1
|
Sedor GJ, Lee AW, Gallitto M, Pasetsky J, Helis CA, Chan MD, Beckham T, McGovern SL, Wang TJC. Multi-Institutional Study of Stereotactic Radiosurgery for Recurrent WHO Grade 2/3 Meningiomas: An Interim Analysis. Int J Radiat Oncol Biol Phys 2023; 117:e148. [PMID: 37784728 DOI: 10.1016/j.ijrobp.2023.06.965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Meningiomas are the most common tumors of the central nervous system (CNS). Approximately 80% are classified as World Health Organization (WHO) grade 1, while 20% correspond to grade 2 or grade 3. In those with grade 2/3 disease, local recurrence is not uncommon. Salvage treatment options vary widely and include resection, external beam radiation therapy (EBRT), stereotactic radiosurgery (SRS), and/or clinical trials. Although retrospective studies have reported on the use of upfront SRS in grade 2/3 meningiomas, large-scale outcomes with SRS in the recurrent setting are lacking. The objective of this study was to report on oncologic outcomes for patients with recurrent grade 2/3 meningioma treated with SRS. MATERIALS/METHODS This is an ongoing multi-institutional retrospective cohort study. Eligibility criteria include patients >18 years old with pathologically confirmed WHO grade 2 or 3 meningioma treated with SRS monotherapy at the time of first recurrence. Patients require pathologic confirmation only at time of diagnosis; those with upfront grade 1 disease must have pathologic confirmation of grade 2/3 disease at time of first recurrence. Patients with multifocal disease upfront were excluded from this study. RESULTS A total of 60 patients met eligibility criteria. Baseline demographics at time of initial diagnosis are shown in table 1. At the time of first recurrence, 57 (95%) were WHO grade 2, and 3 (5%) were grade 3. Median follow up time from first recurrence was 5.02 years. Median marginal SRS dose was 16 Gy (IQR 14-17) to a 2.67cc planning treatment volume (IQR 1.4-5.1). 92% of patients received single fraction SRS. Median time to second recurrence was 5.92 years. 1, 3, and 5-year progression-free survival (PFS) was 95%, 68%, and 51%, respectively. 1, 3, and 5-year overall survival (OS) was 100%, 98%, and 96%, respectively. On multivariate analysis, grade 3 disease was independently associated with worse PFS (HR 15.7, p = 0.03). Median SRS dose and treatment volume did not correlate with PFS. 1 patient (1.7%) experienced symptomatic radiation necrosis requiring steroids, 3 (5.0%) experienced new seizure activity, and 2 (3.3%) additional patients showed clinical evidence of post-treatment neurocognitive decline. CONCLUSION Based on this interim analysis, primary SRS for recurrent grade 2/3 meningioma appears safe and feasible, with outcomes comparable to prospective data on high-risk grade 2/3 patients treated with post-operative fractionated EBRT. We look forward to further analysis with a larger cohort which may help guide further prospective studies.
