA Health, Los Angeles, CA; Srinivas Raman, MD, Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Canada; Dirk Rades, MD, Department of Radiation Oncology, University of Lübeck, Germany; Agata Rembielak, MD, PhD, Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; Joanna Kazmierska, MD, PhD, Radiotherapy Department II, Greater Poland Cancer Centre, Poznan, Poland, Electroradiology Department, University of Medical Sciences, Poznan, Poland; Vassilios Vassiliou, MD, PhD, Department of Radiation Oncology, Bank of Cyprus Oncology Centre, Strovolos, Cyprus; Sara Alcorn, MD, PhD, Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN; Pierluigi Bonomo, MD, Department of Radiation Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; and Eva Oldenburger, MD, Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
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Chow R, Simone CB, Rimner A. Management of malignant superior vena cava syndrome. Ann Palliat Med 2024; 0:apm-23-573. [PMID: 38600814 DOI: 10.21037/apm-23-573] [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] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
Superior vena cava (SVC) syndrome occurs due to obstructed blood flow through the SVC. It can present clinically on a spectrum, between asymptomatic and life-threatening emergency. Patients commonly report a feeling of fullness in the head, facial, neck and upper extremity edema, and dyspnea. On imaging, patients commonly have superior mediastinal widening and pleural effusion. The majority of cases are due to malignant causes, with non-small cell lung cancer, small cell lung cancer, and lymphoma the most commonly associated malignancies. When evaluating patients, a complete staging workup is recommended, as it will determine whether treatment should be definitive/curative or palliative in intent. If the patient requires urgent treatment of venous obstruction, such as in the cases of acute central airway obstruction, severe laryngeal edema and/or coma from cerebral edema, direct opening of the occlusion by endovascular stenting and angioplasty with thrombolysis should be considered. Such an approach can provide immediate relief of symptoms before cancer-specific therapies are initiated. The intent of treatment is to manage the underlying disease while palliating symptoms. Treatment approaches most commonly employ chemotherapy and/or radiation therapy depending on the primary histology. Mildly hypofractionated radiation regimens are most commonly employed and achieve high rates of symptomatic responses generally within 2 weeks of initiating therapy.
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Affiliation(s)
- Ronald Chow
- New York Proton Center, New York, NY, USA; Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Charles B Simone
- New York Proton Center, New York, NY, USA; Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Evanson D, Griffin M, O'Reilly SE, Johnson T, Werner T, Kothekar E, Jahangiri P, Simone CB, Swisher-McClure S, Feigenberg SJ, Revheim ME, Zou J, Alavi A. Comparative assessment of radiation therapy-induced vasculitis using [ 18F]FDG-PET/CT in patients with non-small cell lung cancer treated with proton versus photon radiotherapy. Eur J Nucl Med Mol Imaging 2024; 51:1444-1450. [PMID: 38095673 PMCID: PMC10957676 DOI: 10.1007/s00259-023-06535-3] [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: 07/20/2023] [Accepted: 11/18/2023] [Indexed: 03/22/2024]
Abstract
PURPOSE To assess radiation therapy (RT)-induced vasculitis in patients with non-small cell lung cancer (NSCLC) by examining changes in the uptake of 18F-fluoro-D-deoxyglucose ([18F]FDG) by positron emission tomography/computed tomography (PET/CT) images of the ascending aorta (AA), descending aorta (DA), and aortic arch (AoA) before and after proton and photon RT. METHOD Thirty-five consecutive locally advanced NSCLC patients were definitively treated with proton (n = 27) or photon (n = 8) RT and concurrent chemotherapy. The patients were prospectively enrolled to undergo [18F]FDG-PET/CT imaging before and 3 months after RT. An adaptive contrast-oriented thresholding algorithm was applied to generate mean standardized uptake values (SUVmean) for regions of interest (ROIs) 3 mm outside and 3 mm inside the outer perimeter of the AA, DA, and AoA. These ROIs were employed to exclusively select the aortic wall and remove the influence of blood pool activity. SUVmeans before and after RT were compared using two-tailed paired t-tests. RESULTS RT treatments were associated with increased SUVmeans in the AA, DA, and AoA-1.9%, 0.3%, and 1.3% for proton and 15.8%, 9.5%, and 15.5% for photon, respectively. There was a statistically significant difference in the ∆SUVmean (post-RT SUVmean - pre-RT SUVmean) in patients treated with photon RT when compared to ∆SUVmean in patients treated with proton RT in the AA (p = 0.043) and AoA (p = 0.015). There was an average increase in SUVmean that was related to dose for photon patients (across structures), but that was not seen for proton patients, although the increase was not statistically significant. CONCLUSION Our results suggest that patients treated with photon RT for NSCLC may exhibit significantly more RT-induced inflammation (measured as ∆SUVmean) in the AA and AoA when compared to patients who received proton RT. Knowledge gained from further analyses in larger cohorts could aid in treatment planning and help prevent the significant morbidity and mortality associated with RT-induced vascular complications. TRIAL REGISTRATION NCT02135679.
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Affiliation(s)
- D Evanson
- Drexel University College of Medicine, Philadelphia, PA, USA
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - M Griffin
- Drexel University College of Medicine, Philadelphia, PA, USA
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - S E O'Reilly
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - T Johnson
- University of Notre Dame, Notre Dame, IN, USA
| | - T Werner
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - E Kothekar
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - P Jahangiri
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - C B Simone
- New York Proton Center, New York, NY, USA
| | - S Swisher-McClure
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - S J Feigenberg
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - M-E Revheim
- The Intervention Center, Oslo University Hospital, Oslo, Norway.
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - J Zou
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - A Alavi
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
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Thor M, Lee C, Sun L, Patel P, Apte A, Grkovski M, Shepherd AF, Gelblum DY, Wu AJ, Simone CB, Chaft JE, Rimner A, Gomez DR, Deasy JO, Shaverdian N. An 18F-FDG PET/CT and Mean Lung Dose Model to Predict Early Radiation Pneumonitis in Stage III Non-Small Cell Lung Cancer Patients Treated with Chemoradiation and Immunotherapy. J Nucl Med 2024; 65:520-526. [PMID: 38485270 PMCID: PMC10995528 DOI: 10.2967/jnumed.123.266965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 01/11/2024] [Indexed: 04/04/2024] Open
Abstract
Radiation pneumonitis (RP) that develops early (i.e., within 3 mo) (RPEarly) after completion of concurrent chemoradiation (cCRT) leads to treatment discontinuation and poorer survival for patients with stage III non-small cell lung cancer. Since no RPEarly risk model exists, we explored whether published RP models and pretreatment 18F-FDG PET/CT-derived features predict RPEarly Methods: One hundred sixty patients with stage III non-small cell lung cancer treated with cCRT and consolidative immunotherapy were analyzed for RPEarly Three published RP models that included the mean lung dose (MLD) and patient characteristics were examined. Pretreatment 18F-FDG PET/CT normal-lung SUV featured included the following: 10th percentile of SUV (SUVP10), 90th percentile of SUV (SUVP90), SUVmax, SUVmean, minimum SUV, and SD. Associations between models/features and RPEarly were assessed using area under the receiver-operating characteristic curve (AUC), P values, and the Hosmer-Lemeshow test (pHL). The cohort was randomly split, with similar RPEarly rates, into a 70%/30% derivation/internal validation subset. Results: Twenty (13%) patients developed RPEarly Predictors for RPEarly were MLD alone (AUC, 0.72; P = 0.02; pHL, 0.87), SUVP10, SUVP90, and SUVmean (AUC, 0.70-0.74; P = 0.003-0.006; pHL, 0.67-0.70). The combined MLD and SUVP90 model generalized in the validation subset and was deemed the final RPEarly model (RPEarly risk = 1/[1+e(- x )]; x = -6.08 + [0.17 × MLD] + [1.63 × SUVP90]). The final model refitted in the 160 patients indicated improvement over the published MLD-alone model (AUC, 0.77 vs. 0.72; P = 0.0001 vs. 0.02; pHL, 0.65 vs. 0.87). Conclusion: Patients at risk for RPEarly can be detected with high certainty by combining the normal lung's MLD and pretreatment 18F-FDG PET/CT SUVP90 This refined model can be used to identify patients at an elevated risk for premature immunotherapy discontinuation due to RPEarly and could allow for interventions to improve treatment outcomes.
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Affiliation(s)
- Maria Thor
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York;
| | - Chen Lee
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lian Sun
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Purvi Patel
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Aditya Apte
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Milan Grkovski
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Annemarie F Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; and
| | - Daphna Y Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; and
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; and
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; and
| | - Jamie E Chaft
- Thoracic Oncology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; and
| | - Daniel R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; and
| | - Joseph O Deasy
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Narek Shaverdian
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; and
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Rimner A, Ahmad U, Lobaugh SM, Zhang Z, Shepherd AF, Huang J, Antonicelli A, Girard N, Moser B, Filosso P, Lucchi M, Marom EM, Roden A, Detterbeck F, Ruffini E, Simone CB. Postoperative Radiation Therapy for Thymic Carcinoma: An Analysis of the International Thymic Malignancy Interest Group/European Society of Thoracic Surgeons Database. J Thorac Oncol 2024; 19:626-635. [PMID: 38070599 DOI: 10.1016/j.jtho.2023.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 11/28/2023] [Accepted: 12/04/2023] [Indexed: 01/06/2024]
Abstract
INTRODUCTION R0 resection and radiation therapy have been associated with improved overall survival (OS) in patients with thymic carcinoma (TC). Here, we analyzed which subgroups of patients derive the greatest benefit from postoperative radiation therapy (PORT). METHODS Clinical, pathologic, treatment, and survival information of 462 patients with TC from the International Thymic Malignancy Interest Group/European Society of Thoracic Surgeons database were analyzed. Variables included age, sex, continent of treatment, paraneoplastic syndrome, carcinoma subtype, tumor size, pathologic Masaoka stage, resection status, and use of chemotherapy. OS was the primary end point using the Kaplan-Meier method. Time to recurrence (TTR) was the secondary end point using a competing risk analysis. A 3-month landmark analysis was performed. RESULTS PORT was associated with a significant OS benefit (5-y OS 68% versus 53%, p = 0.002). In patients with R0 resection, PORT was associated with increased OS for advanced (stages III-IV, p = 0.04), but not early (stages I-II, p = 0.14) stage TC. In patients with an R1/2 resection of advanced-stage TC, PORT was associated with significantly longer OS (5-y OS 53% versus 38%; p < 0.001). Subset analyses did not reveal clear associations of PORT with TTR. On multivariable analysis, lower pathologic stage, PORT, and R0 resection status were associated with an OS benefit, whereas only higher age and lower pathologic stage had an association with longer TTR. CONCLUSIONS In the largest individual patient data set on patients with TC reported to date, PORT was associated with a meaningful OS benefit in patients with advanced-stage TC after an R0 or R1/2 resection.
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Affiliation(s)
- Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Usman Ahmad
- Department of Thoracic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Stephanie M Lobaugh
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Zhigang Zhang
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Annemarie F Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - James Huang
- Department of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alberto Antonicelli
- Department of Thoracic Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Nicolas Girard
- Department of Thoracic Oncology, Institut Curie, Paris, France
| | - Bernhard Moser
- Department of Thoracic Surgery, University of Vienna, Vienna, Austria
| | | | - Marco Lucchi
- Division of Thoracic Surgery, Cardiac and Thoracic Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Edith M Marom
- Department of Diagnostic Imaging, Chaim Sheba Medical Center, Tel-Aviv University, Ramat Gan, Israel
| | - Anja Roden
- Department of Pathology, Mayo Clinic, Rochester, Minnesota
| | - Frank Detterbeck
- Department of Thoracic Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Enrico Ruffini
- Department of Thoracic Surgery, University of Torino, Turin, Italy
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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Shin JY, Offin M, Simone CB, Shepherd AF, Wu AJ, Shaverdian N, Gelblum DY, Gomez DR, Sauter JL, Ginsberg MS, Adusumilli PS, Rusch VW, Zauderer MG, Rimner A. Response letter to "Stereotactic body radiation therapy for pleural mesothelioma: Which goal, which patients". Radiother Oncol 2024; 193:110138. [PMID: 38342346 DOI: 10.1016/j.radonc.2024.110138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 02/01/2024] [Indexed: 02/13/2024]
Affiliation(s)
- Jacob Y Shin
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA.
| | - Michael Offin
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Annemarie F Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Narek Shaverdian
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Daphna Y Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Daniel R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Jennifer L Sauter
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Michelle S Ginsberg
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Prasad S Adusumilli
- Department of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Valerie W Rusch
- Department of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Marjorie G Zauderer
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
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15
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Hardy-Abeloos C, Gorovets D, Lewis A, Ji W, Lozano A, Tung CC, Yu F, Hanlon A, Lin H, Kha A, Yamada Y, Kabarriti R, Lazarev S, Hasan S, Chhabra AM, Simone CB, Choi JI. Prospective evaluation of patient-reported outcomes of invisible ink tattoos for the delivery of external beam radiation therapy: the PREFER trial. Front Oncol 2024; 14:1374258. [PMID: 38590650 PMCID: PMC10999588 DOI: 10.3389/fonc.2024.1374258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 03/11/2024] [Indexed: 04/10/2024] Open
Abstract
Introduction Invisible ink tattoos (IITs) avoid cosmetic permanence of visible ink tattoos (VITs) while serving as more reliable landmarks for radiation setup than tattooless setups. This trial evaluated patient-reported preference and feasibility of IIT implementation. Methods and materials In an IRB-approved, single institution, prospective trial, patients receiving proton therapy underwent IIT-based treatment setup. A survey tool assessed patient preference on tattoos using a Likert scale. Matched patients treated using our institutional standard tattooless setup were identified; treatment times and image guidance requirements were evaluated between tattooless and IIT-based alignment approaches. Distribution differences were estimated using Wilcoxon rank-sum tests or Chi-square tests. Results Of 94 eligible patients enrolled, median age was 58 years, and 58.5% were female. Most common treatment sites were breast (18.1%), lung (17.0%) and pelvic (14.9%). Patients preferred to receive IITs versus VITs (79.8% pre-treatment and 75.5% post-treatment, respectively). Patients were willing to travel farther from home to avoid VITs versus IITs (p<0.01). Females were willing to travel (45.5% vs. 23.1%; p=0.04) and pay additional money to avoid VITs (34.5% vs. 5.1%; p<0.01). Per-fraction average +treatment time and time from on table/in room to first beam were shorter with IIT-based vs. tattooless setup (12.3min vs. 14.1min; p=0.04 and 24.1min vs. 26.2min; p=0.02, respectively). Discussion In the largest prospective trial on IIT-based radiotherapy setup to date, we found that patients prefer IITs to VITs. Additionally, IIT-based alignment is an effective and efficient strategy in comparison with tattooless setup. Standard incorporation of IITs for patient setup should be strongly considered.
