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Raleigh DR, Chen WC, Gondi V, Rogers L, Mehta M. Implications and interchangeability of meningioma biomarkers for clinical trials and clinical practice. J Neurooncol 2024:10.1007/s11060-024-04700-8. [PMID: 38743346 DOI: 10.1007/s11060-024-04700-8] [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] [Received: 04/02/2024] [Accepted: 04/29/2024] [Indexed: 05/16/2024]
Affiliation(s)
- David R Raleigh
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA.
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA.
- Department of Pathology, University of California San Francisco, San Francisco, CA, USA.
- Departments of Radiation Oncology, Neurological Surgery, and Pathology, University of California San Francisco, Helen Diller Family Cancer Research Building 1450 3rd Street, HD481, 94158, San Francisco, CA, USA.
| | - William C Chen
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Vinai Gondi
- Department of Radiation Oncology, Northwestern University, Chicago, IL, USA
| | - Leland Rogers
- Radiation Oncology, Utah Cancer Specialists, Salt Lake City, UT, USA
| | - Minesh Mehta
- Miami Cancer Institute, Baptist Health, Miami, FL, USA
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Cherng HRR, Sun K, Bentzen S, Armstrong TS, Gondi V, Brown PD, Mehta M, Mishra MV. Evaluating the heterogeneity of hippocampal avoidant whole brain radiotherapy treatment effect: A secondary analysis of NRG CC001. Neuro Oncol 2024; 26:911-921. [PMID: 38069666 PMCID: PMC11066939 DOI: 10.1093/neuonc/noad226] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2024] Open
Abstract
BACKGROUND Hippocampal avoidant whole brain radiotherapy (HA-WBRT) is the standard of care for patients needing WBRT for brain metastases. This study, using existing data from NRG Oncology CC001 including baseline tumor characteristics and patient-reported MD Anderson Symptom Inventory-Brain Tumor (MDASI-BT) scores, sought to identify subgroups of patients that demonstrate differential neuroprotective treatment response to HA-WBRT. METHODS An exploratory analysis of NRG CC001, a phase 3 trial in which 518 patients were randomly assigned to WBRT plus memantine or HA-WBRT plus memantine, was performed. Rates of neurocognitive function failure (NCFF) were estimated between subgroups and stratified by arm. Covariate and subgroup interaction with differential treatment response were calculated. RESULTS The benefit of HA-WBRT on decreasing NCFF was seen in patients living ≥ 4 months (HR 0.75, 95% CI: 0.58-0.97, P = .03), whereas patients living < 4 months derived no significant neurocognitive benefit. A significant association between baseline MDASI-BT cognitive factor and treatment response (interaction P = .03) was identified. Patients with lower MDASI-BT scores (less patient-reported cognitive impairment) derived significantly greater benefit (HR = 0.64, 95% CI: 0.48-0.85, P = .002) compared to those with highest MDASI-BT scores (HR = 1.24, 95% CI: 0.76-2.04, P = .39). Tumor histology also had a significant interaction (P = .01) with treatment response. Primary lung histology patients derived cognitive failure risk reduction (HR = 0.58, 95% CI: 0.43-0.77, P = .0007) from HA-WBRT, in contrast to nonlung primary histology patients (HR = 1.15, 95% CI: 0.78-1.50, P = .48). CONCLUSIONS Differential neuroprotective response to HA-WBRT was identified in this analysis. Patients surviving ≥ 4 months derived benefit from HA-WBRT. There is evidence of heterogeneity of treatment effect for patients with less severe patient-reported cognitive impairment at baseline and those with primary lung histology.
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Affiliation(s)
- Hua-Ren R Cherng
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Kai Sun
- Division of Biostatistics and Bioinformatics, University of Maryland Greenebaum Cancer Center, Baltimore, Maryland, USA
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Søren Bentzen
- Division of Biostatistics and Bioinformatics, University of Maryland Greenebaum Cancer Center, Baltimore, Maryland, USA
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Terri S Armstrong
- National Cancer Institute Center for Cancer Research, Bethesda, Maryland, USA
| | - Vinai Gondi
- Department of Radiation Oncology, Northwestern Medicine Cancer Center and Proton Center, Warrenville, Illinois, USA
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Minesh Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Mark V Mishra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Abstract
Sarcomas are a heterogeneous group of bone and soft tissue tumors. Survival outcomes for advanced (unresectable or metastatic) disease remain poor, so therapeutic improvements are needed. Radiotherapy plays an integral role in the neoadjuvant and adjuvant treatment of localized disease as well as in the treatment of metastatic disease. Combining radiotherapy with immunotherapy to potentiate immunotherapy has been used in a variety of cancers other than sarcoma, and there is opportunity to further investigate combining immunotherapy with radiotherapy to try to improve outcomes in sarcoma. In this review, we describe the diversity of the tumor immune microenvironments for sarcomas and describe the immunomodulatory effects of radiotherapy. We discuss studies on the timing of radiotherapy relative to immunotherapy and studies on the radiotherapy dose and fractionation regimen to be used in combination with immunotherapy. We describe the impact of radiotherapy on the tumor immune microenvironment. We review completed and ongoing clinical trials combining radiotherapy with immunotherapy for sarcoma and propose future directions for studies combining immunotherapy with radiotherapy in the treatment of sarcoma.
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Affiliation(s)
- Qian S Zhang
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - John P Hayes
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Vinai Gondi
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Seth M Pollack
- Division of Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL..
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Cherng HRR, Qu M, Zafari Z, Bentzen S, Armstrong TS, Gondi V, Brown PD, Mehta M, Mishra MV. Evaluating the sensitivity of EQ-5D-5L in patients with brain metastases: a secondary analysis of NRG CC001. J Natl Cancer Inst 2024:djae020. [PMID: 38281073 DOI: 10.1093/jnci/djae020] [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: 09/20/2023] [Revised: 01/16/2024] [Accepted: 01/23/2024] [Indexed: 01/29/2024] Open
Abstract
BACKGROUND EuroQoL EQ-5D is a commonly used measure of health-related quality of life (HRQOL) in clinical trials given the use of its index score as a measure of health utilities. It is unclear whether EQ-5D is sensitive to changes in neurocognitive function and progression that occur following brain radiation. This study sought to evaluate the sensitivity of EQ-5D-5L in reflecting these changes. PATIENTS AND METHODS A secondary analysis of NRG Oncology CC001 was performed. Mean EQ-5D-5L index and visual analog scale (VAS) score changes from baseline between groups of patients stratified by neurocognitive function and intracranial progression status were assessed. MD Anderson Symptom Inventory for brain tumor (MDASI-BT) symptom and interference items were also analyzed between groups. RESULTS EQ-5D-5L index and VAS score changes between patients who had cognitive failure and those that had preserved cognition showed no significant differences at any time point. In contrast, VAS changes at 4 (1.61 vs -5.13, P = .05) and 6 months (8.17 vs -0.14, P = .04) were significantly improved in the patients who survived without intracranial progression.MDASI-BT cognitive factor scores were significantly improved in the cohort of patients with preserved neurocognitive function at 2 (1.68 vs 2.08, P = .05) and 4 months (1.35 vs 1.83, P = .04). MDASI-BT symptom interference was significantly associated with intracranial progression at 4 months, but not with neurocognitive status. CONCLUSION EQ-5D-5L index and VAS scores were not sensitive to neurocognitive changes that patients experienced, but VAS scores were sensitive to progression. This study challenges the routine use of EQ-5D as a QoL metric in brain metastases clinical trials that are focused on preventing neurocognitive dysfunction. TRIAL REGISTRATION NCT# 02360215.