Collapse
Affiliation(s)
- G J Sedor
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - A W Lee
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - M Gallitto
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - J Pasetsky
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - C A Helis
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC
| | - M D Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC
| | - T Beckham
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - S L McGovern
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - T J C Wang
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| |
Collapse
|
2
|
Zarabi H, Helis CA, Russell G, Huang J, Liu W, Soltys SG, Mendoza M, Braunstein SE, Salans MA, Wang TJC, Gallitto M, Shi W, Cappelli L, Shen C, Young MD, Mignano JE, Halasz LM, Barbour AB, Masters AH, Chan MD. Multi-Institutional Report of Re-Irradiation for Recurrent High-Grade Glioma. Int J Radiat Oncol Biol Phys 2023; 117:S85-S86. [PMID: 37784590 DOI: 10.1016/j.ijrobp.2023.06.408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Significant heterogeneity exists with regards to prior published reports of re-irradiation (re-RT) in patients with recurrent high grade glioma (HGG). A multi-institutional database of 10 academic centers across the United States was created to analyze prognostic outcomes for re-RT for recurrent HGG, which included WHO Grade III and Grade IV tumors. MATERIALS/METHODS Patients with HGG who had initially received standard radiotherapy (RT) and were subsequently treated with a course of re-RT at recurrence were included in the study. Factors assessed to delineate a significant association with overall survival (OS) and toxicity included age, KPS, number of relapses, dose, use of bevacizumab (BEV) or temozolomide (TMZ), time from prior RT, histology, RT target, re-RT target> 5cm and extent of resection, and MGMT methylation status. The Kaplan-Meier Method was used to estimate OS. Cox proportional hazards regression models were used to identify factors associated with OS. Toxicity outcomes were assessed using logistic regression. Significance was assumed if p<0.05. Data management and decision management software were used for all analyses. RESULTS Between 2001 and 2022, 280 patients from 10 academic institutions were treated with re-RT for diagnosis of recurrent HGG. 133 patients (71.1%) had a histologic glioblastoma (GBM) at the time of re-RT, with the remainder having Grade 3 gliomas. Median dose delivered at re-RT was 47 Gy BED10 (IQR 47 - 53 Gy BED10), with the most common regimen being 35 Gy in 10 fractions. 83 patients (56%) had GTV greater than 5 cm treated with re-RT. 183 patients (79%) received concurrent systemic therapy, including 95 (41%) who received concurrent TMZ and 86 (45%) who received concurrent BEV. Median OS for the entire cohort was 10 months. Increasing dose at re-RT was associated with improved OS (OR 0.80 95% CI 0.67-0.95, p = 0.10 per 10 Gy BED10), as was dose greater than 47 Gy BED10, which is equivalent to 35 Gy in 10 fractions (OR 0.70, 95% CI 0.54-0.91). Concurrent TMZ was also associated with improved OS (OR 0.68, 95% CI 0.46-0.83, p < 0.01). 32/143 (22%) patients evaluable for toxicity experienced Grade 2 or greater adverse radiation effect (ARE). Use of BEV was associated with decreased toxicity (OR 0.45, 95% CI 0.21-0.98, p = 0.05). Dose at re-RT (OR 1.07 per 10 Gy BED10, p = 0.78), a GTV > 5cm (OR 1.39, p = 0.44), and the use of concurrent TMZ (OR 1.90, p = 0.10) were not associated with Grade 2 or greater ARE. CONCLUSION Higher dose of re-RT and use of concurrent TMZ led to improved OS in recurrent HGG patients without an associated increased rate of ARE. Use of BEV decreased the likelihood of Grade 2 or greater ARE in the re-RT setting for these recurrent HGG patients.
Collapse
Affiliation(s)
- H Zarabi
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC
| | - C A Helis
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC
| | - G Russell
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC
| | - J Huang
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO
| | - W Liu
- University of Iowa, Iowa City, IA
| | - S G Soltys
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA
| | - M Mendoza
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, CA
| | - S E Braunstein
- University of California San Francisco, Department of Radiation Oncology, San Francisco, CA
| | - M A Salans
- University of California San Francisco, San Francisco, CA
| | | | - M Gallitto
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - W Shi
- Thomas Jefferson University Hospital, Philadelphia, PA
| | - L Cappelli