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Affiliation(s)
- Camille Hardy-Abeloos
- Department of Radiation Oncology, NYU School of Medicine, New York, NY, United States
| | - Daniel Gorovets
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- New York Proton Center, New York, NY, United States
| | - Aurora Lewis
- New York Proton Center, New York, NY, United States
- Rutgers Robert Wood Johnson Medical School, Newark, NJ, United States
| | - Wenyan Ji
- Center for Biostatistics and Health Data Science, Department of Statistics, Virginia Tech, Roanoke, VA, United States
| | - Alicia Lozano
- Center for Biostatistics and Health Data Science, Department of Statistics, Virginia Tech, Roanoke, VA, United States
| | | | - Francis Yu
- New York Proton Center, New York, NY, United States
| | - Alexandra Hanlon
- Center for Biostatistics and Health Data Science, Department of Statistics, Virginia Tech, Roanoke, VA, United States
| | - Haibo Lin
- New York Proton Center, New York, NY, United States
| | - Anh Kha
- New York Proton Center, New York, NY, United States
| | - Yoshiya Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- New York Proton Center, New York, NY, United States
| | - Rafi Kabarriti
- New York Proton Center, New York, NY, United States
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, United States
| | - Stanislav Lazarev
- New York Proton Center, New York, NY, United States
- Department of Radiation Oncology, Mount Sinai Health System, New York, NY, United States
| | - Shaakir Hasan
- New York Proton Center, New York, NY, United States
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, United States
| | - Arpit M. Chhabra
- New York Proton Center, New York, NY, United States
- Department of Radiation Oncology, Mount Sinai Health System, New York, NY, United States
| | - Charles B. Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- New York Proton Center, New York, NY, United States
| | - J. Isabelle Choi
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- New York Proton Center, New York, NY, United States
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16
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Rades D, Simone CB, Wong HCY, Chow E, Lee SF, Johnstone PAS. Reirradiation of metastases of the central nervous system: part 2-metastatic epidural spinal cord compression. Ann Palliat Med 2024; 0:apm-23-594. [PMID: 38600819 DOI: 10.21037/apm-23-594] [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] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
An increasing number of patients irradiated for metastatic epidural spinal cord compression (MESCC) experience an in-field recurrence and require a second course of radiotherapy. Reirradiation can be performed with conventional radiotherapy or highly-conformal techniques such as intensity-modulated radiation therapy (IMRT), volumetric modulated arc therapy (VMAT), and stereotactic body radiation therapy (SBRT). When using conventional radiotherapy, a cumulative biologically effective dose (BED) ≤120 calculated with an α/β value of 2 Gy (Gy2) was not associated with radiation myelopathy in a retrospective study of 124 patients and is considered safe. In that study, conventional reirradiation led to improvements of motor deficits in 36% of patients and stopped further symptomatic progression in another 50% (overall response 86%). In four other studies, overall response rates were 82-89%. In addition to the cumulative BED or equivalent dose in 2 Gy fractions (EQD2), the interval between both radiotherapy courses <6 months and a BED per course ≥102 Gy2 (corresponding to an EQD2 ≥51 Gy2) were identified as risk factors for radiation myelopathy. Without these risk factors, a BED >120 Gy2 may be possible. Scoring tools have been developed that can assist physicians in estimating the risk of radiation myelopathy and selecting the appropriate dose-fractionation regimen of re-treatment. Reirradiation of MESCC may also be performed with highly-conformal radiotherapy. With IMRT or VMAT, rates of pain relief and improvement of neurologic symptoms of 60-93.5% and 42-73%, respectively, were achieved. One-year local control rates ranged between 55% and 88%. Rates of myelopathy or radiculopathy and vertebral compression fractures were 0% and 0-9.3%, respectively. With SBRT, rates of pain relief were 65-86%. Two studies reported improvements in neurologic symptoms of 0% and 82%, respectively. One-year local control rates were 74-83%. Rates of myelopathy or radiculopathy and vertebral compression fractures were 0-4.5% and 4.5-13.8%, respectively. For SBRT, a cumulative maximum EQD2 to thecal sac ≤70 Gy2, a maximum EQD2 of SBRT ≤25 Gy2, a ratio ≤0.5 of thecal sac maximum EQD2 of SBRT to maximum cumulative EQD2, and an interval between both courses ≥5 months were associated with a lower risk of myelopathy. Additional prospective trials are required to better define the options of reirradiation of MESCC.
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Affiliation(s)
- Dirk Rades
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany
| | | | - Henry C Y Wong
- Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong, China
| | - Edward Chow
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Shing Fung Lee
- Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore, Singapore
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17
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Rades D, Simone CB, Wong HCY, Chow E, Lee SF, Johnstone PAS. Reirradiation of metastases of the central nervous system: part 1-brain metastasis. Ann Palliat Med 2024; 0:apm-23-593. [PMID: 38509654 DOI: 10.21037/apm-23-593] [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] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
Because of improved survival of cancer patients, more patients irradiated for brain metastases develop intracerebral recurrences requiring subsequent courses of radiotherapy. Five studies focused on reirradiation with whole-brain radiation therapy (WBRT) after initial WBRT for brain metastases. Following the second WBRT course, improvement of clinical symptoms was found in 31-68% of patients. Rates of neurotoxicity, such as encephalopathy or cognitive decline, were reported in two studies (1.4% and 32%). In another study, severe or unexpected adverse events were not observed. Survival following the second WBRT course was generally poor, with median survival times of 2.9-4.1 months. The survival prognosis of patients receiving two courses of WBRT can be estimated by a scoring tool considering five prognostic factors. Three studies investigated reirradiation with single-fraction stereotactic radiosurgery (SF-SRS) following primary WBRT. One-year local control rates were 74-91%, and median survival times ranged between 7.8 and 14 months. Rates of radiation necrosis (RN) after reirradiation were 0-6%. Seven studies were considered that investigated re-treatment with SF-SRS or fractionated stereotactic radiation therapy (FSRT) following initial SF-SRS or FSRT. One-year local control rates were 60-88%, and the median survival times ranged between 8.3 and 25 months. During follow-up after reirradiation, rates of overall (asymptomatic or symptomatic) RN ranged between 12.5% and 30.4%. Symptomatic RN occurred in 4.3% to 23.9% of cases (patients or lesions). The risk of RN associated with symptoms and/or requiring surgery or corticosteroids appears lower after reirradiation with FSRT when compared to SF-SRS. Other potential risk factors of RN include the volume of overlap of normal tissue receiving 12 Gy at the first course and 18 Gy at the second course of SF-SRS, maximum doses ≥40 Gy of the first or the second SF-SRS courses, V12 Gy >9 cm3 of the second course, initial treatment with SF-SRS, volume of normal brain receiving 5 Gy during reirradiation with FSRT, and systemic treatment. Cumulative EQD2 ≤100-120 Gy2 to brain, <100 Gy2 to brainstem, and <75 Gy2 to chiasm and optic nerves may be considered safe. Since most studies were retrospective in nature, prospective trials are required to better define safety and efficacy of reirradiation for recurrent or progressive brain metastases.
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Affiliation(s)
- Dirk Rades
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany
| | | | - Henry C Y Wong
- Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong, China
| | - Edward Chow
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Shing Fung Lee
- Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore, Singapore
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18
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Daugherty EC, Zhang Y, Xiao Z, Mascia AE, Sertorio M, Woo J, McCann C, Russell KJ, Sharma RA, Khuntia D, Bradley JD, Simone CB, Breneman JC, Perentesis JP. FLASH radiotherapy for the treatment of symptomatic bone metastases in the thorax (FAST-02): protocol for a prospective study of a novel radiotherapy approach. Radiat Oncol 2024; 19:34. [PMID: 38475815 PMCID: PMC10935811 DOI: 10.1186/s13014-024-02419-4] [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: 09/21/2023] [Accepted: 02/08/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND FLASH therapy is a treatment technique in which radiation is delivered at ultra-high dose rates (≥ 40 Gy/s). The first-in-human FAST-01 clinical trial demonstrated the clinical feasibility of proton FLASH in the treatment of extremity bone metastases. The objectives of this investigation are to assess the toxicities of treatment and pain relief in study participants with painful thoracic bone metastases treated with FLASH radiotherapy, as well as workflow metrics in a clinical setting. METHODS This single-arm clinical trial is being conducted under an FDA investigational device exemption (IDE) approved for 10 patients with 1-3 painful bone metastases in the thorax, excluding bone metastases in the spine. Treatment will be 8 Gy in a single fraction administered at ≥ 40 Gy/s on a FLASH-enabled proton therapy system delivering a single transmission proton beam. Primary study endpoints are efficacy (pain relief) and safety. Patient questionnaires evaluating pain flare at the treatment site will be completed for 10 consecutive days post-RT. Pain response and adverse events (AEs) will be evaluated on the day of treatment and on day 7, day 15, months 1, 2, 3, 6, 9, and 12, and every 6 months thereafter. The outcomes for clinical workflow feasibility are the occurrence of any device issues as well as time on the treatment table. DISCUSSION This prospective clinical trial will provide clinical data for evaluating the efficacy and safety of proton FLASH for palliation of bony metastases in the thorax. Positive findings will support the further exploration of FLASH radiation for other clinical indications including patient populations treated with curative intent. REGISTRATION ClinicalTrials.gov NCT05524064.
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Affiliation(s)
- E C Daugherty
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - Y Zhang
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH, USA
- Cancer and Blood Disease Institute , Cincinnati Children's Hospital , Cincinnati, OH, USA
| | - Z Xiao
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH, USA
- Cancer and Blood Disease Institute , Cincinnati Children's Hospital , Cincinnati, OH, USA
| | - A E Mascia
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH, USA
- Cancer and Blood Disease Institute , Cincinnati Children's Hospital , Cincinnati, OH, USA
| | - M Sertorio
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - J Woo
- Varian, a Siemens Healthineers Company, Palo Alto, USA
| | - C McCann
- Varian, a Siemens Healthineers Company, Palo Alto, USA
| | - K J Russell
- Varian, a Siemens Healthineers Company, Palo Alto, USA
| | - R A Sharma
- Varian, a Siemens Healthineers Company, Palo Alto, USA
| | - D Khuntia
- Varian, a Siemens Healthineers Company, Palo Alto, USA
| | - J D Bradley
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - C B Simone
- Department of Radiation Oncology, New York Proton Center , New York, NY, USA
| | - J C Breneman
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - J P Perentesis
- Cancer and Blood Disease Institute , Cincinnati Children's Hospital , Cincinnati, OH, USA.
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Sabouri P, Molitoris J, Ranjbar M, Moreau J, Simone CB, Mohindra P, Langen K, Mossahebi S. Dosimetric Evaluation and Reproducibility of Breath-hold Plans in Intensity Modulated Proton Therapy: An Initial Clinical Experience. Adv Radiat Oncol 2024; 9:101392. [PMID: 38292885 PMCID: PMC10826160 DOI: 10.1016/j.adro.2023.101392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 10/05/2023] [Indexed: 02/01/2024] Open
Abstract
Purpose Breath-hold (BH) technique can mitigate target motion, minimize target margins, reduce normal tissue doses, and lower the effect of interplay effects with intensity-modulated proton therapy (IMPT). This study presents dosimetric comparisons between BH and nonbreath-hold (non-BH) IMPT plans and investigates the reproducibility of BH plans using frequent quality assurance (QA) computed tomography scans (CT). Methods and Materials Data from 77 consecutive patients with liver (n = 32), mediastinal/lung (n = 21), nonliver upper abdomen (n = 20), and malignancies in the gastroesophageal junction (n = 4), that were treated with a BH spirometry system (SDX) were evaluated. All patients underwent both BH CT and 4-dimensional CT simulations. Clinically acceptable BH and non-BH plans were generated on each scan, and dose-volume histograms of the 2 plans were compared. Reproducibility of the BH plans for 30 consecutive patients was assessed using 1 to 3 QA CTs per patient and variations in dose-volume histograms for deformed target and organs at risk (OARs) volumes were compared with the initial CT plan. Results Use of BH scans reduced initial and boost target volumes to 72% ± 20% and 70% ± 17% of non-BH volumes, respectively. Additionally, mean dose to liver, stomach, kidney, esophagus, heart, and lung V20 were each reduced to 71% to 79% with the BH technique. Similarly, small and large bowels, heart, and spinal cord maximum doses were each lowered to 68% to 84%. Analysis of 62 QA CT scans demonstrated that mean target and OAR doses using BH scans were reproducible to within 5% of their nominal plan values. Conclusions The BH technique reduces the irradiated volume, leading to clinically significant reductions in OAR doses. By mitigating tumor motion, the BH technique leads to reproducible target coverage and OAR doses. Its use can reduce motion-related uncertainties that are normally associated with the treatment of thoracic and abdominal tumors and, therefore, optimize IMPT delivery.