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Affiliation(s)
- Hua-Ren R Cherng
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Melody Qu
- Department of Radiation Oncology, London Regional Cancer Centre, London, ON, Canada
| | - Zafar Zafari
- University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Søren Bentzen
- Division of Biostatistics and Bioinformatics, University of Maryland Greenebaum Cancer Center, and Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Terri S Armstrong
- National Cancer Institute Center for Cancer Research, Bethesda, Maryland, USA
| | - Vinai Gondi
- Department of Radiation Oncology, Northwestern Medicine Cancer Center and Proton Center, Warrenville, IL, USA
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Minesh Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Mark V Mishra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
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Driscoll RK, Lyne SB, Voce DJ, Maraka S, Gondi V, Chmura SJ, Dixit KS, Kumthekar PU, Karrison TG, Pytel P, Collins JM, Stupp R, Merrell RT, Lukas RV, Yamini B. A multi-institutional phase I study of acetazolamide with temozolomide in adults with newly diagnosed MGMT-methylated malignant glioma. Neurooncol Adv 2024; 6:vdae014. [PMID: 38420615 PMCID: PMC10901541 DOI: 10.1093/noajnl/vdae014] [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] [Indexed: 03/02/2024] Open
Abstract
Background A significant unmet need exists for the treatment of glioblastoma, IDH-wildtype (GBM). Preclinical work shows that acetazolamide sensitizes GBM to temozolomide (TMZ) by overcoming TMZ resistance due to BCL-3-dependent upregulation of carbonic anhydrase. Acetazolamide is Food and Drug Administration-approved for the treatment of altitude sickness. Drug repurposing enables the application of drugs to diseases beyond initial indications. This multi-institutional, open-label, phase I trial examined a combination of acetazolamide and TMZ in patients with MGMT promoter-methylated high-grade glioma. Methods A total of 24 patients (GBM, IDH-wildtype = 22; Grade 4 astrocytoma, IDH-mutant = 1; Grade 3 astrocytoma, IDH-mutant = 1) were accrued over 17 months. All patients received oral acetazolamide (250 mg BID for 7 days increased to 500 mg BID for Days 8-21 of each 28-day cycle) during the adjuvant phase of TMZ for up to 6 cycles. Results No patient had a dose-limiting toxicity. Adverse events were consistent with known sequelae of acetazolamide and TMZ. In the 23 WHO Grade 4 patients, the median overall survival (OS) was 30.1 months and the median progression-free survival was 16.0 months. The 2-year OS was 60.9%. In total 37% of the study population had high BCL-3 staining and trended toward shorter OS (17.2 months vs N.R., P = .06). Conclusions The addition of acetazolamide is safe and tolerable in GBM patients receiving standard TMZ. Survival results compare favorably to historical data from randomized trials in patients with MGMT promoter-methylated GBM and support examination of acetazolamide in a randomized trial. BCL-3 expression is a potential biomarker for prognosis in GBM or for patients more likely to benefit from TMZ.
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Affiliation(s)
- Riley K Driscoll
- Department of Neurological Surgery, University of Chicago Medicine, Chicago, Illinois, USA
| | - Sean B Lyne
- Department of Neurological Surgery, University of Chicago Medicine, Chicago, Illinois, USA
| | - David J Voce
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Stefania Maraka
- Department of Neurology and Rehabilitation, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Vinai Gondi
- Proton Therapy Center and Northwestern Medicine Cancer Center, Warrensville, Illinois, USA
| | - Steven J Chmura
- Department of Radiation and Cellular Oncology, University of Chicago Medicine, Chicago, Illinois, USA
| | - Karan S Dixit
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Lou & Jean Malnati Brain Tumor Institute, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois, USA
| | - Priya U Kumthekar
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Lou & Jean Malnati Brain Tumor Institute, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois, USA
| | - Theodore G Karrison
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois, USA
| | - Peter Pytel
- Department of Pathology, University of Chicago Medicine, Chicago, Illinois, USA
| | - John M Collins
- Department of Radiology, University of Chicago Medicine, Chicago, Illinois, USA
| | - Roger Stupp
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Lou & Jean Malnati Brain Tumor Institute, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois, USA
- Division of Hematology/Oncology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Ryan T Merrell
- NorthShore University Health System, Evanston, Illinois, USA
| | - Rimas V Lukas
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Lou & Jean Malnati Brain Tumor Institute, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois, USA
| | - Bakhtiar Yamini
- Department of Neurological Surgery, University of Chicago Medicine, Chicago, Illinois, USA
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Gondi V, Deshmukh S, Brown PD, Wefel JS, Armstrong TS, Tome WA, Gilbert MR, Konski A, Robinson CG, Bovi JA, Benzinger TLS, Roberge D, Kundapur V, Kaufman I, Shah S, Usuki KY, Baschnagel AM, Mehta MP, Kachnic LA. Sustained Preservation of Cognition and Prevention of Patient-Reported Symptoms With Hippocampal Avoidance During Whole-Brain Radiation Therapy for Brain Metastases: Final Results of NRG Oncology CC001. Int J Radiat Oncol Biol Phys 2023; 117:571-580. [PMID: 37150264 PMCID: PMC11070071 DOI: 10.1016/j.ijrobp.2023.04.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 04/18/2023] [Accepted: 04/29/2023] [Indexed: 05/09/2023]
Abstract
PURPOSE Initial report of NRG Oncology CC001, a phase 3 trial of whole-brain radiation therapy plus memantine (WBRT + memantine) with or without hippocampal avoidance (HA), demonstrated neuroprotective effects of HA with a median follow-up of fewer than 8 months. Herein, we report the final results with complete cognition, patient-reported outcomes, and longer-term follow-up exceeding 1 year. METHODS AND MATERIALS Adult patients with brain metastases were randomized to HA-WBRT + memantine or WBRT + memantine. The primary endpoint was time to cognitive function failure, defined as decline using the reliable change index on the Hopkins Verbal Learning Test-Revised (HVLT-R), Controlled Oral Word Association, or the Trail Making Tests (TMT) A and B. Patient-reported symptom burden was assessed using the MD Anderson Symptom Inventory with Brain Tumor Module and EQ-5D-5L. RESULTS Between July 2015 and March 2018, 518 patients were randomized. The median follow-up for living patients was 12.1 months. The addition of HA to WBRT + memantine prevented cognitive failure (adjusted hazard ratio, 0.74, P = .016) and was associated with less deterioration in TMT-B at 4 months (P = .012) and HVLT-R recognition at 4 (P = .055) and 6 months (P = .011). Longitudinal modeling of imputed data showed better preservation of all HVLT-R domains (P < .005). Patients who received HA-WBRT + Memantine reported less symptom burden at 6 (P < .001 using imputed data) and 12 months (P = .026 using complete-case data; P < .001 using imputed data), less symptom interference at 6 (P = .003 using complete-case data; P = .0016 using imputed data) and 12 months (P = .0027 using complete-case data; P = .0014 using imputed data), and fewer cognitive symptoms over time (P = .043 using imputed data). Treatment arms did not differ significantly in overall survival, intracranial progression-free survival, or toxicity. CONCLUSIONS With median follow-up exceeding 1 year, HA during WBRT + memantine for brain metastases leads to sustained preservation of cognitive function and continued prevention of patient-reported neurologic symptoms, symptom interference, and cognitive symptoms with no difference in survival or toxicity.