- Department of Radiation Oncology, Thomas Jefferson University Hospital, Philadelphia, PA
| | - C Shen
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, NC
| | - M D Young
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - J E Mignano
- Tufts Medical Center, Department of Radiation Oncology, Boston, MA
| | - L M Halasz
- Department of Radiation Oncology, University of Washington/ Fred Hutchinson Cancer Center, Seattle, WA
| | | | | | - M D Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, NC
| |
Collapse
|
3
|
Kokossis D, Wei HJ, Gallitto M, Yoh N, McQuillan N, Tazhibi M, Berg X, Zhang X, Szalontay L, Gartrell R, Jovana P, Zhang Z, Molotkov A, Mintz A, Konofagou EE, Wu CC. Focused Ultrasound for Blood-Brain Barrier Opening and Delivery of Anti-PD1 in Diffuse Midline Gliomas. Int J Radiat Oncol Biol Phys 2023; 117:e523-e524. [PMID: 37785629 DOI: 10.1016/j.ijrobp.2023.06.1796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Diffuse midline glioma with H3K27 mutation is a fatal pediatric brain tumor, most commonly arising in the brainstem. This tumor remains universally fatal, despite a multitude of clinical trials, with a median overall survival of only 9-12 months. While immune-checkpoint inhibitors (ICIs) have transformed the treatment landscape of multiple solid tumors, delivery past the blood brain barrier (BBB) remains challenging. Programmed cell death protein 1 (PD1) is an immune checkpoint protein expressed on the surface of activated T cells; interaction with its ligand, PDL1, is tumor-protective, dampening T cell response. Recent phase I clinical trials have shown that ICIs targeting proteins along the PD1/PDL1 axis are well tolerated in patients with DMG; however, efficacy remains low. The blood-brain barrier (BBB) poses a major challenge to the efficacious delivery of therapeutic agents with large molecular size, such as anti-PD1. We hypothesize that BBB opening (BBBO) using focused ultrasound (FUS), a form of non-ionizing acoustic radiation, can enhance delivery and efficacy of anti-PD1 for treatment of DMG. MATERIALS/METHODS We established a syngeneic mouse DMG model with intracranial injection of cell line 4423 (PDGFB+, H3.3K27M, p53-/-). Magnetic resonance imaging (MRI) was utilized to evaluate BBBO and tumor progression. We measured delivery of anti-PD1 after BBBO using Western Blot and 3D in vivo optical fluorescent imaging/CT (OI/CT) of Cy7 labeled anti-PD1. RESULTS We demonstrate that delivery of anti-PD1 can be enhanced over 3.5-fold after reversible BBBO with FUS and concurrent microbubble administration. OI/CT revealed enhanced real-time antibody distribution peritumorally. Furthermore, we demonstrate that combined treatment of FUS and anti-PD1 led to benefit in local control of tumor growth using volumetric analysis of MRI. Preliminary survival studies suggest a positive trend for overall survival. CONCLUSION Our results support that FUS-mediated BBBO can increase treatment efficacy of anti-PD1 in a DMG murine model, due to improved targeted delivery to the tumoral region after systemic antibody administration. We consider these findings strong rationale for further investigation of the therapeutic effects of combinatorial treatment using FUS-mediated BBBO and ICIs for the treatment of DMG.
Collapse
Affiliation(s)
- D Kokossis
- Columbia University Irving Medical Center, New York, NY
| | - H J Wei
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - M Gallitto
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - N Yoh
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, NY
| | - N McQuillan
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | | | - X Berg
- Columbia University Irving Medical Center, New York, NY
| | - X Zhang
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY
| | - L Szalontay
- Department of Pediatrics Oncology, Columbia University Irving Medical Center, New York, NY
| | - R Gartrell
- Department of Pediatrics Oncology, Columbia University Irving Medical Center, New York, NY
| | - P Jovana
- Columbia University Irving Medical Center, New York, NY
| | - Z Zhang
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY
| | - A Molotkov
- Columbia University Irving Medical Center, New York, NY
| | - A Mintz
- Columbia University Irving Medical Center, New York, NY
| | - E E Konofagou
- Department of Biomedical Engineering, Columbia University, New York, NY
| | - C C Wu
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
| |
Collapse
|
4
|