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Affiliation(s)
- Pouya Sabouri
- Department of Radiation Oncology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Jason Molitoris
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
- Maryland Proton Treatment Center, Baltimore, Maryland
| | - Maida Ranjbar
- Department of Radiation Oncology, University of California San Diego, La Jolla, California
| | | | | | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
- Maryland Proton Treatment Center, Baltimore, Maryland
| | - Katja Langen
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | - Sina Mossahebi
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
- Maryland Proton Treatment Center, Baltimore, Maryland
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20
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Martin EJ, Bruggeman AR, Chang E, Alcorn S, Tseng YD, Mattes MD, Robbins JR, Johnstone C, Simone CB. Society for Palliative Radiation Oncology: report from the Tenth Annual Meeting (2023). Ann Palliat Med 2024; 13:465-467. [PMID: 38584477 DOI: 10.21037/apm-24-25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 02/27/2024] [Indexed: 04/09/2024]
Affiliation(s)
- Emily J Martin
- Department of Medicine, University of California, Los Angeles, CA, USA
| | | | - Eric Chang
- Department of Radiation Oncology, Northwest Permanente, Portland, OR, USA
| | - Sara Alcorn
- Department of Radiation Oncology, University of Minnesota, Minneapolis, MN, USA
| | - Yolanda D Tseng
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Malcolm D Mattes
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Jared R Robbins
- Department of Radiation Oncology, University of Arizona Cancer Center, Phoenix, AZ, USA
| | - Candice Johnstone
- Department of Radiation Oncology, Medical college of Wisconsin, Milwaukee, WI, USA
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21
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Simone CB. The optimal timing of oral anticoagulation therapy for ischemic stroke management. Ann Palliat Med 2024; 13:208-210. [PMID: 38584478 DOI: 10.21037/apm-24-47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 03/20/2024] [Indexed: 04/09/2024]
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22
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Isabelle Choi J, Wojcieszynski A, Amos RA, Giap H, Apisarnthanarax S, Ashman JB, Anand A, Perles LA, Williamson T, Ramkumar S, Molitoris J, Simone CB, Chuong MD. PTCOG Gastrointestinal Subcommittee Lower Gastrointestinal Tract Malignancies Consensus Statement. Int J Part Ther 2024; 11:100019. [PMID: 38757077 PMCID: PMC11095104 DOI: 10.1016/j.ijpt.2024.100019] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 01/02/2024] [Indexed: 05/18/2024] Open
Abstract
Purpose Radiotherapy delivery in the definitive management of lower gastrointestinal (LGI) tract malignancies is associated with substantial risk of acute and late gastrointestinal (GI), genitourinary, dermatologic, and hematologic toxicities. Advanced radiation therapy techniques such as proton beam therapy (PBT) offer optimal dosimetric sparing of critical organs at risk, achieving a more favorable therapeutic ratio compared with photon therapy. Materials and Methods The international Particle Therapy Cooperative Group GI Subcommittee conducted a systematic literature review, from which consensus recommendations were developed on the application of PBT for LGI malignancies. Results Eleven recommendations on clinical indications for which PBT should be considered are presented with supporting literature, and each recommendation was assessed for level of evidence and strength of recommendation. Detailed technical guidelines pertaining to simulation, treatment planning and delivery, and image guidance are also provided. Conclusion PBT may be of significant value in select patients with LGI malignancies. Additional clinical data are needed to further elucidate the potential benefits of PBT for patients with anal cancer and rectal cancer.
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Affiliation(s)
- J. Isabelle Choi
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- New York Proton Center, New York, New York, USA
| | | | - Richard A. Amos
- Department of Medical Physics & Biomedical Engineering, University College London, London, UK
| | - Huan Giap
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Smith Apisarnthanarax
- Department of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | | | - Aman Anand
- Department of Radiation Oncology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Luis A. Perles
- Department of Radiation Physics, UT MD Anderson Cancer Center, Houston, Texas, USA
| | - Tyler Williamson
- Department of Radiation Physics, UT MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Jason Molitoris
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Charles B. Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- New York Proton Center, New York, New York, USA
| | - Michael D. Chuong
- Department of Radiation Oncology, Miami Cancer Institute, Miami, Florida, USA
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23
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Shen J, Taylor PA, Vargas CE, Kang M, Saini J, Zhou J, Wang P, Liu W, Simone CB, Xiao Y, Lin L. The Status and Challenges for Prostate Stereotactic Body Radiation Therapy Treatments in United States Proton Therapy Centers: An NRG Oncology Practice Survey. Int J Part Ther 2024; 11:100020. [PMID: 38757080 PMCID: PMC11095093 DOI: 10.1016/j.ijpt.2024.100020] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 02/17/2024] [Accepted: 02/20/2024] [Indexed: 05/18/2024] Open
Abstract
Purpose To report the current practice pattern of the proton stereotactic body radiation therapy (SBRT) for prostate treatments. Materials and Methods A survey was designed to inquire about the practice of proton SBRT treatment for prostate cancer. The survey was distributed to all 30 proton therapy centers in the United States that participate in the National Clinical Trial Network in February, 2023. The survey focused on usage, patient selection criteria, prescriptions, target contours, dose constraints, treatment plan optimization and evaluation methods, patient-specific QA, and image-guided radiation therapy (IGRT) methods. Results We received responses from 25 centers (83% participation). Only 8 respondent proton centers (32%) reported performing SBRT of the prostate. The remaining 17 centers cited 3 primary reasons for not offering this treatment: no clinical need, lack of volumetric imaging, and/or lack of clinical evidence. Only 1 center cited the reduction in overall reimbursement as a concern for not offering prostate SBRT. Several common practices among the 8 centers offering SBRT for the prostate were noted, such as using Hydrogel spacers, fiducial markers, and magnetic resonance imaging (MRI) for target delineation. Most proton centers (87.5%) utilized pencil beam scanning (PBS) delivery and completed Imaging and Radiation Oncology Core (IROC) phantom credentialing. Treatment planning typically used parallel opposed lateral beams, and consistent parameters for setup and range uncertainties were used for plan optimization and robustness evaluation. Measurements-based patient-specific QA, beam delivery every other day, fiducial contours for IGRT, and total doses of 35 to 40 GyRBE were consistent across all centers. However, there was no consensus on the risk levels for patient selection. Conclusion Prostate SBRT is used in about 1/3 of proton centers in the US. There was a significant consistency in practices among proton centers treating with proton SBRT. It is possible that the adoption of proton SBRT may become more common if proton SBRT is more commonly offered in clinical trials.
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Affiliation(s)
| | | | | | | | | | - Jun Zhou
- Emory University, Atlanta, Georgia, USA
| | | | - Wei Liu
- Mayo Clinic Arizona, Phoenix, Arizona, USA
| | | | - Ying Xiao
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Hasan S, Verma V, Abel S, Wegner RE, Choi JI, Press RH, Chhabra A, Simone CB. Differences in Patterns of Care and Referral Between Proton and Photon Therapy. Int J Part Ther 2024; 11:100005. [PMID: 38757072 PMCID: PMC11095099 DOI: 10.1016/j.ijpt.2023.10.001] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 10/26/2023] [Accepted: 10/27/2023] [Indexed: 05/18/2024] Open
Abstract
Purpose To report demographic and clinical characteristics of patients who were more likely to receive proton beam therapy (PBT) than photon therapy from facilities with access to proton centers. Materials and Methods We utilized the national cancer database to identify the facilities with access to PBT between 2004 and 2015 and compared the relative usage of photons and PBT for demographic and clinical scenarios in breast, prostate, and nonsmall cell cancer. Results In total, 231 facilities with access to proton centers accounted for 168 323 breast, 39 975 lung, and 77 297 prostate cancer patients treated definitively. Proton beam therapy was used in 0.5%, 1.5%, and 8.9% of breast, lung, and prostate cases. Proton beam therapy was correlated with a farther distance traveled and longer start time from diagnosis for each site (P < .05).For breast, demographic correlates of PBT were treatment in the west coast (odds ratio [OR] = 4.81), age <60 (OR = 1.25), white race (OR = 1.94), and metropolitan area (OR = 1.58). Left-sided cancers (OR = 1.28), N2 (OR = 1.71), non-ER+/PR+/Her2Neu- cancers (OR = 1.24), accelerated partial breast irradiation (OR = 1.98), and hypofractionation (OR = 2.35) were predictors of PBT.For nonsmall cell cancer, demographic correlates of PBT were treatment in the south (OR = 2.6), metropolitan area (OR = 1.72), and Medicare insurance (OR = 1.64). Higher comorbid score (OR = 1.36), later year treated (OR = 3.16), and hypofractionation (not SBRT) (OR = 3.7) were predictors of PBT.For prostate, correlates of PBT were treatment in the west coast (OR = 2.48), age <70 (OR = 1.19), white race (OR = 1.41), metropolitan area (OR = 1.25), higher income/education (OR = 1.25), and treatment at an academic center (OR = 33.94). Lower comorbidity score (OR = 1.42), later year treated (OR = 1.37), low-risk disease (OR = 1.45), definitive compared to postoperative (OR = 6.10), and conventional fractionation (OR = 1.64) were predictors of PBT. Conclusion Even for facilities with established referrals to proton centers, PBT utilization was low; socioeconomic status was potentially a factor. Proton beam therapy was more often used with left-sided breast and low-risk prostate cancers, without a clear clinical pattern in lung cancer.
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Affiliation(s)
- Shaakir Hasan
- Department of Radiation Oncology, Allegheny Health Network, Pittsburgh, PA, USA
- New York Proton Center, New York, NY, USA
| | - Vivek Verma
- Department of Radiation Oncology, Allegheny Health Network, Pittsburgh, PA, USA
| | - Stephen Abel
- Department of Radiation Oncology, Allegheny Health Network, Pittsburgh, PA, USA
| | - Rodney E. Wegner
- Department of Radiation Oncology, Allegheny Health Network, Pittsburgh, PA, USA
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25
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Gullhaug A, Haakensen VD, De Ruysscher D, Simone CB, Hotca-Cho AE, Chhabra AM, Hellebust TP, Paulsen EE, Dimopoulos MP, Johansen S. Lung cancer reirradiation: Exploring modifications to utilization, treatment modalities and factors associated with outcomes. J Med Imaging Radiat Sci 2024:S1939-8654(24)00018-3. [PMID: 38429174 DOI: 10.1016/j.jmir.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 01/18/2024] [Accepted: 02/02/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND Patients treated for lung cancer (LC) often experience locoregional failure after initial treatment. Due to technological advances, thoracic reirradiation (re-RT) has become a viable treatment option. We sought to investigate the use of thoracic re-RT in LC patients over a time period characterized by technological advances in a large, multi-center cohort. METHODS AND MATERIALS LC patients treated with thoracic re-RT in two University Hospitals from 2010-2020 were identified. Clinical variables and RT data were extracted from the medical records and treatment planning systems. Overall survival (OS) was calculated from the last day of re-RT until death or last follow up. RESULTS 296 patients (small cell LC n=30, non-small cell LC n=266) were included. Three-dimensional conformal radiation therapy was the RT technique used most frequently (63%), and 86% of all patients were referred for re-RT with palliative treatment intent. During the second half of the study period, the use of thoracic re-RT increased in general, more patients received curative re-RT, and there was an increased use of stereotactic body radiation therapy (SBRT). Median time between initial RT and re-RT was 18 months (range 1-213 months). Only 83/296 patients had combined treatment plans that allowed for registration of combined doses to organs at risk (OAR). Most of the combined doses to OAR were below recommendations from guidelines. Multivariate analysis showed superior OS (p<0.05) in patients treated with curative intent, SBRT or intensity modulated radiation therapy or had excellent performance status prior to re-RT. CONCLUSIONS The use of re-RT increased in the second half of the study period, although 2020 did not follow the trend. The use of SBRT and IMRT became more frequent over the years, yet the majority received palliative re-RT. Combined dose plans were only created for one third of the patients.
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Affiliation(s)
- Anna Gullhaug
- Department of Life Sciences and Health, Oslo Metropolitan University, Faculty of Health Sciences, Oslo, Norway; Department of Oncology, Oslo University Hospital, Oslo, Norway.
| | - Vilde D Haakensen
- Department of Oncology, Oslo University Hospital, Oslo, Norway; Department of Cancer Genetics, Institute for Cancer Research, Oslo University Hospital, Oslo, Norway
| | - Dirk De Ruysscher
- Department of Radiation Oncology (Maastro), Maastricht University Medical Center, GROW School for Oncology and Developmental Biology, the Netherlands
| | - Charles B Simone
- New York Proton Center and Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Alexandra E Hotca-Cho
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, USA
| | | | - Taran P Hellebust
- Department of Medical Physics, Oslo University Hospital, Oslo, Norway; Department of Physics, University of Oslo, Oslo, Norway
| | - Erna E Paulsen
- Department of Clinical Medicine, UiT, The Arctic University of Norway, Tromso, Norway; Department of Oncology, University Hospital of North Norway, Tromso, Norway
| | - Maria P Dimopoulos
- Department of Radiation Oncology, Mount Sinai Health System, New York, New York, USA
| | - Safora Johansen
- Department of Life Sciences and Health, Oslo Metropolitan University, Faculty of Health Sciences, Oslo, Norway; Department of Oncology, Oslo University Hospital, Oslo, Norway; Singapore institute of Technology, Health and Social Sciences, Singapore
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26
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Liu W, Feng H, Taylor PA, Kang M, Shen J, Saini J, Zhou J, Giap HB, Yu NY, Sio TS, Mohindra P, Chang JY, Bradley JD, Xiao Y, Simone CB, Lin L. NRG Oncology and PTCOG Patterns of Practice Survey and Consensus Recommendations on Pencil-Beam Scanning Proton Stereotactic Body Radiation Therapy and Hypofractionated Radiation Therapy for Thoracic Malignancies. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00297-9. [PMID: 38395086 DOI: 10.1016/j.ijrobp.2024.01.216] [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: 06/24/2023] [Revised: 11/25/2023] [Accepted: 01/28/2024] [Indexed: 02/25/2024]
Abstract
Stereotactic body radiation therapy (SBRT) and hypofractionation using pencil-beam scanning (PBS) proton therapy (PBSPT) is an attractive option for thoracic malignancies. Combining the advantages of target coverage conformity and critical organ sparing from both PBSPT and SBRT, this new delivery technique has great potential to improve the therapeutic ratio, particularly for tumors near critical organs. Safe and effective implementation of PBSPT SBRT/hypofractionation to treat thoracic malignancies is more challenging than the conventionally fractionated PBSPT because of concerns of amplified uncertainties at the larger dose per fraction. The NRG Oncology and Particle Therapy Cooperative Group Thoracic Subcommittee surveyed proton centers in the United States to identify practice patterns of thoracic PBSPT SBRT/hypofractionation. From these patterns, we present recommendations for future technical development of proton SBRT/hypofractionation for thoracic treatment. Among other points, the recommendations highlight the need for volumetric image guidance and multiple computed tomography-based robust optimization and robustness tools to minimize further the effect of uncertainties associated with respiratory motion. Advances in direct motion analysis techniques are urgently needed to supplement current motion management techniques.