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Affiliation(s)
- Vinai Gondi
- Northwestern Medicine Cancer Center Warrenville and Northwestern Medicine Proton Center, Department of Radiation Oncology, Warrenville, Illinois.
| | - Snehal Deshmukh
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | - Paul D Brown
- Mayo Clinic, Department of Radiation Oncology, Rochester, Minnesota
| | - Jeffrey S Wefel
- University of Texas MD Anderson Cancer Center, Department of Neuro-Oncology, Houston, Texas
| | - Terri S Armstrong
- National Cancer Institute Center for Cancer Research, Bethesda, Maryland
| | - Wolfgang A Tome
- Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Mark R Gilbert
- University of Texas MD Anderson Cancer Center, Department of Neuro-Oncology, Houston, Texas
| | - Andre Konski
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | - Joseph A Bovi
- Froedtert and the Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | | | | | - Isaac Kaufman
- Wayne State University/Karmanos Cancer Institute, Detroit, Michigan
| | - Sunjay Shah
- Delaware/Christiana Care National Cancer Institute Community Oncology Research Program, Wilmington, Delaware
| | | | | | | | - Lisa A Kachnic
- Columbia University, Vagelos Colleg of Physicians and Surgeons, New York, New York
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Toesca DAS, Hartsell WF, DeWees TA, Chang J, Laughlin B, Voss MM, Mohammed N, Keole SR, McGee LA, Gondi V, Sweeney PJ, Dorn PL, Sinesi CC, Jr LSD, Rich TA, Vargas CE. Final Analysis of a Phase III Controlled Randomized Study of Stereotactic Body Proton Therapy or Conventionally Fractionated Proton Therapy for Early Prostate Cancer: PCG GU002. Int J Radiat Oncol Biol Phys 2023; 117:S24-S25. [PMID: 37784460 DOI: 10.1016/j.ijrobp.2023.06.282] [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) To determine if stereotactic body proton therapy (SBPT) is non-inferior to conventionally fractionated proton therapy (CFPT) in patients with early prostate cancer. MATERIALS/METHODS Multicenter, randomized, controlled, open-label, non-inferiority phase 3 trial that included patients with histologically confirmed low-risk prostate adenocarcinoma defined by Gleason score ≤6, PSA <10 ng/mL, and clinical stage T1-2a N0 M0 by AJCC 7th Ed. Eligible participants were randomly assigned (initially 1:1 and later 2:1 ratio) to CFPT (79.2 Gy in 44 fractions for 9 weeks) or SBPT (38 Gy in 5 fractions for 1 week). Concurrent or adjuvant androgen deprivation therapy was not allowed. The primary endpoint was freedom from failure (FFF) at 2 years, defined as the first occurrence of local, regional, or distant recurrence, biochemical failure by the Phoenix definition (increase of PSA ≥2 ng/mL over the nadir PSA), or the start of salvage therapy including ADT. Secondary endpoints included GI and GU grade ≥2 toxicity according to CTCAE v4 criteria, as well as health-related quality of life (HRQoL) metrics assessed by AUASI and EPIC scores. Non-inferiority would be declared if the 1-sided 95% confidence interval limit for the difference in 2-year FFF rate was below 4.2% between both groups by Clopper-Pearson exact method. RESULTS Between November 2010 and September 2020, 133 patients were enrolled and randomly assigned to CFPT (n = 45) or SBPT (n = 88). Median follow-up was 5 years (IQ 3.9-5.2), with the last patient enrolled followed for at least 2 years. The 2-year FFF was 100% for both groups, fulfilling the pre-specified criteria for non-inferiority of SBPT compared to CFPT. By KM estimates, 5-year FFF was 97.4% and 100% (P = 0.1), and the 5-year OS was 97.1% and 95.5% (P = 0.46) for patients treated with CFPT and SBPT, respectively. The cumulative incidence of any grade ≥3 toxicities at 5 years was 0% and 5.7% (P = 0.14) for patients treated with CFPT and SBPT, respectively. The frequency of GI grade ≥2 toxicity at 6 months was of 0% and 2.3% (P = 0.55), and at 2 years was of 6.7% and 3.4% (P = 0.69) for patients treated with CFPT and SBPT, respectively. The frequency of GU grade ≥2 toxicity at 6 months was of 2.2% and 5.7% (P = 0.42), and at 2 years was of 8.9% and 5.7% (P = 0.54) for patients treated with CFPT and SBPT, respectively. Changes in HRQoL scores at 2 years were similar between groups (Table). CONCLUSION SBPT is non-inferior to CFPT regarding FFF and associated with similar long-term toxicity rates and HRQoL metric scores.
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Affiliation(s)
- D A S Toesca
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
| | | | - T A DeWees
- Department of Qualitative Health Sciences, Section of Biostatistics, Mayo Clinic, Scottsdale, AZ
| | - J Chang
- The Oklahoma Proton Center and University of Oklahoma Health Science Center, Oklahoma City, OK
| | - B Laughlin
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
| | - M M Voss
- Department of Quantitative Health Sciences, Mayo Clinic, Arizona, Phoenix, AZ
| | - N Mohammed
- Northwestern Medicine Chicago Proton Center, Warrenville, IL
| | - S R Keole
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
| | - L A McGee
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
| | - V Gondi
- Northwestern Medicine Cancer Center Warrenville and Northwestern Medicine Chicago Proton Center, Warrenville, IL
| | - P J Sweeney
- Northwestern Medicine Chicago Proton Center, Warrenville, IL
| | - P L Dorn
- Department of Radiation Oncology, Rocky Mountain Hospital for Children, Denver, CO
| | - C C Sinesi
- Hampton University Proton Therapy Institute, Hampton, VA
| | - L S Doh Jr
- Radiation Medicine Associates, Oklahoma City, OK
| | - T A Rich
- University of Virginia Medical Center, Charlottesville, VA
| | - C E Vargas
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
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8
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Kim MM, Mehta MP, Smart DK, Steeg PS, Hong JA, Espey MG, Prasanna PG, Crandon L, Hodgdon C, Kozak N, Armstrong TS, Morikawa A, Willmarth N, Tanner K, Boire A, Gephart MH, Margolin KA, Hattangadi-Gluth J, Tawbi H, Trifiletti DM, Chung C, Basu-Roy U, Burns R, Oliva ICG, Aizer AA, Anders CK, Davis J, Ahluwalia MS, Chiang V, Li J, Kotecha R, Formenti SC, Ellingson BM, Gondi V, Sperduto PW, Barnholtz-Sloan JS, Rodon J, Lee EQ, Khasraw M, Yeboa DN, Brastianos PK, Galanis E, Coleman CN, Ahmed MM. National Cancer Institute Collaborative Workshop on Shaping the Landscape of Brain Metastases Research: challenges and recommended priorities. Lancet Oncol 2023; 24:e344-e354. [PMID: 37541280 PMCID: PMC10681121 DOI: 10.1016/s1470-2045(23)00297-8] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/13/2023] [Accepted: 06/21/2023] [Indexed: 08/06/2023]
Abstract
Brain metastases are an increasing global public health concern, even as survival rates improve for patients with metastatic disease. Both metastases and the sequelae of their treatment are key determinants of the inter-related priorities of patient survival, function, and quality of life, mandating a multidimensional approach to clinical care and research. At a virtual National Cancer Institute Workshop in September, 2022, key stakeholders convened to define research priorities to address the crucial areas of unmet need for patients with brain metastases to achieve meaningful advances in patient outcomes. This Policy Review outlines existing knowledge gaps, collaborative opportunities, and specific recommendations regarding consensus priorities and future directions in brain metastases research. Achieving major advances in research will require enhanced coordination between the ongoing efforts of individual organisations and consortia. Importantly, the continual and active engagement of patients and patient advocates will be necessary to ensure that the directionality of all efforts reflects what is most meaningful in the context of patient care.
