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Mensour EA, Alam S, Mawani S, Bahig H, Lang P, Nichols A, Palma DA, Jasper K. What is the future of treatment de-escalation for HPV-positive oropharyngeal cancer? A review of ongoing clinical trials. Front Oncol 2022; 12:1067321. [PMID: 36620554 PMCID: PMC9816564 DOI: 10.3389/fonc.2022.1067321] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 12/05/2022] [Indexed: 12/25/2022] Open
Abstract
Background Human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) has increased in incidence in recent decades. With higher cure rates in younger populations, long-term survivors may live with acute- and long-term toxicity, leading to increased interest in de-escalation treatment strategies for HPV-related OPSCC. Herein, we have examined the current landscape of clinical trials in this context. Methods A review of active clinical trials related to de-escalation of HPV-associated OPSCC treatment was performed using the clinicaltrials.gov database from inception to January 2022. A search using the key words "oropharyngeal cancer" and "HPV" was completed. Three investigators independently reviewed each trial, with any discrepancies settled by a fourth. Data collected from each study included study phase, study design, primary, and secondary endpoints, and de-escalation treatment strategies. A final 24 articles were selected for full text review. Results Many trials (n=19, 79%) were non-randomized, and most studies employed a phase II design (n=14, 58%). Only 13% (n=3) were randomized trials, and 8% (n=2) included a phase III component. The most frequent primary endpoint was progression-free survival (PFS) (n=9, 37.5%). With regards to the identified de-escalation strategies, all the studies (n=24) had at least one component assessing changes in RT dose/fractionation and/or a reduction in RT volumes. A smaller percentage of trials assessed surgical interventions (n=9, 37.5%) and/or changes in systemic therapy (n=8, 33.3%). Conclusion A small number of randomized trials are underway, and a transition to more randomized phase III trials in the future will be important to change clinical practice.
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Affiliation(s)
- Emma A. Mensour
- Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada
| | - Shintha Alam
- Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada
| | - Seliya Mawani
- Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada
| | - Houda Bahig
- Department of Radiology, Radiation Oncology and Nuclear Medicine, Université de Montréal, Montréal, QC, Canada
| | - Pencilla Lang
- Department of Radiation Oncology, London Health Sciences Centre, University of Western Ontario, London, ON, Canada
| | - Anthony Nichols
- Department of Otolaryngology-Head and Neck Surgery, University of Western Ontario, London, ON, Canada
| | - David A. Palma
- Department of Radiation Oncology, London Health Sciences Centre, University of Western Ontario, London, ON, Canada,*Correspondence: David A. Palma,
| | - Katie Jasper
- Department of Radiation Oncology, London Health Sciences Centre, University of Western Ontario, London, ON, Canada
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Abstract
Local ablative therapies, including surgery or stereotactic radiotherapy (SABR), are becoming an integral component in the treatment of oligometastatic disease in non-small-cell lung cancer. In this review, we summarize recent randomized evidence supporting progression-free survival and overall survival benefits of local ablation in these patients, as well as upcoming phase III data which should help us better understand the ideal treatment conditions and provide more insight into the oligometastatic state. Since practical management of oligometastatic disease in non-small-cell lung cancer can be challenging, we discuss a modern framework to identify patient, tumor, and treatment characteristics that can best guide management.
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Affiliation(s)
- Katie Jasper
- Division of Radiation Oncology, Western University, London Health Sciences Centre, London, Canada.,Division of Radiation Oncology, University of British Columbia, BC Cancer, Vancouver, Canada
| | - Brendon Stiles
- Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Fiona McDonald
- Department of Cardiothoracic and Vascular Surgery, Montefiore-Einstein Cancer Center, New York, NY
| | - David A Palma
- Division of Radiation Oncology, Western University, London Health Sciences Centre, London, Canada
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Jasper K, Liu B, Olson R, Matthews Q. Evidence-Based Planning Target Volume Margin Reduction for Modern Lung Stereotactic Ablative Radiation Therapy Using Deformable Registration. Adv Radiat Oncol 2021; 6:100750. [PMID: 34401609 PMCID: PMC8349747 DOI: 10.1016/j.adro.2021.100750] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 05/20/2021] [Accepted: 06/25/2021] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Standard planning target volume (PTV) margins for lung stereotactic ablative radiation therapy (SABR) are 5 mm. High-dose-rate volumetric modulated arc therapy delivered using flattening filter-free (FFF) beams with modern immobilization systems may allow for PTV margin reduction. This study assesses whether PTV margins can be reduced from 5 to 3 mm. METHODS Target intrafractional motions derived from pretreatment and posttreatment cone beam computed tomography (CBCT) scans for 33 patients receiving lung SABR treated with 10XFFF energy and 5-mm PTV margins from 2016 to 2019 were used to calculate the required PTV margin. Deformable registration of the planning CT scan and internal gross tumor volume (IGTV) contour to posttreatment CBCT scans for 36 consecutive patients with 4 fraction schedules was completed to capture volume changes and intrafractional movement. Plans were replanned with 3-mm margins and recalculated on each deformed CT scan to assess deformed IGTV (d-IGTV) coverage and organ-at-risk doses. RESULTS Margin analysis showed PTV margins may be reduced to 3 mm. The mean d-IGTV coverage (percentage of the d-IGTV receiving ≥100% of the prescription dose [V100%] and the minimum dose covering 99.9% of the d-IGTV volume [D99.9%]) over 4 fractions for each patient was >95% with both margins. With 5-mm PTV margins, all 144 fractions had a d-IGTV V100% of >95% and a D99.9% >95%. With 3-mm PTV margins, the d-IGTV V100% was >95% in 99.3% of fractions (143 of 144) and the D99.9% was >95% in 98.6% of fractions (142 of 144). With 3-mm PTV margins, significant reductions in body V50%, body V80%, the volume of the lung receiving ≥20 Gy, and the mean lung dose and chest wall dose to 0.035 cm3 and 30 cm3 were observed (all P < .001). Using theoretical models, the normal tissue complication probability for radiation pneumonitis decreased by a mean of 0.8% (range, 0.1%-2.7%), and the mean 2-year tumor control probability was 96.1% and 95.2% with 5-mm and 3-mm PTV margins, respectively. CONCLUSION With modern treatment and immobilization techniques in lung SABR, 3-mm PTV margins maintain acceptable IGTV coverage, modestly reduce toxicity to organs at risk, and maintain a calculated 2-year local control rate of >95%.