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Affiliation(s)
- Wei Liu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona.
| | - Hongying Feng
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona; College of Mechanical and Power Engineering, China Three Gorges University, Yichang, Hubei, China; Department of Radiation Oncology, Guangzhou Concord Cancer Center, Guangzhou, Guangdong, China
| | - Paige A Taylor
- Imaging and Radiation Oncology Core Houston Quality Assurance Center, University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Jiajian Shen
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Jatinder Saini
- Seattle Cancer Care Alliance Proton Therapy Center and Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington
| | - Jun Zhou
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Huan B Giap
- Department of Radiation Oncology, Medical University of South Carolina, Charleston, South Carolina
| | - Nathan Y Yu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Terence S Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Pranshu Mohindra
- Department of Radiation Oncology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Joe Y Chang
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jeffrey D Bradley
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ying Xiao
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Liyong Lin
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
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27
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Kaulfers T, Lattery G, Cheng C, Zhao X, Selvaraj B, Wu H, Chhabra AM, Choi JI, Lin H, Simone CB, Hasan S, Kang M, Chang J. Pencil Beam Scanning Proton Bragg Peak Conformal FLASH in Prostate Cancer Stereotactic Body Radiotherapy. Cancers (Basel) 2024; 16:798. [PMID: 38398188 PMCID: PMC10886659 DOI: 10.3390/cancers16040798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/29/2024] [Accepted: 02/12/2024] [Indexed: 02/25/2024] Open
Abstract
Bragg peak FLASH radiotherapy (RT) uses a distal tracking method to eliminate exit doses and can achieve superior OAR sparing. This study explores the application of this novel method in stereotactic body radiotherapy prostate FLASH-RT. An in-house platform was developed to enable intensity-modulated proton therapy (IMPT) planning using a single-energy Bragg peak distal tracking method. The patients involved in the study were previously treated with proton stereotactic body radiotherapy (SBRT) using the pencil beam scanning (PBS) technique to 40 Gy in five fractions. FLASH plans were optimized using a four-beam arrangement to generate a dose distribution similar to the conventional opposing beams. All of the beams had a small angle of two degrees from the lateral direction to increase the dosimetry quality. Dose metrics were compared between the conventional PBS and the Bragg peak FLASH plans. The dose rate histogram (DRVH) and FLASH metrics of 40 Gy/s coverage (V40Gy/s) were investigated for the Bragg peak plans. There was no significant difference between the clinical and Bragg peak plans in rectum, bladder, femur heads, large bowel, and penile bulb dose metrics, except for Dmax. For the CTV, the FLASH plans resulted in a higher Dmax than the clinical plans (116.9% vs. 103.3%). For the rectum, the V40Gy/s reached 94% and 93% for 1 Gy dose thresholds in composite and single-field evaluations, respectively. Additionally, the FLASH ratio reached close to 100% after the application of the 5 Gy threshold in composite dose rate assessment. In conclusion, the Bragg peak distal tracking method can yield comparable plan quality in most OARs while preserving sufficient FLASH dose rate coverage, demonstrating that the ultra-high dose technique can be applied in prostate FLASH SBRT.
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Affiliation(s)
- Tyler Kaulfers
- Department of Physics and Astronomy, Hofstra University, Hempstead, NY 11549, USA; (T.K.); (G.L.)
| | - Grant Lattery
- Department of Physics and Astronomy, Hofstra University, Hempstead, NY 11549, USA; (T.K.); (G.L.)
| | - Chingyun Cheng
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, 195 Little Albany Street, New Brunswick, NJ 08901, USA;
| | - Xingyi Zhao
- New York Proton Center, 225 E 126th Street, New York, NY 10035, USA; (X.Z.); (B.S.); (A.M.C.); (J.I.C.); (H.L.); (S.H.)
| | - Balaji Selvaraj
- New York Proton Center, 225 E 126th Street, New York, NY 10035, USA; (X.Z.); (B.S.); (A.M.C.); (J.I.C.); (H.L.); (S.H.)
| | - Hui Wu
- Department of Radiation Oncology, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou 450008, China;
| | - Arpit M. Chhabra
- New York Proton Center, 225 E 126th Street, New York, NY 10035, USA; (X.Z.); (B.S.); (A.M.C.); (J.I.C.); (H.L.); (S.H.)
| | - Jehee Isabelle Choi
- New York Proton Center, 225 E 126th Street, New York, NY 10035, USA; (X.Z.); (B.S.); (A.M.C.); (J.I.C.); (H.L.); (S.H.)
| | - Haibo Lin
- New York Proton Center, 225 E 126th Street, New York, NY 10035, USA; (X.Z.); (B.S.); (A.M.C.); (J.I.C.); (H.L.); (S.H.)
| | - Charles B. Simone
- New York Proton Center, 225 E 126th Street, New York, NY 10035, USA; (X.Z.); (B.S.); (A.M.C.); (J.I.C.); (H.L.); (S.H.)
| | - Shaakir Hasan
- New York Proton Center, 225 E 126th Street, New York, NY 10035, USA; (X.Z.); (B.S.); (A.M.C.); (J.I.C.); (H.L.); (S.H.)
| | - Minglei Kang
- New York Proton Center, 225 E 126th Street, New York, NY 10035, USA; (X.Z.); (B.S.); (A.M.C.); (J.I.C.); (H.L.); (S.H.)
| | - Jenghwa Chang
- Department of Physics and Astronomy, Hofstra University, Hempstead, NY 11549, USA; (T.K.); (G.L.)
- Northwell, 2000 Marcus Ave, Suite 300, New Hyde Park, NY 11042, USA
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28
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Shin JY, Offin M, Simone CB, Zhang Z, Shepherd AF, Wu AJ, Shaverdian N, Gelblum DY, Gomez DR, Sauter JL, Ginsberg MS, Adusumilli PS, Rusch VW, Zauderer MG, Rimner A. Clinical outcomes of stereotactic body radiation therapy for malignant pleural mesothelioma. Radiother Oncol 2024; 191:110057. [PMID: 38104783 PMCID: PMC10923065 DOI: 10.1016/j.radonc.2023.110057] [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] [Revised: 12/07/2023] [Accepted: 12/11/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND The objective of this study is to determine the outcomes and toxicities of patients with malignant pleural mesothelioma (MPM) treated with stereotactic body radiotherapy (SBRT). MATERIALS AND METHODS Data were extracted from an institutional tumor registry for patients diagnosed with mesothelioma and treated with SBRT. Kaplan-Meier and Cox regression analyses were employed to determine local control (LC) and overall survival (OS). RESULTS Forty-four patients with 59 total treated tumors from December 2006 to April 2022 were identified. Fifty-one (86.4 %) cases had oligoprogressive disease (five sites or less). The median prescription dose delivered was 3000 cGy in 5 fractions (range: 2700-6000 cGy in 3-8 fractions). Fifty-one (86.4 %) tumors were in the pleura, 4 (6.8 %) spine, 2 (3.4 %) bone, 1 (1.7 %) brain, and 1 (1.7 %) pancreas. The median follow-up from SBRT completion for those alive at last follow-up was 28 months (range: 14-52 months). The most common toxicities were fatigue (50.8 %), nausea (22.0 %), pain flare (15.3 %), esophagitis (6.8 %), dermatitis (6.8 %), and pneumonitis (5.1 %). There were no grade ≥ 3 acute or late toxicities. There were 2 (3.4 %) local failures, one of the pleura and another of the spine. One-year LC was 92.9 % (95 % CI: 74.6-98.2 %) for all lesions and 96.3 % (95 % CI: 76.5-99.5 %) for pleural tumors. One-year LC was 90.9 % (95 % CI: 68.1-97.6 %) for epithelioid tumors and 92.1 % (95 % CI: 72.1-98.0 %) for oligoprogressive tumors. One-year OS from time of SBRT completion was 36.4 % (95 % CI: 22.6-50.3 %). On multivariable analysis, KPS was the lone significant predictor for OS (p = 0.029). CONCLUSIONS Our single-institutional experience on patients with MPM suggests that SBRT is safe with a low toxicity profile and potentially achieve good local control.
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Affiliation(s)
- Jacob Y Shin
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States.
| | - Michael Offin
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Annemarie F Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Narek Shaverdian
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Daphna Y Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Daniel R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Jennifer L Sauter
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Michelle S Ginsberg
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Prasad S Adusumilli
- Department of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Valerie W Rusch
- Department of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Marjorie G Zauderer
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
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Mayr NA, Mohiuddin M, Snider JW, Zhang H, Griffin RJ, Amendola BE, Hippe DS, Perez NC, Wu X, Lo SS, Regine WF, Simone CB. Practice Patterns of Spatially Fractionated Radiation Therapy: A Clinical Practice Survey. Adv Radiat Oncol 2024; 9:101308. [PMID: 38405319 PMCID: PMC10885580 DOI: 10.1016/j.adro.2023.101308] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 06/26/2023] [Indexed: 02/27/2024] Open
Abstract
Purpose Spatially fractionated radiation therapy (SFRT) is increasingly used for bulky advanced tumors, but specifics of clinical SFRT practice remain elusive. This study aimed to determine practice patterns of GRID and Lattice radiation therapy (LRT)-based SFRT. Methods and Materials A survey was designed to identify radiation oncologists' practice patterns of patient selection for SFRT, dosing/planning, dosimetric parameter use, SFRT platforms/techniques, combinations of SFRT with conventional external beam radiation therapy (cERT) and multimodality therapies, and physicists' technical implementation, delivery, and quality procedures. Data were summarized using descriptive statistics. Group comparisons were analyzed with permutation tests. Results The majority of practicing radiation oncologists (United States, 100%; global, 72.7%) considered SFRT an accepted standard-of-care radiation therapy option for bulky/advanced tumors. Treatment of metastases/recurrences and nonmetastatic primary tumors, predominantly head and neck, lung cancer and sarcoma, was commonly practiced. In palliative SFRT, regimens of 15 to 18 Gy/1 fraction predominated (51.3%), and in curative-intent treatment of nonmetastatic tumors, 15 Gy/1 fraction (28.0%) and fractionated SFRT (24.0%) were most common. SFRT was combined with cERT commonly but not always in palliative (78.6%) and curative-intent (85.7%) treatment. SFRT-cERT time sequencing and cERT dose adjustments were variable. In curative-intent treatment, concurrent chemotherapy and immunotherapy were found acceptable by 54.5% and 28.6%, respectively. Use of SFRT dosimetric parameters was highly variable and differed between GRID and LRT. SFRT heterogeneity dosimetric parameters were more commonly used (P = .008) and more commonly thought to influence local control (peak dose, P = .008) in LRT than in GRID therapy. Conclusions SFRT has already evolved as a clinical practice pattern for advanced/bulky tumors. Major treatment approaches are consistent and follow the literature, but SFRT-cERT combination/sequencing and clinical utilization of dosimetric parameters are variable. These areas may benefit from targeted education and standardization, and knowledge gaps may be filled by incorporating identified inconsistencies into future clinical research.
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Affiliation(s)
- Nina A. Mayr
- College of Human Medicine, Michigan State University, East Lansing, Michigan
| | - Majid Mohiuddin
- Radiation Oncology Consultants and Northwestern Proton Center, Warrenville, Illinois
| | - James W. Snider
- Radiation Oncology, South Florida Proton Therapy Institute, Delray Beach, Florida
| | - Hualin Zhang
- Department of Radiation Oncology, University of Southern California, Los Angeles, California
| | - Robert J. Griffin
- Department of Radiation Oncology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | - Daniel S. Hippe
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | | | - Xiaodong Wu
- Executive Medical Physics Associates, Miami, Florida
| | - Simon S. Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington
| | - William F. Regine
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Charles B. Simone
- Department of Radiation Oncology, New York Proton Center, New York, New York
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30
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Simone CB, Serebrenik AA, Gore EM, Mohindra P, Brown SL, Wang D, Chetty IJ, Vujaskovic Z, Menon S, Thompson J, Fine G, Kaytor MD, Movsas B. Multicenter Phase 1b/2a Clinical Trial of Radioprotectant BIO 300 Oral Suspension for Patients With Non-Small Cell Lung Cancer Receiving Concurrent Chemoradiotherapy. Int J Radiat Oncol Biol Phys 2024; 118:404-414. [PMID: 37652301 DOI: 10.1016/j.ijrobp.2023.08.048] [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: 06/27/2022] [Revised: 08/03/2023] [Accepted: 08/17/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE Radiation therapy is part of the standard treatment regimen for non-small cell lung cancer (NSCLC). Although radiation therapy is an effective tool to manage NSCLC, it can be associated with significant dose-limiting toxicities. These toxicities can lead to treatment interruption or early termination and worsening clinical outcomes in addition to reductions in patient quality of life. Based on preclinical efficacy for radioprotection of normal tissues, we evaluated the clinical utility of BIO 300 Oral Suspension (BIO 300; synthetic genistein nanosuspension) in patients with NSCLC. METHODS AND MATERIALS In this multicenter, open-label, single-arm, ascending dose phase 1b/2a study, patients were enrolled with newly diagnosed stage II-IV NSCLC planned for 60 to 70/1.8-2.0 Gy radiation therapy and concurrent weekly paclitaxel/carboplatin. Oral BIO 300 (cohort 1, 500 mg/d; cohort 2, 1000 mg/d; cohort 3, 1500 mg/d) was self-administered once daily starting 2 to 7 days before initiating concurrent chemoradiotherapy and continued until the end of radiation therapy. The primary endpoint was acute dose-limiting toxicities attributable to BIO 300. Secondary outcomes included pharmacokinetics, pharmacodynamics, overall toxicity profile, quality of life, local response rate, and survival. RESULTS Twenty-one participants were enrolled. No dose-limiting toxicities were reported. BIO 300 dosing did not alter chemotherapy pharmacokinetics. Adverse events were not dose-dependent, and those attributable to BIO 300 (n = 11) were all mild to moderate in severity (grade 1, n = 9; grade 2, n = 2) and predominantly gastrointestinal (n = 7). A dose-dependent decrease in serum transforming growth factor β1 levels was observed across cohorts. Based on safety analysis, the maximum tolerated dose of BIO 300 was not met. Patient-reported quality of life and weight were largely stable throughout the study period. No patient had progression as their best overall response, and a 65% tumor response rate was achieved (20% complete response rate). CONCLUSIONS The low toxicity rates, along with the pharmacodynamic results and tumor response rates, support further investigation of BIO 300 as an effective radioprotector.