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Affiliation(s)
- Michelle M Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA.
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - DeeDee K Smart
- Radiation Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Patricia S Steeg
- Women's Malignancies Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Julie A Hong
- Radiation Research Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Rockville, MD, USA
| | - Michael G Espey
- Radiation Research Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Rockville, MD, USA
| | - Pataje G Prasanna
- Radiation Research Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Rockville, MD, USA
| | | | | | | | - Terri S Armstrong
- Neuro-Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Aki Morikawa
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Kirk Tanner
- National Brain Tumor Society, Newton, MA, USA
| | - Adrienne Boire
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | - Jona Hattangadi-Gluth
- Department of Radiation Oncology, University of California San Diego Health, La Jolla, CA, USA
| | - Hussein Tawbi
- Department of Melanoma Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Caroline Chung
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Robyn Burns
- Melanoma Research Foundation, Washington, DC, USA
| | - Isabella C Glitza Oliva
- Department of Melanoma Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ayal A Aizer
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA, USA
| | - Carey K Anders
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | | | - Manmeet S Ahluwalia
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Veronica Chiang
- Department of Neurosurgery and Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Jing Li
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Silvia C Formenti
- Department of Radiation Oncology, Weill Cornell Medicine, New York, NY, USA
| | - Benjamin M Ellingson
- UCLA Brain Tumor Imaging Laboratory, Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Vinai Gondi
- Department of Radiation Oncology, Northwestern Medicine Cancer Center Warrenville and Proton Center, Warrenville, IL, USA
| | - Paul W Sperduto
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Jill S Barnholtz-Sloan
- Informatics and Data Science Program, Center for Biomedical Informatics and Information Technology, Trans-Divisional Research Program, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | - Jordi Rodon
- Department of Investigational Cancer Therapeutics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eudocia Q Lee
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Mustafa Khasraw
- Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA
| | - Debra Nana Yeboa
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Priscilla K Brastianos
- Division of Hematology/Oncology and Division of Neuro-Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Evanthia Galanis
- Department of Oncology, Mayo Clinic Comprehensive Cancer Center, Mayo Clinic, Rochester, MN, USA
| | - C Norman Coleman
- Radiation Research Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Rockville, MD, USA
| | - Mansoor M Ahmed
- Radiation Research Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Rockville, MD, USA.
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9
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Baskaran AB, Buerki RA, Khan OH, Gondi V, Stupp R, Lukas RV, Villaflor VM. Building Team Medicine in the Management of CNS Metastases. J Clin Med 2023; 12:3901. [PMID: 37373596 DOI: 10.3390/jcm12123901] [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: 04/13/2023] [Revised: 05/30/2023] [Accepted: 06/03/2023] [Indexed: 06/29/2023] Open
Abstract
CNS metastases are often terminal for cancer patients and occur at an approximately 10-fold higher rate than primary CNS tumors. The incidence of these tumors is approximately 70,000-400,000 cases annually in the US. Advances that have occurred over the past two decades have led to more personalized treatment approaches. Newer surgical and radiation techniques, as well as targeted and immune therapies, have enanled patient to live longer, thus increasing the risk for the development of CNS, brain, and leptomeningeal metastases (BM and LM). Patients who develop CNS metastases have often been heavily treated, and options for future treatment could best be addressed by multidisciplinary teams. Studies have indicated that patients with brain metastases have improved survival outcomes when cared for in high-volume academic institutions using multidisciplinary teams. This manuscript discusses a multidisciplinary approach for both parenchymal brain metastases as well as leptomeningeal metastases implemented in three academic institutions. Additionally, with the increasing development of healthcare systems, we discuss optimizing the management of CNS metastases across healthcare systems and integrating basic and translational science into our clinical care to further improve outcomes. This paper summarizes the existing therapeutic approaches to the treatment of BM and LM and discusses novel and emerging approaches to optimizing access to neuro-oncologic care while simultaneously integrating multidisciplinary teams in the care of patients with BM and LM.
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Affiliation(s)
- Archit B Baskaran
- Department of Neurology, The University of Chicago, Chicago, IL 60637, USA
| | - Robin A Buerki
- Health System Clinician of Neurology (Neuro-Oncology), Northwestern Medicine Regional Medical Group, Warrenville, IL 60555, USA
| | - Osaama H Khan
- Surgical Neuro-Oncology, Northwestern Medicine Central DuPage Hospital, Winfield, IL 60190, USA
| | - Vinai Gondi
- Department of Radiation Oncology, Nothwestern Medicine West Region, Lou & Jean Malnati Brain Tumor Institute, Northwestern University, Warrenville, IL 60555, USA
| | - Roger Stupp
- Neuro-Oncology Division, Neurological Surgery, Medicine (Hematology and Oncology), Neurology, Department of Neurology, Lou & Jean Malnati Brain Tumor Institute Northwestern University, Chicago, IL 60611, USA
| | - Rimas V Lukas
- Neuro-Oncology Division, Department of Neurology, Lou & Jean Malnati Brain Tumor Institute, Northwestern University, Chicago, IL 60611, USA
| | - Victoria M Villaflor
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA
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10
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Palmer JD, Prasad RN, Cioffi G, Kruchtko C, Zaorsky NG, Trifiletti DM, Gondi V, Brown PD, Perlow HK, Mishra MV, Chakravarti A, Barnholtz-Sloan JS, Ostrom QT. Exposure to radon and heavy particulate pollution and incidence of brain tumors. Neuro Oncol 2023; 25:407-417. [PMID: 35762336 PMCID: PMC9925706 DOI: 10.1093/neuonc/noac163] [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: 04/06/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Global incidence for brain tumors varies substantially without explanation. Studies correlating radon exposure and incidence are inconclusive. Particulate pollution has been linked to increased tumor incidence. Particulates may disrupt the blood-brain barrier allowing intracranial exposure to oncogenic radon. We investigated the relationship between exposure to residential radon, particulate pollution, and brain tumor incidence in the United States (US). METHODS County-level median radon testing results and annual air quality index values were obtained and divided into tertiles. Counties without both values were excluded. Four groups of counties were generated: high particulate/high radon (high/high), high/low, low/high, and low/low. Using incidence data from the Central Brain Tumor Registry of the US (provided by CDC's National Program of Cancer Registries and NCI's SEER), annual age-adjusted incidence rates (AAAIRs) by group were generated by behavior. Incidence rate ratios were calculated to examine for significant differences (α = .05). Poisson regression accounting for possible confounders was conducted. RESULTS Counties with available data included 83% of the US population. High/high exposure was significantly associated with increased AAAIR of all non-malignant tumors (up to 26% higher, including most meningiomas) even after accounting for potential confounders. An increased AAAIR was noted for all malignant tumors (up to 10% higher), including glioblastoma, but was negated after accounting for demographic/socioeconomic differences. CONCLUSIONS We present the first report suggesting increased non-malignant brain tumor incidence in regions with high particulate and radon exposure. These findings provide insight into unexplained variation in tumor incidence. Future studies are needed to validate these findings in other populations.