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Affiliation(s)
- Katie Jasper
- BC Cancer–Vancouver, Vancouver, British Columbia, Canada
- Division of Radiation Oncology, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Baochang Liu
- BC Cancer–Prince George, Prince George, British Columbia, Canada
- Radiation Medicine Program, Walker Family Cancer Centre, St. Catharines, Ontario, Canada
| | - Robert Olson
- Division of Radiation Oncology, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
- BC Cancer–Prince George, Prince George, British Columbia, Canada
| | - Quinn Matthews
- BC Cancer–Prince George, Prince George, British Columbia, Canada
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Jasper K, Matthews Q, Liu B, Olson R. 28: Deformable Registration for Evidence-Based Ptv Margins in Lung SABR: Can Modern Techniques Facilitate Reduction in Ptv Margins While Maintaining Igtv Coverage? Radiother Oncol 2020. [DOI: 10.1016/s0167-8140(20)30920-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Gupta P, Leahul L, Wang X, Wang C, Bakos B, Jasper K, Hansen D. Proteasome regulation of the chromodomain protein MRG-1 controls the balance between proliferative fate and differentiation in the C. elegans germ line. Development 2015; 142:291-302. [PMID: 25564623 DOI: 10.1242/dev.115147] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The level of stem cell proliferation must be tightly controlled for proper development and tissue homeostasis. Multiple levels of gene regulation are often employed to regulate stem cell proliferation to ensure that the amount of proliferation is aligned with the needs of the tissue. Here we focus on proteasome-mediated protein degradation as a means of regulating the activities of proteins involved in controlling the stem cell proliferative fate in the C. elegans germ line. We identify five potential E3 ubiquitin ligases, including the RFP-1 RING finger protein, as being involved in regulating proliferative fate. RFP-1 binds to MRG-1, a homologue of the mammalian chromodomain-containing protein MRG15 (MORF4L1), which has been implicated in promoting the proliferation of neural precursor cells. We find that C. elegans with reduced proteasome activity, or that lack RFP-1 expression, have increased levels of MRG-1 and a shift towards increased proliferation in sensitized genetic backgrounds. Likewise, reduction of MRG-1 partially suppresses stem cell overproliferation. MRG-1 levels are controlled independently of the spatially regulated GLP-1/Notch signalling pathway, which is the primary signal controlling the extent of stem cell proliferation in the C. elegans germ line. We propose a model in which MRG-1 levels are controlled, at least in part, by the proteasome, and that the levels of MRG-1 set a threshold upon which other spatially regulated factors act in order to control the balance between the proliferative fate and differentiation in the C. elegans germ line.
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Affiliation(s)
- Pratyush Gupta
- Department of Biological Sciences, University of Calgary, 2500 University Drive, Calgary, Alberta, Canada T2N 1N4
| | - Lindsay Leahul
- Department of Biological Sciences, University of Calgary, 2500 University Drive, Calgary, Alberta, Canada T2N 1N4
| | - Xin Wang
- Department of Biological Sciences, University of Calgary, 2500 University Drive, Calgary, Alberta, Canada T2N 1N4
| | - Chris Wang
- Department of Biological Sciences, University of Calgary, 2500 University Drive, Calgary, Alberta, Canada T2N 1N4
| | - Brendan Bakos
- Department of Biological Sciences, University of Calgary, 2500 University Drive, Calgary, Alberta, Canada T2N 1N4
| | - Katie Jasper
- Department of Biological Sciences, University of Calgary, 2500 University Drive, Calgary, Alberta, Canada T2N 1N4
| | - Dave Hansen
- Department of Biological Sciences, University of Calgary, 2500 University Drive, Calgary, Alberta, Canada T2N 1N4
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Abstract
George Will, the well-known pundit, once observed: “A society's recreation is charged with moral significance. Sport—and a society that takes it seriously—would be debased if it did not strictly forbid things that blur the distinction between the triumph of character and the triumph of chemistry.” In opposition, Dan Duchaine, the highly publicized “steroid guru” and counter-culture columnist, declared: “There comes a time for many in competitive athletics where winning is more important than those initial goals of health, recreation, and relaxation.” Theparallels of these twophilosophies to life in general are patent simply by substituting “sports” and “winning” for “career” and “success,” respectively.This paper will review the basis for banning anabolic steroids in athletics, and consider especially the recent medical findings that support this prohibition. This survey leads into a discussion of the available deterrents, and the secondary, but essential, role of random drug testing as a final safeguard.
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