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Affiliation(s)
- Charles B Simone
- Baltimore and Maryland Proton Treatment Center, University of Maryland School of Medicine, Baltimore, Maryland; New York Proton Center, New York, New York; Memorial Sloan Kettering Cancer Center, New York, New York.
| | | | - Elizabeth M Gore
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Pranshu Mohindra
- Baltimore and Maryland Proton Treatment Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Stephen L Brown
- Department of Radiation Oncology, Henry Ford Cancer Institute, Detroit, Michigan
| | - Ding Wang
- Department of Radiation Oncology, Henry Ford Cancer Institute, Detroit, Michigan
| | - Indrin J Chetty
- Department of Radiation Oncology, Henry Ford Cancer Institute, Detroit, Michigan
| | - Zeljko Vujaskovic
- Baltimore and Maryland Proton Treatment Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Smitha Menon
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jonathan Thompson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Gil Fine
- Humanetics Corporation, Minneapolis, Minnesota
| | | | - Benjamin Movsas
- Department of Radiation Oncology, Henry Ford Cancer Institute, Detroit, Michigan
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Liu W, Feng H, Taylor PA, Kang M, Shen J, Saini J, Zhou J, Giap HB, Yu NY, Sio TS, Mohindra P, Chang JY, Bradley JD, Xiao Y, Simone CB, Lin L. Proton Pencil-Beam Scanning Stereotactic Body Radiation Therapy and Hypofractionated Radiation Therapy for Thoracic Malignancies: Patterns of Practice Survey and Recommendations for Future Development from NRG Oncology and PTCOG. ArXiv 2024:arXiv:2402.00489v1. [PMID: 38351927 PMCID: PMC10862926] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/19/2024]
Abstract
Stereotactic body radiation therapy (SBRT) and hypofractionation using pencil-beam scanning (PBS) proton therapy (PBSPT) is an attractive option for thoracic malignancies. Combining the advantages of target coverage conformity and critical organ sparing from both PBSPT and SBRT, this new delivery technique has great potential to improve the therapeutic ratio, particularly for tumors near critical organs. Safe and effective implementation of PBSPT SBRT/hypofractionation to treat thoracic malignancies is more challenging than the conventionally-fractionated PBSPT due to concerns of amplified uncertainties at the larger dose per fraction. NRG Oncology and Particle Therapy Cooperative Group (PTCOG) Thoracic Subcommittee surveyed US proton centers to identify practice patterns of thoracic PBSPT SBRT/hypofractionation. From these patterns, we present recommendations for future technical development of proton SBRT/hypofractionation for thoracic treatment. Amongst other points, the recommendations highlight the need for volumetric image guidance and multiple CT-based robust optimization and robustness tools to minimize further the impact of uncertainties associated with respiratory motion. Advances in direct motion analysis techniques are urgently needed to supplement current motion management techniques.
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Affiliation(s)
- Wei Liu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Hongying Feng
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Paige A. Taylor
- The Imaging and Radiation Oncology Core Houston Quality Assurance Center, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Minglei Kang
- New York Proton Center, New York City, New York, USA
| | - Jiajian Shen
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Jatinder Saini
- Seattle Cancer Care Alliance Proton Therapy Center and Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA 98195, USA
| | - Jun Zhou
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Huan B. Giap
- Department of Radiation Oncology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Nathan Y. Yu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Terence S. Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Pranshu Mohindra
- Department of Radiation Oncology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Joe Y. Chang
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Jeffrey D. Bradley
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ying Xiao
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Liyong Lin
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
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Simone CB. The evolution of palliative medicine and its integration with oncology care. Ann Palliat Med 2024; 13:205-207. [PMID: 38316403 DOI: 10.21037/apm-24-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 01/20/2024] [Indexed: 02/07/2024]
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Shah S, Chow R, Simone CB. Bacterial Decolonization for Prevention of Radiation Dermatitis-Fragility Index Analysis. JAMA Oncol 2024; 10:142. [PMID: 37943535 DOI: 10.1001/jamaoncol.2023.5007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Affiliation(s)
- Shubhangi Shah
- VCU School of Medicine, Virginia Commonwealth University, Richmond
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Li X, Yorke E, Jackson A, Yue Y, Simone CB, Apte AP, Rimner A, Gomez DR, Shaverdian N, Gelblum DY, Wu AJ, Shepherd AF. Clinical and Dosimetric Risk Factors Associated With Radiation-Induced Lung Toxicities After Multiple Courses of Lung Stereotactic Body Radiation Therapy. Adv Radiat Oncol 2024; 9:101284. [PMID: 38260213 PMCID: PMC10801636 DOI: 10.1016/j.adro.2023.101284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 05/27/2023] [Indexed: 01/24/2024] Open
Abstract
Purpose Data are limited on radiation-induced lung toxicities (RILT) after multiple courses of lung stereotactic body radiation therapy (SBRT). We herein analyze a large cohort of patients to explore the clinical and dosimetric risk factors associated with RILT in such settings. Methods and Materials A single institutional database of patients treated with multiple courses of lung SBRT between January 2014 and December 2019 was analyzed. Grade 2 or higher (G2+) RILT after the last course of SBRT was the primary endpoint. Composite plans were generated with advanced algorithms including deformable registration and equivalent dose adjustment. Logistic regression analyses were performed to examine correlations between patient or treatment factors including dosimetry and G2+ RILT. Risk stratification of patients and lung constraints based on acceptable normal tissue complication probability were calculated based on risk factors identified. Results Among 110 eligible patients (56 female and 54 male), there were 64 synchronous (58.2%; defined as 2 courses of SBRT delivered within 30 days) and 46 metachronous (41.8%) courses of SBRT. The composite median lung V20, lung V5, and mean lung dose were 9.9% (interquartile range [IQR], 7.3%-12.4%), 32.2% (IQR, 25.5%-40.1%), and 7.0 Gy (IQR, 5.5 Gy-8.6 Gy), respectively. With a median follow-up of 21.1 months, 30 patients (27.3%) experienced G2+ RILT. Five patients (4.5%) developed G3 RILT, and 1 patient (0.9%) developed G4 RILT, and no patients developed G5 RILT. On multivariable regression analysis, female sex (odds ratio [OR], 4.35; 95% CI, 1.49%-14.3%; P = .01), synchronous SBRT (OR, 8.78; 95% CI, 2.27%-47.8%; P = .004), prior G2+ RILT (OR, 29.8; 95% CI, 2.93%-437%; P = .007) and higher composite lung V20 (OR, 1.18; 95% CI, 1.02%-1.38%; P = .030) were associated with significantly higher likelihood of G2+ RILT. Conclusions Our data suggest an acceptable incidence of G2+ RILT after multiple courses of lung SBRT. Female sex, synchronous SBRT, prior G2+ RILT, and higher composite lung V20 may be risk factors for G2+ RILT.
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Affiliation(s)
- Xingzhe Li
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, Texas
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew Jackson
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yujuan Yue
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Charles B. Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Aditya P. Apte
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel R. Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Narek Shaverdian
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daphna Y. Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Abraham J. Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Annemarie F. Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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Fang W, Girard N, Cilento V, Goren E, Dibaba D, Ruffini E, Ahmad U, Appel S, Bille A, Boubia S, Brambilla C, Cangir AK, Detterbeck F, Falkson C, Filosso PL, Giaccone G, Guerrera F, Huang J, Infante M, Kim DK, Lucchi M, Marino M, Marom EM, Nicholson AG, Okumura M, Rami-Porta R, Rimner A, Simone CB, Asamura H. The International Association for the Study of Lung Cancer Thymic Epithelial Tumors Staging Project: Proposals for the N and the M Components for the Forthcoming (Ninth) Edition of the TNM Classification of Malignant Tumors. J Thorac Oncol 2024; 19:52-70. [PMID: 37774950 DOI: 10.1016/j.jtho.2023.09.1447] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 09/06/2023] [Accepted: 09/21/2023] [Indexed: 10/01/2023]
Abstract
INTRODUCTION Stage classification is an important underpinning of management in patients with cancer and rests on a combination of three components-T for tumor extent, N for nodal involvement, and M for distant metastases. This article details the revision of the N and the M components of thymic epithelial tumors for the ninth edition of the TNM classification of malignant tumors proposed by the Thymic Domain of the International Association for the Study of Lung Cancer Staging and Prognostic Factors Committee. METHODS The N and M components of the eighth edition staging system were verified by a large international collaborative data source through a data-driven analysis. A total of 9147 cases were included for analysis, including 7662 thymomas, 1345 thymic carcinomas, and 140 neuroendocrine thymic tumors. RESULTS Lymph node involvement rates were 1.5% in thymomas and 17.6% and 27.7% in thymic carcinomas and neuroendocrine thymic tumors, respectively. Rates of lymph node metastasis were increasingly higher in tumors with higher T stage and higher-grade histologic type. Survival analysis validated the differences in the N and M categories proposed in the eighth edition staging system. Good discrimination in overall survival was detected among pathologic (p)N and pM categories in patients with thymoma and thymic carcinoma. CONCLUSIONS No changes are proposed from the eighth edition for the N and M components. The proposed stage classification will provide a useful tool for management of the disease among the global thymic community.
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Affiliation(s)
- Wentao Fang
- Shanghai Chest Hospital, Jiaotong University Medical School, Shanghai, People's Republic of China
| | | | - Vanessa Cilento
- Cancer Research And Biostatistics (CRAB), Seattle, Washington
| | - Emily Goren
- Cancer Research And Biostatistics (CRAB), Seattle, Washington
| | - Daniel Dibaba
- Cancer Research And Biostatistics (CRAB), Seattle, Washington
| | | | - Usman Ahmad
- Thoracic Surgery in the Heart, Vascular & Thoracic Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | | | | | | | - Cecilia Brambilla
- Royal Brompton and Harefield NHS Hospitals, Guy's and St. Thomas' NHS Foundation Trust and National Heart and Lung Institute, Imperial College, London, United Kingdom
| | | | | | | | | | | | | | - James Huang
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Dong Kwan Kim
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Marco Lucchi
- Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Mirella Marino
- IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Edith M Marom
- Department of Diagnostic Imaging, Chaim Sheba Medical Center, Tel-Aviv University, Ramat Gan, Israel
| | - Andrew G Nicholson
- Royal Brompton and Harefield NHS Hospitals, Guy's and St. Thomas' NHS Foundation Trust and National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Meinoshin Okumura
- National Hospital Organization Osaka Toneyama Medical Center, Osaka, Japan
| | - Ramon Rami-Porta
- Hospital Universitari Mutua Terrassa, Terrassa, Spain, and Network of Centers for Biomedical Research in Respiratory Diseases (CIBERES) Lung Cancer Group, Terrassa, Spain
| | - Andreas Rimner
- Memorial Sloan Kettering Cancer Center, New York, New York
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Neubauer Z, Hasan S, Press RH, Chhabra AM, Fox J, Bakst R, Simone CB, Choi JI. Prognostic implications of HER2NEU-low in metastatic breast cancer. Cancer Med 2024; 13:e6979. [PMID: 38379326 PMCID: PMC10839127 DOI: 10.1002/cam4.6979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 11/17/2023] [Accepted: 01/18/2024] [Indexed: 02/22/2024] Open
Abstract
INTRODUCTION We explored characteristics and clinical outcomes of HER2-negative and HER2-low metastatic breast cancers using real-world data. METHODS We queried the National Cancer Database to identify MBC patients that were HER2-low or HER2-negative per immunohistochemical staining. A binomial regression analysis identified demographic and clinical correlates of each subtype. A Cox multivariable regression analysis (MVA) and propensity-match analysis were performed to identify correlates of survival. RESULTS Excluding missing data, 24,636 MBC patients diagnosed between 2008 and 2015 were identified; 27.9% were HER2-negative and 72.1% were HER2-low. There were no relevant demographic differences between the groups. HER2-low tumors were half as likely to have concomitant hormone receptor-positive status (p < 0.01). The 3-year survival rate among hormone receptor-negative patients was 33.8% for HER2-low and 32.2% for HER2-negative (p < 0.05), and 60.9% and 55.6% in HER2-low and HER2-negative cases among hormone receptor-positive patients (p < 0.05), respectively. HER2-low cases were associated with better survival on MVA (HR =0.95, 95% CI 0.91-0.99) and remained superior with propensity-matching (HR = 0.92, 95% CI 0.89-0.96). In a subset analysis isolated to hormone receptor-positive cases, HER2-low remained correlated with improved survival (HR = 0.93, 95% CI 0.89-0.98) with propensity-matched MVA. Correlates of worse survival include older age as a continuous variable (HR = 1.02, 95% CI 1.02-1.02) and Black race (HR = 1.26, 95% CI 1.20-1.32) [all p < 0.01]. CONCLUSIONS In the largest such analysis performed to date, our study demonstrates a small but statistically significant association with improved survival for HER2-low tumors compared to HER2-negative tumors in MBC.