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Affiliation(s)
- Joshua D Palmer
- Department of Radiation Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Rahul N Prasad
- Department of Radiation Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Gino Cioffi
- Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA.,Trans Divisional Research Program, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
| | - Carol Kruchtko
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Vinai Gondi
- Brain and Spine Tumor Center, Northwestern Medicine Cancer Center and Proton Center, Warrensville, Illinois, USA
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Haley K Perlow
- Department of Radiation Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Mark V Mishra
- Department of Radiation Oncology, University of Maryland, Baltimore, Maryland, USA
| | - Arnab Chakravarti
- Department of Radiation Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Jill S Barnholtz-Sloan
- Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA.,Trans Divisional Research Program, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA.,Center for Biomedical Informatics and Information Technology (CBIIT), National Cancer Institute, Bethesda, Maryland, USA
| | - Quinn T Ostrom
- Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA.,Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA.,The Preston Robert Tisch Brain Tumor Center, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA
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11
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Iwamoto F, Gondi V, Butowski N, Falchook G, Williams A, Peters KB, Evans J, Lakhani N, McKean M, Symeonides S, Ellingson B, Rotolo J, Capiaux G, Wiegert E, Michel R, Kaesshaefer S, Bexon A. CTNI-49. EARLY SIGNAL OF ACTIVITY FROM A PHASE 2 STUDY OF ST101, A FIRST-IN-CLASS PEPTIDE ANTAGONIST OF CCAAT/ENHANCER-BINDING PROTEIN Β (C/EBPΒ), IN RECURRENT GLIOBLASTOMA (GBM). Neuro Oncol 2022. [PMCID: PMC9660938 DOI: 10.1093/neuonc/noac209.314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
BACKGROUND
C/EBPβ is a transcription factor that is active during embryofetal development but held in an inactive state in most mature cells (Zahnow 2009). C/EBPβ activates a proliferation/survival gene signature in multiple cancers, where it inversely correlates with disease prognosis and survival. ST101 is a cell-penetrating peptide antagonist of C/EBPβ. ST101 exposure leads to selective tumor cell death in multiple human cancer cell lines, including GBM, without impacting normal cell viability. In vivo, ST101 displays rapid uptake into multiple organs, the ability to cross the blood-brain barrier, and a long plasma half-life due to its resistance to degradation. It has potent anti-tumor activity in multiple GBM models, as a single agent or in combination, which supported moving into clinical development. TRIAL DESIGN: This phase 2 study is enrolling adult patients with GBM that has recurred or progressed after one standard treatment regimen (surgery, radiotherapy +/-temozolomide). Patients require measurable disease at baseline and at least 3 months from prior radiotherapy. Subjects receive the recommended phase 2 dose of ST101 (500mg IV weekly). Recruitment in the phase 2 portion of this trial began in January, 2022.
RESULTS
As of June 1, 2022, 14 GBM patients were enrolled. One patient has a confirmed mRANO partial response (PR) after 18 weeks of therapy, seven patients have not reached the first on-study assessment and six patients progressed. The median duration of therapy was 5 weeks. ST101 has a favorable safety profile with minor infusion related reactions being the most common adverse event. Based on the confirmed PR, the GBM cohort will be expanded.
CONCLUSION
This first-in-class C/EBPβ inhibitor, ST101, showed an early signal of activity in recurrent GBM. More extensive follow-up and clinical experience will be presented as this trial expands and matures.
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Affiliation(s)
- Fabio Iwamoto
- Division of Neuro-Oncology, New York-Presbyterian/Columbia University Medical Center , New York, NY , USA
| | - Vinai Gondi
- Northwestern Memorial Hospital , Chicago , USA
| | - Nicholas Butowski
- Department of Neurological Surgery, University of California San Francisco , San Francisco, CA , USA
| | - Gerald Falchook
- Sarah Cannon Research Institute at HealthONE , Denver, CO , USA
| | - Anja Williams
- Sarah Cannon UL and UCL, London , London , United Kingdom
| | - Katherine B Peters
- The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center , Durham, NC , USA
| | - Jeff Evans
- University of Glasgow and Beatson West of Scotland Cancer Centre , Glasgow , United Kingdom
| | | | - Meredith McKean
- Sarah Cannon Research Institute, Tennessee Oncology , Nashville, TN , USA
| | - Stefan Symeonides
- Edinburgh Cancer Research Centre, University of Edinburgh , Edinburgh , United Kingdom
| | | | - Jim Rotolo
- Sapience Therapeutics Inc , Harrison, NY , USA
| | | | | | - Rob Michel
- Bexon Clinical Consulting , Montclair, NJ , USA
| | | | - Alice Bexon
- Bexon Clinical Consulting , Montclair, NJ , USA
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12
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Devisetty K, Pugh S, Brown P, Gondi V, Wefel J, Solanki A, Kalapparambath T, Harmon G, Saripalli A, Chou B, Venkatesulu BP, Boike T, Kundapur V, Roberge D, Bovi J, McGee M, Kruser T, Baschnagel A, Usuki K, Mehta M, Kachnic L. NCOG-03. IMPACT OF THE RATE OF RADIOGRAPHIC RESPONSE (RR) OF BRAIN METASTASES (BM) TO WHOLE BRAIN RADIATION THERAPY (WBRT) ON NEUROCOGNITIVE FUNCTION (NCF) ON NRG-CC001. Neuro Oncol 2022. [PMCID: PMC9660887 DOI: 10.1093/neuonc/noac209.756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
BACKGROUND
The assessment of BM response to WBRT and its impact on NCF in clinical trials has been limited by lack of standardized imaging protocols. NRG-CC001 is a randomized clinical trial requiring pre-specified MRI protocols at baseline and 6-months, providing a uniform dataset to investigate if RR correlates with NCF changes.
METHODS
NRG-CC001 randomized patients with BM to hippocampal avoidance WBRT (HA-WBRT) or WBRT. NCF was analyzed using 6-month standardized change scores and deterioration, defined using the reliable change index. Chi-square and t-tests were used for pretreatment characteristic comparisons. Inter-rater reliability between central and institutional assessment of RR was assessed with weighted kappa, κ. Linear regression was used to test trends in NCF change scores across types of response and multivariable logistic regression was used to test the association of RR to NCF deterioration.
RESULTS
149 and 135 patients were evaluable for RR and NCF assessment, respectively. Pretreatment characteristics were well-balanced, except for post-high school education (70.6% HA-WBRT vs. 52.5% WBRT, p=0.023). Inter-rater reliability between central and institutional assessment of RR was fair (κ=0.36). There was no difference between arms in RR (p=0.41) with overall rates of 14.1% CR, 42.2% PR, 17% SD, and 26.7% PD. Patients with CR had improved 6-month NCF change as measured by HVLT-R Total Recall (p=0.0005), HVLT-R Delayed Recall (p=0.0003), HVLT-R Delayed Recognition (p=0.011), TMT-B (p=0.033), COWA (p=0.016), and Clinical Trial Battery Composite score (p=0.0011). Multivariable analysis demonstrated less deterioration in HVLT-R Delayed Recall for CR (p=0.019) and PR (p=0.0086) vs. SD/PD and HVLT-R Recognition for PR (p=0.031) vs. SD/PD.
CONCLUSIONS
HA-WBRT and WBRT result in similar RR at 6-months. CR or PR is associated with better NCF preservation. This suggests investigation into treatment escalation for patients with SD/PD may provide further NCF benefit along with HA-WBRT and memantine.Grant support from NCI-UG1CA189867 and U24CA180803.