Lee AW, Pasetsky J, Lavrova E, Wang YF, Sedor GJ, Li F, Gallitto M, Garrett MD, Elliston C, Price M, Kachnic LA, Horowitz DP. CT-Guided Online Adaptive Stereotactic Body Radiotherapy for Pancreas Ductal Adenocarcinoma: Dosimetric and Initial Clinical Experience. Int J Radiat Oncol Biol Phys 2023; 117:e312. [PMID: 37785126 DOI: 10.1016/j.ijrobp.2023.06.2340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Retrospective analysis suggests that dose escalation to a biologically effective dose of more than 70 Gy may improve overall survival in patients with pancreatic ductal adenocarcinoma (PDAC), but such treatments in practice are limited by proximity of organs at risk (OARs). We hypothesized that CT-guided online adaptive radiotherapy (OART) can account for interfraction movement of OARs, reduce dose to OARs, and improve coverage of targets. MATERIALS/METHODS This is a single institution retrospective analysis of patients with PDAC treated with OART on a CBCT-based OART platform. All patients were treated to 40 Gy in 5 fractions. PTV overlapping with a 5 mm planning risk volume expansion on the stomach, duodenum and bowel received 25 Gy. Initial treatment plans were created conventionally. For each fraction, PTV and OAR volumes were recontoured with AI assistance after initial cone beam CT (CBCT). The adapted plan was calculated, underwent QA, and then compared to the scheduled plan. A second CBCT was obtained prior to delivery of the selected plan. Total treatment time (first CBCT to end of radiation delivery) and active physician time (first to second CBCT) were recorded. PTV_4000 V95%, PTV_2500 V95%, and D0.03 cc to stomach, duodenum and bowel were reported for scheduled (S) and adapted (A) plans. CTCAEv5.0 toxicities were recorded. Statistical analysis was performed using a two-sided T test and α of 0.05. RESULTS Seven patients with unresectable or locally-recurrent PDAC were analyzed, with a total of 35 fractions. Average total time was 33:00 minutes (22:25-49:40) and average active time was 22:48 minutes (14:15-39:34). All fractions were treated with adapted plans. All adapted plans met PTV_4000 V95.0% > 95.0% coverage goal and OAR dose constraints. Dosimetric data for scheduled and adapted plans per fraction are in Table 1. Median follow up was 1.7 months. 5 (71%) patients experienced either Grade 1 or 2 toxicities. No patients experienced Grade 3+ toxicities. CONCLUSION Daily OART significantly reduced dose OARs while achieving superior PTV coverage. Treatment was generally well tolerated with no grade 3+ acute toxicity, and required only 22:48 minutes on average of active physician time. Our initial clinical experience demonstrates OART allows for safe dose escalation in the treatment of PDAC.
Collapse
Affiliation(s)
- A W Lee
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - J Pasetsky
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - E Lavrova
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - Y F Wang
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - G J Sedor
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - F Li
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - M Gallitto
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - M D Garrett
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - C Elliston
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - M Price
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - L A Kachnic
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - D P Horowitz
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| |
Collapse
|
5
|
Rayn K, Lee A, Lavrova E, Gallitto M, Mayeda M, Hwang M, Padilla O, Spina C, Deutsch I, Koutcher L. Multiparametric MRI as a Predictor of PSA Response in Patients Undergoing Stereotactic Body Radiation (SBRT) Therapy for Prostate Cancer. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.1214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
|
6
|
Rayn K, Lemus OD, Li F, Gallitto M, Padilla O, Price M, Savacool M, Kachnic L, Horowitz D. Trigger-Based Adaptive Planning to Reduce Bowel Dose in Patients Receiving Radiotherapy for Anal Cancer. Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.1437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
7
|
Smith A, Gallitto M, Wasserman I, Gupta V, Sharma S, Westra W, Genden E, Haidar Y, Yao M, Teng M, Miles B, Bakst R. Redefining Patients at Risk of Contralateral Neck Disease for HPV-related Oropharyngeal Cancer: A Pathologic Study of Patients with Bilateral Neck Dissection. Int J Radiat Oncol Biol Phys 2019. [DOI: 10.1016/j.ijrobp.2019.06.1543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
8
|
Dickstein D, Gallitto M, Egerman M, Powers A, Gupta V, Sharma S, Miles B, Posner M, Misiukiewicz K, Bakst R. Treatment Tolerability and Outcomes in Advanced-Age Oropharyngeal Cancer Patients. Int J Radiat Oncol Biol Phys 2019. [DOI: 10.1016/j.ijrobp.2019.06.1518] [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: 10/26/2022]
|