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Affiliation(s)
| | | | | | | | - Jana Fox
- Montefiore Medical CenterDepartment of Radiation OncologyNew YorkNew YorkUSA
| | - Richard Bakst
- Mount Sinai Medical Center. Department of Radiation OncologyNew YorkNew YorkUSA
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Hartsell WF, Simone CB, Godes D, Maggiore J, Mehta MP, Frank SJ, Metz JM, Choi JI. Temporal Evolution and Diagnostic Diversification of Patients Receiving Proton Therapy in the United States: A Ten-Year Trend Analysis (2012 to 2021) From the National Association for Proton Therapy. Int J Radiat Oncol Biol Phys 2023:S0360-3016(23)08315-3. [PMID: 38163519 DOI: 10.1016/j.ijrobp.2023.12.041] [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: 06/11/2023] [Revised: 12/22/2023] [Accepted: 12/27/2023] [Indexed: 01/03/2024]
Abstract
PURPOSE The National Association for Proton Therapy conducted 8 surveys of all operational United States proton centers (2012-2021) and analyzed the patients treated, diagnoses, and treatment complexity to evaluate trends and diversification of patients receiving proton therapy. METHODS AND MATERIALS Detailed surveys were sent in 2015, which requested data from 2012 to 2014, and then annually thereafter to active proton centers in the United States. The numbers of patient treated at each center for the preceding calendar year(s) were collated for tumors in the following categories: central nervous system, intraocular, pituitary, skull base/skeleton, head/neck, lung, retroperitoneal/soft tissue sarcoma, pediatric (solid tumors in children of age ≤18), gastrointestinal tract, urinary tract, female pelvic, prostate, breast, and "other." Complexity levels were assessed using Current Procedural Terminology codes 77520-77525. RESULTS Survey response rates were excellent (100% in 2015 to 94.9% in 2021); additional publicly available information provided near-complete information on all centers. Trend comparisons between 2012 and 2021 showed that the total annual number of patients treated with protons gradually increased from 5377 to 15,829. The largest numeric increases were for head/neck (316 to 2303; 7.3-fold), breast (93 to 1452; 15.6-fold), and gastrointestinal tumors (170 to 1259; 7.4-fold). Patient numbers also increased significantly for central nervous system (598 to 1743; 2.9-fold), pediatric (685 to 1870; 2.7-fold), and skull base tumors (179 to 514; 2.9-fold). For prostate cancer, the percentage of proton-treated patients decreased from 43.4% to 25.0% of the total. Simple compensated treatments decreased from 43% in 2012 to 7% in 2021, whereas intermediate complexity treatments increased from 45% to 73%. CONCLUSIONS The number of patients treated with protons is gradually increasing, with a substantial proportionate decline in patients with prostate cancer receiving proton therapy. The number of patients treated for "commonly accepted" indications for protons (eg, pediatric, central nervous system, and skull base tumors) is gradually increasing. Greater proportional increases were observed for breast, lung, head/neck, and gastrointestinal tumors. Treatment complexity is gradually increasing over time.
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Affiliation(s)
- William F Hartsell
- Ascension Alexian Brothers Medical Center, Elk Grove Village, Illinois; Northwestern Medicine Chicago Proton Center, Warrenville, Illinois.
| | | | | | | | | | | | - James M Metz
- University of Pennsylvania, Philadelphia, Pennsylvania
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Rimner A, Gelblum DY, Wu AJ, Shepherd AF, Mueller B, Zhang S, Cuaron J, Shaverdian N, Flynn J, Fiasconaro M, Zhang Z, von Reibnitz D, Li H, McKnight D, McCune M, Gelb E, Gomez DR, Simone CB, Deasy JO, Yorke ED, Ng KK, Chaft JE. Stereotactic Body Radiation Therapy for Stage IIA to IIIA Inoperable Non-Small Cell Lung Cancer: A Phase 1 Dose-Escalation Trial. Int J Radiat Oncol Biol Phys 2023:S0360-3016(23)08252-4. [PMID: 38154510 DOI: 10.1016/j.ijrobp.2023.12.018] [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: 07/16/2023] [Revised: 12/10/2023] [Accepted: 12/15/2023] [Indexed: 12/30/2023]
Abstract
PURPOSE Larger tumors are underrepresented in most prospective trials on stereotactic body radiation therapy (SBRT) for inoperable non-small cell lung cancer (NSCLC). We performed this phase 1 trial to specifically study the maximum tolerated dose (MTD) of SBRT for NSCLC >3 cm. METHODS AND MATERIALS A 3 + 3 dose-escalation design (cohort A) with an expansion cohort at the MTD (cohort B) was used. Patients with inoperable NSCLC >3 cm (T2-4) were eligible. Select ipsilateral hilar and single-station mediastinal nodes were permitted. The initial SBRT dose was 40 Gy in 5 fractions, with planned escalation to 50 and 60 Gy in 5 fractions. Adjuvant chemotherapy was mandatory for cohort A and optional for cohort B, but no patients in cohort B received chemotherapy. The primary endpoint was SBRT-related acute grade (G) 4+ or persistent G3 toxicities (Common Terminology Criteria for Adverse Events version 4.03). Secondary endpoints included local failure (LF), distant metastases, disease progression, and overall survival. RESULTS The median age was 80 years; tumor size was >3 cm and ≤5 cm in 20 (59%) and >5 cm in 14 patients (41%). In cohort A (n = 9), 3 patients treated to 50 Gy experienced G3 radiation pneumonitis (RP), thus defining the MTD. In the larger dose-expansion cohort B (n = 25), no radiation therapy-related G4+ toxicities and no G3 RP occurred; only 2 patients experienced G2 RP. The 2-year cumulative incidence of LF was 20.2%, distant failure was 34.7%, and disease progression was 54.4%. Two-year overall survival was 53%. A biologically effective dose (BED) <100 Gy was associated with higher LF (P = .006); advanced stage and higher neutrophil/lymphocyte ratio were associated with greater disease progression (both P = .004). CONCLUSIONS Fifty Gy in 5 fractions is the MTD for SBRT to tumors >3 cm. A higher BED is associated with fewer LFs even in larger tumors. Cohort B appears to have had less toxicity, possibly due to the omission of chemotherapy.
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Affiliation(s)
- Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Radiation Oncology, University of Freiburg, Robert-Koch-Strasse 3, 79106 Freiburg, Germany.
| | - Daphna Y Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Annemarie F Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Boris Mueller
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Siyuan Zhang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital & Institute, Beijing, China
| | - John Cuaron
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Narek Shaverdian
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jessica Flynn
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Megan Fiasconaro
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York; Flatiron Health, New York, New York
| | - Zhigang Zhang
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Donata von Reibnitz
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Surgery, Stadtspital Waid, Zurich, Switzerland
| | - Henry Li
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Dominique McKnight
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Megan McCune
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Emily Gelb
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joseph O Deasy
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ellen D Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kenneth K Ng
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jamie E Chaft
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
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Li H, Mayr NA, Griffin RJ, Zhang H, Pokhrel D, Grams M, Penagaricano J, Chang S, Spraker MB, Kavanaugh J, Lin L, Sheikh K, Mossahebi S, Simone CB, Roberge D, Snider JW, Sabouri P, Molineu A, Xiao Y, Benedict SH. Overview and Recommendations for Prospective Multi-institutional Spatially Fractionated Radiation Therapy Clinical Trials. Int J Radiat Oncol Biol Phys 2023:S0360-3016(23)08246-9. [PMID: 38110104 DOI: 10.1016/j.ijrobp.2023.12.013] [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: 07/14/2023] [Revised: 10/30/2023] [Accepted: 12/09/2023] [Indexed: 12/20/2023]
Abstract
PURPOSE The highly heterogeneous dose delivery of spatially fractionated radiation therapy (SFRT) is a profound departure from standard radiation planning and reporting approaches. Early SFRT studies have shown excellent clinical outcomes. However, prospective multi-institutional clinical trials of SFRT are still lacking. This NRG Oncology/American Association of Physicists in Medicine working group consensus aimed to develop recommendations on dosimetric planning, delivery, and SFRT dose reporting to address this current obstacle toward the design of SFRT clinical trials. METHODS AND MATERIALS Working groups consisting of radiation oncologists, radiobiologists, and medical physicists with expertise in SFRT were formed in NRG Oncology and the American Association of Physicists in Medicine to investigate the needs and barriers in SFRT clinical trials. RESULTS Upon reviewing the SFRT technologies and methods, this group identified challenges in several areas, including the availability of SFRT, the lack of treatment planning system support for SFRT, the lack of guidance in the physics and dosimetry of SFRT, the approximated radiobiological modeling of SFRT, and the prescription and combination of SFRT with conventional radiation therapy. CONCLUSIONS Recognizing these challenges, the group further recommended several areas of improvement for the application of SFRT in cancer treatment, including the creation of clinical practice guidance documents, the improvement of treatment planning system support, the generation of treatment planning and dosimetric index reporting templates, and the development of better radiobiological models through preclinical studies and through conducting multi-institution clinical trials.
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Affiliation(s)
- Heng Li
- Department of Radiation Oncology, John Hopkins University, Baltimore, Maryland.
| | - Nina A Mayr
- College of Human Medicine, Michigan State University, East Lansing, Michigan
| | - Robert J Griffin
- Department of Radiation Oncology, University of Arkansas for Medical Science, Little Rock, Arkansas
| | - Hualin Zhang
- Department of Radiation Oncology, University of Southern California, Los Angeles, California
| | - Damodar Pokhrel
- Department of Radiation Medicine, University of Kentucky, Lexington, Kentucky
| | - Michael Grams
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Jose Penagaricano
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Sha Chang
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
| | | | - James Kavanaugh
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Liyong Lin
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | - Khadija Sheikh
- Department of Radiation Oncology, John Hopkins University, Baltimore, Maryland
| | - Sina Mossahebi
- Department of Radiation Oncology, University of Maryland, Baltimore, Maryland
| | - Charles B Simone
- Department of Radiation Oncology, New York Proton Center, New York, New York
| | - David Roberge
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - James W Snider
- South Florida Proton Therapy Institute, 5280 Linton Blvd, Delray Beach, Florida
| | - Pouya Sabouri
- Department of Radiation Oncology, University of Arkansas for Medical Science, Little Rock, Arkansas
| | - Andrea Molineu
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ying Xiao
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stanley H Benedict
- Department of Radiation Oncology, University of California, Davis, Sacramento, California
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Harrison N, Kang M, Liu R, Charyyev S, Wahl N, Liu W, Zhou J, Higgins KA, Simone CB, Bradley JD, Dynan WS, Lin L. A Novel Inverse Algorithm To Solve the Integrated Optimization of Dose, Dose Rate, and Linear Energy Transfer of Proton FLASH Therapy With Sparse Filters. Int J Radiat Oncol Biol Phys 2023:S0360-3016(23)08187-7. [PMID: 38104869 DOI: 10.1016/j.ijrobp.2023.11.061] [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: 04/20/2023] [Revised: 09/27/2023] [Accepted: 11/25/2023] [Indexed: 12/19/2023]
Abstract
PURPOSE The recently proposed Integrated Physical Optimization Intensity Modulated Proton Therapy (IPO-IMPT) framework allows simultaneous optimization of dose, dose rate, and linear energy transfer (LET) for ultra-high dose rate (FLASH) treatment planning. Finding solutions to IPO-IMPT is difficult because of computational intensiveness. Nevertheless, an inverse solution that simultaneously specifies the geometry of a sparse filter and weights of a proton intensity map is desirable for both clinical and preclinical applications. Such solutions can reduce effective biologic dose to organs at risk in patients with cancer as well as reduce the number of animal irradiations needed to derive extra biologic dose models in preclinical studies. METHODS AND MATERIALS Unlike the initial forward heuristic, this inverse IPO-IMPT solution includes simultaneous optimization of sparse range compensation, sparse range modulation, and spot intensity. The daunting computational tasks vital to this endeavor were resolved iteratively with a distributed computing framework to enable Simultaneous Intensity and Energy Modulation and Compensation (SIEMAC). SIEMAC was demonstrated on a human patient with central lung cancer and a minipig. RESULTS SIEMAC simultaneously improves maps of spot intensities and patient-field-specific sparse range compensators and range modulators. For the patient with lung cancer, at our maximum nozzle current of 300 nA, dose rate coverage above 100 Gy/s increased from 57% to 96% in the lung and from 93% to 100% in the heart, and LET coverage above 4 keV/µm dropped from 68% to 9% in the lung and from 26% to <1% in the heart. For a simple minipig plan, the full-width half-maximum of the dose, dose rate, and LET distributions decreased by 30%, 1.6%, and 57%, respectively, again with similar target dose coverage, thus reducing uncertainty in these quantities for preclinical studies. CONCLUSIONS The inverse solution to IPO-IMPT demonstrated the capability to simultaneously modulate subspot proton energy and intensity distributions for clinical and preclinical studies.
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Affiliation(s)
| | | | - Ruirui Liu
- Emory University, Atlanta, Georgia; University of Nebraska, Omaha, Nebraska
| | | | - Niklas Wahl
- German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Wei Liu
- Mayo Clinic, Phoenix, Arizona
| | - Jun Zhou
- Emory University, Atlanta, Georgia
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Marom EM, Fang W, Ruffini E, Detterbeck F, Ahmad U, Appel S, Bille A, Boubia S, Brambilla C, Cilento V, Cangir AK, Falkson C, Filosso PL, Giaccone G, Girard N, Goren E, Guerrera F, Huang J, Infante M, Kim DK, Lucchi M, Marino M, Nicholson AG, Okumura M, Rami-Porta R, Rimner A, Simone CB, Asamura H. The International Association for the Study of Lung Cancer Thymic Epithelial Tumor Staging Project: A Re-Assessment of the International Thymic Malignancy Interest Group/International Association for the Study of Lung Cancer Lymph Node Map for Thymic Epithelial Tumors for the Forthcoming Ninth Edition of the TNM Classification of Malignant Tumors. J Thorac Oncol 2023; 18:1672-1688. [PMID: 37689390 DOI: 10.1016/j.jtho.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 08/29/2023] [Accepted: 09/01/2023] [Indexed: 09/11/2023]
Abstract
INTRODUCTION A lymph node map is the pillar on which accurate assignment and documentation of nodal classification stands. The International Thymic Malignancy Interest Group created the first map for thymic epithelial malignancies in conjunction with the eighth edition of the TNM classification, representing the first official TNM classification of thymic epithelial malignancies. The map was based on clinical experience and published studies, but it was largely empirical because of limited available data. Dissemination of the map and implementation of a standard thymic stage classification across the world in 2017 have provided more consistent and granular data. METHODS More than twice as many cases of node involvement are available for analysis in the current database compared with that of the eighth edition database, allowing validation of many aspects of the eighth edition map. This article details the process and considerations for refinement of the thymic map for the ninth TNM used by the Thymic Domain of the Staging and Prognostic Factors Committee of the International Association for the Study of Lung Cancer. The committee evaluated a large international collaborative data set, published anatomical and clinical studies pertaining to lymph node spread from thymic epithelial tumors, in conjunction with the analysis underlying refinements of the TNM components for the ninth edition TNM classification. RESULTS The node map boundaries of the N1 and N2 categories remain unchanged. Visual clarifications have been added to the nomenclature of nodal stations within these regions. CONCLUSIONS On the basis of the recommendation to keep the N component unchanged for the ninth edition TNM classification, the lymph node map remains unchanged as well; however, clarifications have been added to facilitate clinical use.