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Affiliation(s)
| | - Stephanie Pugh
- NRG Oncology Statistics and Data Management Center , Philadelphia, PA , USA
| | - Paul Brown
- Department of Radiation Oncology, Mayo Clinic , Rochester, MN , USA
| | - Vinai Gondi
- Northwestern Medicine Cancer Center Warrenville , Warrenville, IL , USA
| | - Jeffrey Wefel
- University of Texas MD Anderson Cancer Center , Houston, TX , USA
| | | | | | | | | | | | | | | | | | - David Roberge
- Centre hospitalier de l'Université de Montréal, Montreal , Quebec , Canada
| | - Joseph Bovi
- Medical College of Wisconsin , Milwaukee, WI , USA
| | | | - Tim Kruser
- Northwestern University , Evanston, IL , USA
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13
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Cherng H, Qu M, Zafari Z, Gondi V, Mehta M, Mishra M. Evaluating the Utility of EQ5D-5L in Patients with Brain Metastases: Secondary Analysis of NRG-CC001. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Liang Y, Lee K, Bovi JA, Palmer JD, Brown PD, Gondi V, Tomé WA, Benzinger TLS, Mehta MP, Li XA. Deep Learning-Based Automatic Detection of Brain Metastases in Heterogenous Multi-Institutional Magnetic Resonance Imaging Sets: An Exploratory Analysis of NRG-CC001. Int J Radiat Oncol Biol Phys 2022; 114:529-536. [PMID: 35787927 PMCID: PMC9641965 DOI: 10.1016/j.ijrobp.2022.06.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 06/09/2022] [Accepted: 06/21/2022] [Indexed: 10/31/2022]
Abstract
PURPOSE Deep learning-based algorithms have been shown to be able to automatically detect and segment brain metastases (BMs) in magnetic resonance imaging, mostly based on single-institutional data sets. This work aimed to investigate the use of deep convolutional neural networks (DCNN) for BM detection and segmentation on a highly heterogeneous multi-institutional data set. METHODS AND MATERIALS A total of 407 patients from 98 institutions were randomly split into 326 patients from 78 institutions for training/validation and 81 patients from 20 institutions for unbiased testing. The data set contained T1-weighted gadolinium and T2-weighted fluid-attenuated inversion recovery magnetic resonance imaging acquired on diverse scanners using different pulse sequences and various acquisition parameters. Several variants of 3-dimensional U-Net based DCNN models were trained and tuned using 5-fold cross validation on the training set. Performances of different models were compared based on Dice similarity coefficient for segmentation and sensitivity and false positive rate (FPR) for detection. The best performing model was evaluated on the test set. RESULTS A DCNN with an input size of 64 × 64 × 64 and an equal number of 128 kernels for all convolutional layers using instance normalization was identified as the best performing model (Dice similarity coefficient 0.73, sensitivity 0.86, and FPR 1.9) in the 5-fold cross validation experiments. The best performing model demonstrated consistent behavior on the test set (Dice similarity coefficient 0.73, sensitivity 0.91, and FPR 1.7) and successfully detected 7 BMs (out of 327) that were missed during manual delineation. For large BMs with diameters greater than 12 mm, the sensitivity and FPR improved to 0.98 and 0.3, respectively. CONCLUSIONS The DCNN model developed can automatically detect and segment brain metastases with reasonable accuracy, high sensitivity, and low FPR on a multi-institutional data set with nonprespecified and highly variable magnetic resonance imaging sequences. For large BMs, the model achieved clinically relevant results. The model is robust and may be potentially used in real-world situations.
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Affiliation(s)
- Ying Liang
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Karen Lee
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Joseph A Bovi
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Joshua D Palmer
- Department of Radiation Oncology, The James Cancer Hospital and Solove Research Institute at the Ohio State University, Columbus, Ohio
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Vinai Gondi
- Department of Radiation Oncology, Northwestern Medicine Cancer Center and Proton Center, Warrenville, Illinois
| | - Wolfgang A Tomé
- Department of Radiation Oncology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Tammie L S Benzinger
- Department of Radiology, Washington University School of Medicine, St Louis, Missouri
| | | | - X Allen Li
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin.
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15
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Matsui JK, Perlow HK, Facer BD, McCalla A, Marrazzo L, Detti B, Scorsetti M, Clerici E, Scoccianti S, Navarria P, Trifiletti DM, Gondi V, Bovi J, Huang J, Brown PD, Palmer JD. Radiotherapy for elderly patients with glioblastoma: an assessment of hypofractionation and modern treatment techniques. Chin Clin Oncol 2022; 11:38. [PMID: 36336897 DOI: 10.21037/cco-22-76] [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: 08/22/2022] [Accepted: 10/21/2022] [Indexed: 06/16/2023]
Abstract
Glioblastoma (GBM) is a disease with a poor prognosis. For decades, radiotherapy has played a critical role in the management of GBM. The standard of care radiation prescription is 60 Gy in 30 fractions, but landmark trials have historically excluded patients older than 70 years. Currently, there is considerable variation in the management of elderly patients with GBM. Shortened radiation treatment (hypofractionated) regimens have been explored since conventional treatment schedules are lengthy and many elderly patients have functional, cognitive, and social limitations. Clinical trials have demonstrated the effectiveness of hypofractionated radiotherapy (40 Gy in 15 fractions) to treat elderly or frail patients with GBM. Although previous studies have suggested these unique hypofractionation prescriptions effectively treat these patients, there are many avenues for improvement in this patient population. Herein, we describe the unique tumor biology of glioblastoma, key hypofractionated radiotherapy studies, and health-related quality of life (HRQOL) studies for elderly patients with GBM. Hypofractionated radiation has emerged as a shortened alternative and retrospective studies have suggested survival outcomes are similar for elderly patients with GBM. Prospective studies comparing hypofractionation with conventional treatment regiments are warranted. In addition to evaluating survival outcomes, HRQOL endpoints should be incorporated into future studies.
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Affiliation(s)
| | - Haley K Perlow
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Benjin D Facer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Aliah McCalla
- Central Michigan University, College of Medicine, Mt. Pleasant, MI, USA
| | - Livia Marrazzo
- Department of Medical Physics, Azienda Ospedaliera Universitaria, Florence, Italy
| | - Beatrice Detti
- Department of Radiation Oncology, Azienda Ospedaliera Universitaria, Florence, Italy
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Elena Clerici
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Silvia Scoccianti
- Department of Radiation Oncology, Azienda Ospedaliera Universitaria, Florence, Italy
| | - Pierina Navarria
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Milan, Italy
| | | | - Vinai Gondi
- Department of Radiation Oncology, Northwestern Medicine Cancer Center and Proton Center, Warrenville, IL, USA
| | - Joseph Bovi
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jiayi Huang
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Joshua D Palmer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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16
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Fontana E, Williams A, Falchook G, Lakhani N, Evans T, Gondi V, Iwamoto F, McKean M, Symeonides S, Butowski N, McLaren A, Henry J, Buerki R, Rotolo J, Capiaux G, Michel R, Kaesshaefer S, Wiegert E, Bexon A. Efficacy signals, long-term exposure and safety data from a phase 1–2 study of a cell-penetrating peptide antagonist of CEBPβ, a novel target, in patients (pts) with refractory solid tumors. Eur J Cancer 2022. [DOI: 10.1016/s0959-8049(22)01018-8] [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: 11/29/2022]
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17
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Liu H, Clark R, Magliari A, Foster R, Reynoso F, Schmidt M, Gondi V, Abraham C, Curry H, Kupelian P, Khuntia D, Beriwal S. SPCR-01 RAPIDPLAN HIPPOCAMPAL SPARING WHOLE BRAIN MODEL VERSION 2 - HOW FAR CAN WE REDUCE THE DOSE? Neurooncol Adv 2022. [DOI: 10.1093/noajnl/vdac078.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Whole-brain radiotherapy (WBRT) has been the standard palliative treatment for patients with brain metastases due to its effectiveness, availability, and ease of administration. Recent clinical trials have shown that limiting radiation dose to the hippocampus is associated with decreased cognitive toxicity. In this study, we updated an existing Knowledge Based Planning (KBP) model to further reduce dose to the hippocampus and improve other dosimetric plan quality characteristics.
METHODS
42 clinical cases were contoured according to NRG-CC001 guidelines. A new dosimetric scorecard was created as an objective measure for plan quality. The new Hippocampal Sparing Whole Brain Version 2 (HSWBv2) model adopted a complex recursive training process and was validated with five additional cases. HSWBv2 treatment plans were generated on the Varian HalcyonTM and TrueBeamTM systems and compared against plans generated from the existing (HSWBv1) model released in 2016.
RESULTS
On the HalcyonTM platform, 42 cases were re-planned. Hippocampal D100% from HSWBv2 and HSWBv1 models had an average dose of 5.75 Gy and 6.46 Gy, respectively (p<0.001). HSWBv2 model also achieved a hippocampal Dmean of 7.49 Gy, versus 8.10 Gy in HSWBv1 model (p<0.001). Hippocampal D0.03CC from HSWBv2 model was 9.86 Gy, in contrast to 10.57 Gy in HSWBv1 (p<0.001). For PTV_3000, D98% and D2% from HSWBv2 model were 28.27 Gy and 31.81 Gy, respectively, compared to 28.08 Gy (p=0.020) and 32.66 Gy from HSWBv1 (p<0.001). Among several other dosimetric quality improvements, there was a significant reduction in PTV_3000 V105% from 35.35% (HSWBv1) to 6.44% (HSWBv2) (p<0.001). On five additional validation cases, dosimetric improvements were also observed on TrueBeamTM.
CONCLUSION
In comparison to published data in addition to the HSWBv1 model, the HSWBv2 model achieved higher quality HA-WBRT treatment plans through further reductions in hippocampal dose while improving target coverage and dose conformity/homogeneity. HSWBv2 model is shared publicly.
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Affiliation(s)
- Hefei Liu
- Varian Medical Systems Inc , Palo Alto, CA , USA
- Medical College of Wisconsin, Department of Radiation Oncology , Wauwatosa, WI , USA
| | - Ryan Clark
- Varian Medical Systems Inc , Palo Alto, CA , USA
| | | | - Robert Foster
- Northwestern Medicine Cancer Center Warrenville and Northwestern Medicine Proton Center , Warrenville, IL , USA
| | - Francisco Reynoso
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology , St. Louis, MO , USA
| | - Matthew Schmidt
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology , St. Louis, MO , USA
| | - Vinai Gondi
- Northwestern Medicine Cancer Center Warrenville and Northwestern Medicine Proton Center , Warrenville, IL , USA
| | - Christopher Abraham
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology , St. Louis, MO , USA
| | | | | | | | - Sushil Beriwal
- Varian Medical Systems Inc , Palo Alto, CA , USA
- Allegheny Health Network Cancer Institute , Pittsburgh, PA , USA
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18
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Mehta M, Brown P, Gondi V, Ahluwalia M. CLRM-10 METIS (EF-25): A PIVOTAL, RANDOMIZED CONTROLLED STUDY OF TUMOR TREATING FIELDS IN PATIENTS WITH 1–10 BRAIN METASTASES FROM NON-SMALL CELL LUNG CANCER. Neurooncol Adv 2022. [PMCID: PMC9354224 DOI: 10.1093/noajnl/vdac078.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Tumor Treating Fields (TTFields) are electric fields that disrupt cancer cell division. TTFields treatment showed efficacy in preclinical non-small cell lung cancer (NSCLC) models. Furthermore, TTFields therapy improved survival with a tolerable safety profile in patients with glioblastoma. The objective of the pivotal METIS trial [NCT02831959] is to evaluate the efficacy and safety of TTFields therapy in NSCLC patients with brain metastases.
METHODS
NSCLC patients (N=270) with 1–10 brain metastases will be randomized 1:1 to stereotactic radiosurgery (SRS) followed by continuous TTFields therapy using NovoTTF-200M (150 kHz, recommended >18 h/day) with best standard of care (BSC) or SRS followed by BSC alone. Follow-ups will be conducted every 2 months until second intracranial progression. Key inclusion criteria are: Karnofsky Performance Status ≥70, new diagnosis of 1 inoperable or 2–10 supra- and/or infratentorial brain metastases from NSCLC amenable to SRS, and optimal therapy for extracranial disease. Key exclusion criteria are: prior whole brain radiotherapy, single operable, or recurrent brain metastases. Primary endpoint is time to first intracranial progression. Secondary endpoints include time to neurocognitive failure, overall survival, radiological response rate (RANO-BM and RECIST V1.1), quality of life, adverse events, time to first/second intracranial progression for patients with 1–4 and 5–10 brain metastases, bi-monthly intracranial progression rate from 2–12 months, and time to second intracranial and distant progression. The study is powered at 80% (2-sided alpha of 0.05) to detect a hazard ratio of 0.57. In July 2021, an independent Data Monitoring Committee (DMC) reviewed the study data and recommended continuation as planned. The trial is currently recruiting at 92 sites in North America, Europe, Israel, mainland China and Hong Kong.
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Affiliation(s)
| | | | - Vinai Gondi
- Northwestern Medicine Cancer Center , Warrenville, IL , USA
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19
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Gondi V, Bauman G, Bradfield L, Burri SH, Cabrera AR, Cunningham DA, Eaton BR, Hattangadi-Gluth JA, Kim MM, Kotecha R, Kraemer L, Li J, Nagpal S, Rusthoven CG, Suh JH, Tomé WA, Wang TJC, Zimmer AS, Ziu M, Brown PD. Radiation Therapy for Brain Metastases: An ASTRO Clinical Practice Guideline. Pract Radiat Oncol 2022; 12:265-282. [PMID: 35534352 DOI: 10.1016/j.prro.2022.02.003] [Citation(s) in RCA: 77] [Impact Index Per Article: 38.5] [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: 02/02/2022] [Accepted: 02/07/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE This guideline provides updated evidence-based recommendations addressing recent developments in the management of patients with brain metastases, including advanced radiation therapy techniques such as stereotactic radiosurgery (SRS) and hippocampal avoidance whole brain radiation therapy and the emergence of systemic therapies with central nervous system activity. METHODS The American Society for Radiation Oncology convened a task force to address 4 key questions focused on the radiotherapeutic management of intact and resected brain metastases from nonhematologic solid tumors. The guideline is based on a systematic review provided by the Agency for Healthcare Research and Quality. Recommendations were created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength. RESULTS Strong recommendations are made for SRS for patients with limited brain metastases and Eastern Cooperative Oncology Group performance status 0 to 2. Multidisciplinary discussion with neurosurgery is conditionally recommended to consider surgical resection for all tumors causing mass effect and/or that are greater than 4 cm. For patients with symptomatic brain metastases, upfront local therapy is strongly recommended. For patients with asymptomatic brain metastases eligible for central nervous system-active systemic therapy, multidisciplinary and patient-centered decision-making to determine whether local therapy may be safely deferred is conditionally recommended. For patients with resected brain metastases, SRS is strongly recommended to improve local control. For patients with favorable prognosis and brain metastases receiving whole brain radiation therapy, hippocampal avoidance and memantine are strongly recommended. For patients with poor prognosis, early introduction of palliative care for symptom management and caregiver support are strongly recommended. CONCLUSIONS The task force has proposed recommendations to inform best clinical practices on the use of radiation therapy for brain metastases with strong emphasis on multidisciplinary care.