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Affiliation(s)
- Edith M Marom
- Department of Diagnostic Imaging, Chaim Sheba Medical Center, Tel-Aviv University, Ramat Gan, Israel
| | - Wentao Fang
- Shanghai Chest Hospital, Jiaotong University Medical School, Shanghai, People's Republic of China
| | | | | | - Usman Ahmad
- Thoracic Surgery in the Heart, Vascular & Thoracic Institute at Cleveland Clinic, Abu Dhabi, United Arab Emirates
| | | | | | | | - Cecilia Brambilla
- Royal Brompton and Harefield NHS Hospitals, Guy's and St. Thomas' NHS Foundation Trust and National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Vanessa Cilento
- Cancer Research And Biostatistics (CRAB), Seattle, Washington
| | | | | | | | | | - Nicolas Girard
- Institut Curie, Thorax Institute Curie Montsouris, Paris, France; Paris Saclay University, UVSQ, Versailles, France
| | - Emily Goren
- Cancer Research And Biostatistics (CRAB), Seattle, Washington
| | | | - James Huang
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Dong-Kwan Kim
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Marco Lucchi
- Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Mirella Marino
- IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Andrew G Nicholson
- Royal Brompton and Harefield NHS Hospitals, Guy's and St. Thomas' NHS Foundation Trust and National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Meinoshin Okumura
- National Hospital Organization Osaka Toneyama Medical Center, Osaka, Japan
| | - Ramon Rami-Porta
- Hospital Universitari Mutua Terrassa, Terrassa, Spain, and Network of Centers for Biomedical Research in Respiratory Diseases (CIBERES) Lung Cancer Group, Terrassa, Spain
| | - Andreas Rimner
- Memorial Sloan Kettering Cancer Center, New York, New York
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Ruffini E, Huang J, Cilento V, Goren E, Detterbeck F, Ahmad U, Appel S, Bille A, Boubia S, Brambilla C, Cangir AK, Falkson C, Fang W, Filosso PL, Giaccone G, Girard N, Guerrera F, Infante M, Kim DK, Lucchi M, Marino M, Marom EM, Nicholson AG, Okumura M, Rami-Porta R, Rimner A, Simone CB, Asamura H. The International Association for the Study of Lung Cancer Thymic Epithelial Tumors Staging Project: Proposal for a Stage Classification for the Forthcoming (Ninth) Edition of the TNM Classification of Malignant Tumors. J Thorac Oncol 2023; 18:1655-1671. [PMID: 37689391 DOI: 10.1016/j.jtho.2023.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 08/12/2021] [Accepted: 08/18/2021] [Indexed: 09/11/2023]
Abstract
INTRODUCTION A TNM-based system for all types of thymic epithelial tumors was introduced in the eighth edition of the TNM classification of thoracic malignancies. The Thymic Domain of the Staging and Prognostic Factors Committee of the International Association for the Study of Lung Cancer, composed of multispecialty international experts, was charged to develop proposals for the ninth edition. This article outlines the proposed definitions for the T, the N, and the M components and their combination into stage groups. METHODS A large central database of 11,347 patients with thymic epithelial tumors was assembled thanks to the contribution of the major thymic organizations worldwide and analyses were carried out for the T, the N, and the M components and the stage groups. Overall survival was the outcome measure for patients with completely and incompletely resected tumors, and recurrence for those with complete resection. When the number of patients was sufficient, analyses were performed separately for thymomas, thymic carcinomas, and neuroendocrine thymic tumors. RESULTS Tumor size is included in the T1 category as T1a (≤5cm) and T1b (>5 cm); the mediastinal pleura is dropped as a T descriptor; invasion of the lung or phrenic nerve is reclassified as T2 (instead of T3). No changes are proposed for the N and the M components from the eighth edition. The stage groups remain the same. CONCLUSIONS The proposed changes for the ninth edition of the TNM classification set the stage for further progress in the future for these rare tumors.
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Affiliation(s)
| | - James Huang
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Vanessa Cilento
- Cancer Research And Biostatistics (CRAB), Seattle, Washington
| | - Emily Goren
- Cancer Research And Biostatistics (CRAB), Seattle, Washington
| | | | - Usman Ahmad
- Thoracic Surgery in the Heart, Vascular, and Thoracic Institute at Cleveland Clinic, Abu Dhabi, United Arab Emirates
| | | | | | | | - Cecilia Brambilla
- Royal Brompton and Harefield National Health Service (NHS) Hospitals, London, United Kingdom; Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom
| | | | | | - Wentao Fang
- Shanghai Chest Hospital, Jiaotong University Medical School, Shanghai, People's Republic of China
| | | | | | - Nicolas Girard
- Institut Curie, Thorax Institute Curie Montsouris, Paris, France; Paris Saclay University, Université de Versailles Saint-Quentin-en-Yvelines (UVSQ), Versailles, France
| | | | | | - Dong Kwan Kim
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Marco Lucchi
- Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Mirella Marino
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Regina Elena National Cancer Institute, Rome, Italy
| | - Edith M Marom
- Department of Diagnostic Imaging, Chaim Sheba Medical Center, Tel-Aviv University, Ramat Gan, Israel
| | - Andrew G Nicholson
- Royal Brompton and Harefield National Health Service (NHS) Hospitals, London, United Kingdom; Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Meinoshin Okumura
- National Hospital Organization Osaka Toneyama Medical Center, Osaka, Japan
| | - Ramon Rami-Porta
- Hospital Universitari Mutua Terrassa, Terrassa, Spain; Network of Centers for Biomedical Research in Respiratory Diseases (CIBERES) Lung Cancer Group, Terrassa, Spain
| | - Andreas Rimner
- Memorial Sloan Kettering Cancer Center, New York, New York
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Okumura M, Marino M, Cilento V, Goren E, Ruffini E, Dibaba D, Ahmad U, Appel S, Bille A, Boubia S, Brambilla C, Cangir AK, Detterbeck F, Falkson C, Fang W, Filosso PL, Giaccone G, Girard N, Guerrera F, Huang J, Infante M, Kim DK, Lucchi M, Marom EM, Nicholson AG, Rami-Porta R, Rimner A, Simone CB, Asamura H. The International Association for the Study of Lung Cancer Thymic Epithelial Tumor Staging Project: Proposal for the T Component for the Forthcoming (Ninth) Edition of the TNM Classification of Malignant Tumors. J Thorac Oncol 2023; 18:1638-1654. [PMID: 37634808 DOI: 10.1016/j.jtho.2023.08.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 08/17/2023] [Accepted: 08/20/2023] [Indexed: 08/29/2023]
Abstract
INTRODUCTION A TNM-based stage classification system of thymic epithelial tumors was adopted for the eighth edition of the stage classification of malignant tumors. The Thymic Domain of the Staging and Prognostics Factor Committee of the International Association for the Study of Lung Cancer developed a new database with the purpose to make proposals for the ninth edition stage classification system. This article outlines the proposed definitions for the T categories for the ninth edition TNM stage classification of thymic malignancies. METHODS A worldwide collective database of 11,347 patients with thymic epithelial tumors was assembled. Analysis was performed on 9147 patients with available survival data. Overall survival, freedom-from-recurrence, and cumulative incidence of recurrence were used as outcome measures. Analysis was performed separately for thymomas, thymic carcinomas, and neuroendocrine thymic tumors. RESULTS Proposals for the T categories include the following: T1 category is divided into T1a (≤5 cm) and T1b (>5 cm), irrespective of mediastinal pleura invasion; T2 includes direct invasion of the pericardium, lung, or phrenic nerve; T3 denotes direct invasion of the brachiocephalic vein, superior vena cava, chest wall, or extrapericardial pulmonary arteries and veins; and T4 category remains the same as in the eighth edition classification, involving direct invasion of the aorta and arch vessels, intrapericardial pulmonary arteries and veins, myocardium, trachea, or esophagus. CONCLUSIONS The proposed T categories for the ninth edition of the TNM classification provide good discrimination in outcome for the T component of the TNM-based stage system of thymic epithelial tumors.
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Affiliation(s)
- Meinoshin Okumura
- National Hospital Organization Osaka Toneyama Medical Center, Osaka, Japan
| | - Mirella Marino
- IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Vanessa Cilento
- Cancer Research And Biostatistics (CRAB), Seattle, Washington
| | - Emily Goren
- Cancer Research And Biostatistics (CRAB), Seattle, Washington
| | | | - Daniel Dibaba
- Cancer Research And Biostatistics (CRAB), Seattle, Washington
| | - Usman Ahmad
- Thoracic Surgery in the Heart, Vascular & Thoracic Institute at Cleveland Clinic, Abu Dhabi, United Arab Emirates
| | | | | | | | - Cecilia Brambilla
- Royal Brompton and Harefield NHS Hospitals, Guy's and St. Thomas' NHS Foundation Trust and National Heart and Lung Institute, Imperial College, London, United Kingdom
| | | | | | | | - Wentao Fang
- Shanghai Chest Hospital, Jiaotong University Medical School, Shanghai, People's Republic of China
| | | | | | - Nicolas Girard
- Institut Curie, Thorax Institute Curie Montsouris, Paris, France; Paris Saclay University, UVSQ, Versailles, France
| | | | - James Huang
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Dong Kwan Kim
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Marco Lucchi
- Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Edith M Marom
- Department of Diagnostic Imaging, Chaim Sheba Medical Center, Tel-Aviv University, Ramat Gan, Israel
| | - Andrew G Nicholson
- Royal Brompton and Harefield NHS Hospitals, Guy's and St. Thomas' NHS Foundation Trust and National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Ramon Rami-Porta
- Hospital Universitari Mutua Terrassa, Terrassa, Spain; Network of Centers for Biomedical Research in Respiratory Diseases (CIBERES) Lung Cancer Group, Terrassa, Spain
| | - Andreas Rimner
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Hisao Asamura
- Keio University, Tokyo, Japan; Present Address: Tokyo Dental College Ichikawa General Hospital, Chiba, Japan
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Wong HCY, Lee SF, Chan AW, Caini S, Hoskin P, Simone CB, Johnstone P, van der Linden Y, van der Velden JM, Martin E, Alcorn S, Johnstone C, Isabelle Choi J, Nader Marta G, Oldenburger E, Raman S, Rembielak A, Vassiliou V, Bonomo P, Nguyen QN, Chow E, Ryu S. Stereotactic body radiation therapy versus conventional external beam radiotherapy for spinal metastases: A systematic review and meta-analysis of randomized controlled trials. Radiother Oncol 2023; 189:109914. [PMID: 37739318 DOI: 10.1016/j.radonc.2023.109914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 08/24/2023] [Accepted: 09/11/2023] [Indexed: 09/24/2023]
Abstract
INTRODUCTION This study aimed to compare SBRT and cEBRT for treating spinal metastases through a systematic review and meta-analysis of randomized controlled trials (RCTs). METHODS PubMed, EMBASE and Cochrane Library were searched up to 6 May 2023 for RCTs comparing SBRT and cEBRT for spinal metastases. Overall and complete pain response, local progression, overall survival, quality of life and adverse events were extracted. Data were pooled using random-effects models. Results were reported as risk ratios (RRs) for dichotomous outcomes, and hazard ratios (HRs) for time-to-event outcomes, along with their 95% confidence intervals (CIs). Heterogeneity was evaluated using the I2 statistic. RESULTS Three RCTs were identified involving 642 patients. No differences were seen in overall pain response comparing SBRT and cEBRT (RR at 3 months: 1.12, 95% CI, 0.74-1.70, p = 0.59; RR at 6 months: 1.29, 95% CI, 0.97-1.72, p = 0.08). Only two of three studies presented complete pain response data. SBRT demonstrated a statistically significant improvement in complete pain response compared to cEBRT (RR at 3 months: 2.52; 95% CI, 1.58-4.01; P < 0.0001; RR at 6 months: 2.48; 95% CI, 1.23-4.99; P = 0.01). There were no significant differences in local progression and overall survival. Adverse events were similar, except for any grade radiation dermatitis, which was significantly lower in SBRT arm (RR 0.17, 95% CI 0.03-0.96, P = 0.04). CONCLUSION SBRT is a safe treatment option for spine metastases. It may provide better complete pain response compared to cEBRT. Additional trials are needed to determine the potential benefits of SBRT in specific patient subsets.
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Affiliation(s)
- Henry C Y Wong
- Department of Oncology, Princess Margaret Hospital, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China.
| | - Shing Fung Lee
- Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore; Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China
| | - Adrian Wai Chan
- Department of Clinical Oncology, Tuen Mun Hospital, New Territories West Cluster, Hospital Authority, Hong Kong S.A.R., China
| | - Saverio Caini
- Cancer Risk Factors and Lifestyle Epidemiology Unit, Institute for Cancer Research, Prevention and Clinical Network (ISPRO), Florence, Italy
| | - Peter Hoskin
- Mount Vernon Cancer Centre, Northwood, United Kingdom; Division of Cancer Sciences, University of Manchester, United Kingdom
| | - Charles B Simone
- Department of Radiation Oncology, New York Proton Center, New York, NY, USA
| | - Peter Johnstone
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Yvette van der Linden
- Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands; Centre of Expertise in Palliative Care, Leiden University Medical Centre, Leiden, the Netherlands
| | - Joanne M van der Velden
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Emily Martin
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, LA, USA
| | - Sara Alcorn
- Department of Radiation Oncology, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - Candice Johnstone
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - J Isabelle Choi
- Department of Radiation Oncology, New York Proton Center, New York, NY, USA
| | - Gustavo Nader Marta
- Department of Radiation Oncology, Hospital Sírio-Libanês, São Paulo, Brazil; Latin America Cooperative Oncology Group (LACOG), Brazil
| | - Eva Oldenburger
- Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Srinivas Raman
- Radiation Medicine Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Agata Rembielak
- Division of Cancer Sciences, University of Manchester, United Kingdom; Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Vassilios Vassiliou
- Bank of Cyprus Oncology Centre, Department of Radiation Oncology, Nicosia, Cyprus
| | - Pierluigi Bonomo
- Department of Oncology, Azienda, Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Quynh-Nhu Nguyen
- Department of Radiation Oncology, the University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Edward Chow
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Samuel Ryu
- Department of Radiation Oncology, Stony Brook University Hospital, New York, NY, USA
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Zhang Y, Shen G, Xu R, Huang G, Huang Z, Duan H, Yang S, Zheng Q, Yang L, Liu R, Ma L, Chen S, Yi Y, Zhang Z, Li K, Birdas TJ, Koyanagi K, Simone CB. Effectiveness and safety of camrelizumab-containing neoadjuvant therapy in patients with esophageal squamous cell carcinoma: a prospective multicenter observational cohort study. J Thorac Dis 2023; 15:6228-6237. [PMID: 38090323 PMCID: PMC10713292 DOI: 10.21037/jtd-23-1408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 11/20/2023] [Indexed: 02/15/2024]
Abstract
Background Camrelizumab has been demonstrated to be a feasible treatment option for locally advanced esophageal squamous cell carcinoma (ESCC) when combined with neoadjuvant chemotherapy. This trial was conducted to investigate the effectiveness and safety of camrelizumab-containing neoadjuvant therapy in patients with ESCC in daily practice. Methods This prospective multicenter observational cohort study was conducted at 13 tertiary hospitals in Southeast China. Patients with histologically or cytologically confirmed ESCC [clinical tumor-node-metastasis (cTNM) stage I-IVA] who had received at least one dose of camrelizumab-containing neoadjuvant therapy were eligible for inclusion. Results Between June 1, 2020 and July 13, 2022, 255 patients were enrolled and included. The median age was 64 (range, 27 to 82) years. Most participants were male (82.0%) and had clinical stage III-IVA diseases (82.4%). A total of 169 (66.3%) participants underwent surgical resection; 146 (86.4%) achieved R0 resection, and 36 (21.3%) achieved pathological complete response (pCR). Grades 3-5 adverse events (AEs) were experienced by 14.5% of participants. Reactive cutaneous capillary endothelial proliferation occurred in 100 (39.2%) of participants and all were grade 1 or 2. Conclusions Camrelizumab-containing neoadjuvant therapy has acceptable effectiveness and safety profiles in real-life ESCC patients.
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Affiliation(s)
- Yi Zhang
- Department of Cardiothoracic Surgery, Zhangzhou Hospital Affiliated to Fujian Medical University, Zhangzhou, China
| | - Guoyi Shen
- Department of Cardiothoracic Surgery, Zhangzhou Hospital Affiliated to Fujian Medical University, Zhangzhou, China
| | - Rongyu Xu
- Department of Thoracic Surgery, Quanzhou First Hospital Affiliated to Fujian Medical University, Quanzhou, China
| | - Guozhong Huang
- Department of Thoracic Surgery, Affiliated Hospital of Putian University, Putian, China
| | - Zhijun Huang
- Department of Gastrointestinal and Esophageal Surgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Hongbing Duan
- Department of Thoracic Surgery, Zhongshan Hospital Affiliated to Xiamen University, Xiamen, China
| | - Shengsheng Yang
- Depatment of Cardiothoracic Surgery, The 900th Hospital of the Joint Logistics Support Force of the Chinese People’s Liberation Army, Fuzhou, China
| | - Qingfeng Zheng
- Department of Thoracic Surgery, Fujian Cancer Hospital, Fuzhou, China
| | - Libao Yang
- Department of Thoracic Surgery, Sanming Second Hospital, Sanming, China
| | - Rongxing Liu
- Depatment of Cardiothoracic Surgery, Longyan Second Hospital, Longyan, China
| | - Liangyun Ma
- Department of Thoracic Surgery, The 910th Hospital of the Joint Logistics Support Force of the Chinese People’s Liberation Army, Quanzhou, China
| | - Shaogeng Chen
- Department of Thoracic Surgery, Quanzhou First Hospital Affiliated to Fujian Medical University, Quanzhou, China
| | - Yunfeng Yi
- Depatment of Cardiothoracic Surgery, Southeast Hospital affiliated to Xiamen University, Xiamen, China
| | - Zheming Zhang
- Department of Thoracic Surgery, The 900th Hospital of the Joint Logistics Support Force of the Chinese People’s Liberation Army Putian Medical District, Putian, China
| | - Kezhi Li
- Department of Thoracic Surgery, Nanping First Hospital, Nanping, China
| | - Thomas J. Birdas
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kazuo Koyanagi
- Department of Gastroenterological Surgery, Tokai University School of Medicine, Kanagawa, Japan
| | - Charles B. Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center and New York Proton Center, New York, NY, USA
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Hu L, Zhai A, Chen Q, Puri V, Chen CC, Yu F, Fox J, Wolden S, Yang J, Simone CB, Lin H. Proton pencil beam scanning craniospinal irradiation (CSI) with a single posterior brain beam: Dosimetry and efficiency. Med Dosim 2023; 49:25-29. [PMID: 38040549 DOI: 10.1016/j.meddos.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 12/03/2023]
Abstract
This study explores the feasibility and potential dosimetric and time efficiency benefit of proton Pencil Beam Scanning (PBS) craniospinal irradiation with a single posterior-anterior (SPA) brain field. The SPA approach was compared to our current clinical protocol using Bilateral Posterior Oblique brain fields (BPO). Ten consecutive patients were simulated in the head-first supine position on a long BOS frame and scanned using 3 mm CT slice thickness. A customized thermoplastic mask immobilized the patient's head, neck, and shoulders. A vac-lock was used to secure the legs. PBS proton plans were robustly optimized with 3mm setup errors and 3.5% range uncertainties in the Eclipse V15.6 treatment planning system (n = 12 scenarios). In order to achieve a smooth gradient dose match at the junction area, at least 5 cm overlap region was maintained between the segments and 5 mm uncertainty along the cranial-cauda direction was applied to each segment independently as additional robust optimization scenarios. The brain doses were planned by SPA or BPO fields. All spine segments were planned with a single PA field. Dosimetric differences between the BPO and SPA approaches were compared, and the treatment efficiency was analyzed according to timestamps of beam delivery. Results: The maximum brain dose increases to 111.1 ± 2.1% for SPA vs. 109.0 ± 1.7% for BPO (p < 0.01). The dose homogeneity index (D5/D95) in brain CTV was comparable between techniques (1.037 ± 0.010 for SPA and 1.033 ± 0.008 for BPO). Lens received lower maximum doses by 2.88 ± 1.58 Gy (RBE) (left) and 2.23 ± 1.37 Gy (RBE) (right) in the SPA plans (p < 0.01). No significant cochlea dose change was observed. SPA reduced the treatment time by more than 4 minutes on average and ranged from 2 to 10 minutes, depending on the beam waiting and allocation time. SPA is dosimetrically comparable to BPO, with reduced lens doses at the cost of slightly higher dose inhomogeneity and hot spots. Implementation of SPA is feasible and can help to improve the treatment efficiency of PBS CSI treatment.
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Affiliation(s)
- Lei Hu
- New York Proton Center, New York, NY, USA; Department of Radiation Oncology, Inova Schar Cancer Institute, FairFax, VA, USA.
| | - Anna Zhai
- New York Proton Center, New York, NY, USA
| | - Qing Chen
- New York Proton Center, New York, NY, USA
| | | | - Chin-Cheng Chen
- New York Proton Center, New York, NY, USA; St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Francis Yu
- New York Proton Center, New York, NY, USA
| | - Jana Fox
- Department of Radiation Oncology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Suzanne Wolden
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jonathan Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Charles B Simone
- New York Proton Center, New York, NY, USA; Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Haibo Lin
- New York Proton Center, New York, NY, USA; Department of Radiation Oncology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA; Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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48
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Simone CB. Focus on oncology: the role of palliative radiation therapy in patients with pancreatic cancer. Ann Palliat Med 2023; 12:1122-1124. [PMID: 38062932 DOI: 10.21037/apm-23-585] [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] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 11/23/2023] [Indexed: 12/18/2023]
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49
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Lubas MJ, Santos PMG, Yerramilli D, Simone CB. Proton therapy in the palliative setting. Ann Palliat Med 2023; 12:1331-1344. [PMID: 37574582 DOI: 10.21037/apm-23-230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 07/13/2023] [Indexed: 08/15/2023]
Abstract
Given its sharp dose fall off and ability to spare healthy surrounding tissue, proton beam therapy (PBT) has traditionally been used to treat various types of malignancies in the definitive setting, with strong, empirical data supporting its utility and safety. In the palliative setting, however, photon therapy has generally remained the standard of care in radiation treatment delivery due to lower cost, and greater availability. However, recent data suggest that the use of PBT may provide benefit in terms of symptom management and disease control in patients with locally advanced or recurrent disease who do not qualify for definitive therapy or with metastatic disease. Additionally, due to its unique dosimetric properties, PBT may confer less overall toxicity, thus helping preserve or improve the quality of life in this patient population, especially for those who are nearing end of life. While there is a need for further study, initial data analyzed from both retrospective and prospective single-institution and multi-institution trials are promising. This review aims to explore the efficacy and safety of PBT in the palliative setting among adults and to summarize pertinent studies that support its usage. To the authors' knowledge, this is the first review of the literature pertaining to PBT used in the palliative setting across multiple disease sites.
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Affiliation(s)
- M Judy Lubas
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Patricia Mae G Santos
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Divya Yerramilli
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA; New York Proton Center, New York, NY, USA
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50
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Heinzerling JH, Pen OV, Robinson M, Foster R, Kelly B, Mileham KF, Moeller B, Prabhu RS, Corso C, Ward MW, Sullivan CM, Burri S, Simone CB. Full Dose SBRT in Combination With Mediastinal Chemoradiation for Locally Advanced, Non-Small Cell Lung Cancer: A Practical Guide for Planning, Dosimetric Results From a Phase 2 Study, and a Treatment Planning Guide for the Phase 3 NRG Oncology LU-008 Trial. Pract Radiat Oncol 2023; 13:531-539. [PMID: 37406774 DOI: 10.1016/j.prro.2023.04.014] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 04/21/2023] [Accepted: 04/25/2023] [Indexed: 07/07/2023]
Abstract
PURPOSE Stereotactic body radiation therapy (SBRT) has been used with high effectiveness in early-stage non-small cell lung cancer (NSCLC) but has not been studied extensively in locally advanced NSCLC. We conducted a phase 2 study delivering SBRT to the primary tumor followed by conventionally fractionated chemoradiation to the involved lymph nodes for patients with node-positive locally advanced NSCLC. This manuscript serves as both a guide to planning techniques used on this trial and the subsequent phase 3 study, NRG Oncology LU-008, and to report patient dosimetry and toxicity results. METHODS AND MATERIALS We initiated a phase 2 multicenter single arm study evaluating SBRT to the primary tumor (50-54 Gy in 3-5 fractions) followed by conventionally fractionated chemoradiation to 60 Gy in 2 Gy fractions with doublet chemotherapy to the involved lymph nodes for patients with stage III or unresectable stage II NSCLC. Patients eligible for adjuvant immunotherapy received up to 12 months of durvalumab. We report a detailed guide for the entire treatment process from computed tomography simulation through treatment planning and delivery. The dosimetric outcomes from the 60 patients who completed therapy on study are reported both for target coverage and normal structure doses. We also report correlation between radiation-related toxicities and dosimetric parameters. RESULTS Sixty patients were enrolled between 2017 and 2022. Planning techniques used were primarily volumetric modulated arc therapy for SBRT to the primary tumor and conventionally fractionated radiation to the involved nodes, with a minority of cases using dynamic conformal arc technique or static dynamic multileaf collimator intensity modulated radiation therapy. Grade 2 or higher pneumonitis was associated with lung dose V5 Gy > 70% and grade 2 or higher pulmonary toxicity was associated with lung dose V10 Gy > 50%. Only 3 patients (5%) experienced grade 3 or higher pneumonitis. Grade 2 or higher esophagitis was associated with esophageal doses, including mean dose > 20 Gy, V60 Gy > 7%, and D1cc > 55 Gy. Only 1 patient (1.7%) experienced grade 3 esophagitis. CONCLUSIONS SBRT to the primary tumor followed by conventionally fractionated chemoradiation to the involved lymph nodes is feasible with planning techniques as described. Radiation-related toxicity on this phase 2 study was low. This manuscript serves as a guideline for the recently activated NRG Oncology LU-008 phase 3 trial evaluating this experimental regimen.
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Affiliation(s)
- John H Heinzerling
- Levine Cancer Institute, Atrium Health, Southeast Radiation Oncology, Charlotte, North Carolina.
| | - Olga V Pen
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Myra Robinson
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Ryan Foster
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Brian Kelly
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | | | - Benjamin Moeller
- Levine Cancer Institute, Atrium Health, Southeast Radiation Oncology, Charlotte, North Carolina
| | - Roshan S Prabhu
- Levine Cancer Institute, Atrium Health, Southeast Radiation Oncology, Charlotte, North Carolina
| | - Christopher Corso
- Levine Cancer Institute, Atrium Health, Southeast Radiation Oncology, Charlotte, North Carolina
| | - Matt W Ward
- Levine Cancer Institute, Atrium Health, Southeast Radiation Oncology, Charlotte, North Carolina
| | - Cara M Sullivan
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Stuart Burri
- Levine Cancer Institute, Atrium Health, Southeast Radiation Oncology, Charlotte, North Carolina
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; New York Proton Center, New York, New York
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