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Affiliation(s)
- Vinai Gondi
- Department of Radiation Oncology, Northwestern Medicine Cancer Center and Proton Center, Warrenville, Illinois.
| | - Glenn Bauman
- Division of Radiation Oncology, Department of Oncology, London Health Sciences Centre & Western University, London, Ontario, Canada
| | - Lisa Bradfield
- American Society for Radiation Oncology, Arlington, Virginia
| | - Stuart H Burri
- Department of Radiation Oncology, Atrium Health, Charlotte, North Carolina
| | - Alvin R Cabrera
- Department of Radiation Oncology, Kaiser Permanente, Seattle, Washington
| | | | - Bree R Eaton
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | | | - Michelle M Kim
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | | | - Jing Li
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Seema Nagpal
- Division of Neuro-oncology, Department of Neurology, Stanford University, Stanford, California
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado, Aurora, Colorado
| | - John H Suh
- Department of Radiation Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio
| | - Wolfgang A Tomé
- Department of Radiation Oncology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Tony J C Wang
- Department of Radiation Oncology, Columbia University, New York, New York
| | - Alexandra S Zimmer
- Women's Malignancies Branch, National Institutes of Health/National Cancer Institute, Bethesda, Maryland
| | - Mateo Ziu
- Department of Neurosciences, INOVA Neuroscience and INOVA Schar Cancer Institute, Falls Church, Virginia
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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20
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Lehrer EJ, Jones BM, Dickstein DR, Green S, Germano IM, Palmer JD, Laack N, Brown PD, Gondi V, Wefel JS, Sheehan JP, Trifiletti DM. The Cognitive Effects of Radiotherapy for Brain Metastases. Front Oncol 2022; 12:893264. [PMID: 35847842 PMCID: PMC9279690 DOI: 10.3389/fonc.2022.893264] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [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: 03/10/2022] [Accepted: 05/27/2022] [Indexed: 12/24/2022] Open
Abstract
Brain metastases are the most common intracranial neoplasm and are seen in upwards of 10-30% of patients with cancer. For decades, whole brain radiation therapy (WBRT) was the mainstay of treatment in these patients. While WBRT is associated with excellent rates of intracranial tumor control, studies have demonstrated a lack of survival benefit, and WBRT is associated with higher rates of cognitive deterioration and detrimental effects on quality of life. In recent years, strategies to mitigate this risk, such as the incorporation of memantine and hippocampal avoidance have been employed with improved results. Furthermore, stereotactic radiosurgery (SRS) has emerged as an appealing treatment option over the last decade in the management of brain metastases and is associated with superior cognitive preservation and quality of life when compared to WBRT. This review article evaluates the pathogenesis and impact of cranial irradiation on cognition in patients with brain metastases, as well as current and future risk mitigation techniques.
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Affiliation(s)
- Eric J. Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Brianna M. Jones
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Daniel R. Dickstein
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Sheryl Green
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Isabelle M. Germano
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Joshua D. Palmer
- Department of Radiation Oncology, Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Nadia Laack
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Paul D. Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - Vinai Gondi
- Department of Radiation Oncology, Northwestern Medicine Cancer Center Warrenville and Proton Center, Warrenville, IL, United States
| | - Jeffrey S. Wefel
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX, United States
| | - Jason P. Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, United States
| | - Daniel M. Trifiletti
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, United States
- *Correspondence: Daniel M. Trifiletti,
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21
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Schiff D, Messersmith H, Brastianos PK, Brown PD, Burri S, Dunn IF, Gaspar LE, Gondi V, Jordan JT, Maues J, Mohile N, Redjal N, Stevens GHJ, Sulman EP, van den Bent M, Wallace HJ, Zadeh G, Vogelbaum MA. Radiation Therapy for Brain Metastases: ASCO Guideline Endorsement of ASTRO Guideline. J Clin Oncol 2022; 40:2271-2276. [PMID: 35561283 DOI: 10.1200/jco.22.00333] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE American Society of Radiation Oncology (ASTRO) has developed a guideline on appropriate radiation therapy for brain metastases. ASCO has a policy and set of procedures for endorsing clinical practice guidelines that have been developed by other professional organizations. METHODS "Radiation Therapy for Brain Metastases: An ASTRO Clinical Practice Guideline"2 was reviewed for developmental rigor by methodologists. An ASCO Endorsement Panel subsequently reviewed the content and the recommendations. RESULTS The ASCO Endorsement Panel determined that the recommendations from the ASTRO guideline, published May 6, 2022, are clear, thorough, and based upon the most relevant scientific evidence. ASCO endorses "Radiation Therapy for Brain Metastases: An ASTRO Clinical Practice Guideline."2. RECOMMENDATIONS Within the guideline, stereotactic radiosurgery (SRS) is recommended for patients with Eastern Cooperative Oncology Group performance status of 0-2 and up to four intact brain metastases, and conditionally recommended for patients with up to 10 intact brain metastases. The guideline provides detailed dosing and fractionation recommendations on the basis of the size of the metastases. For patients with resected brain metastases, radiation therapy (SRS or whole-brain radiation therapy [WBRT]) is recommended to improve intracranial disease control; if there are limited additional brain metastases, SRS is recommended over WBRT. For patients with favorable prognosis and brain metastases ineligible for surgery and/or SRS, WBRT is recommended with hippocampal avoidance where possible and the addition of memantine is recommended. For patients with brain metastases, limiting the single-fraction V12Gy to brain tissue to ≤ 10 cm3 is conditionally recommended.Additional information is available at www.asco.org/neurooncology-guidelines.
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Affiliation(s)
- David Schiff
- University of Virginia Medical Center, Charlottesville, VA
| | | | | | | | - Stuart Burri
- Levine Cancer Institute at Atrium Health, Charlotte, NC
| | - Ian F Dunn
- Stephenson Cancer Center at the University of Oklahoma, Oklahoma City, OK
| | - Laurie E Gaspar
- Banner MD Anderson Cancer Center, Loveland, CO.,University of Colorado School of Medicine, Aurora, CO
| | - Vinai Gondi
- Northwestern Medicine Cancer Center Warrenville and Proton Center, Warrenville, IL
| | | | - Julia Maues
- GRASP (Guiding Researchers & Advocates to Scientific Partnerships), Baltimore, MD
| | - Nimish Mohile
- University of Rochester Medical Center, Rochester, NY
| | | | | | | | - Martin van den Bent
- Brain Tumor Center at Erasmus MC Cancer Institute, Rotterdam, the Netherlands
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22
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Perlow HK, Yaney A, Yang M, Klamer B, Matsui J, Raval RR, Blakaj DM, Arnett A, Beyer S, Elder JB, Ammirati M, Lonser R, Hardesty D, Ong S, Giglio P, Pillainayagam C, Goranovich J, Grecula J, Chakravarti A, Gondi V, Brown PD, Palmer JD. Dose-escalated accelerated hypofractionation for elderly or frail patients with a newly diagnosed glioblastoma. J Neurooncol 2022; 156:399-406. [PMID: 35013838 DOI: 10.1007/s11060-021-03925-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 12/06/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND The standard of care for elderly glioblastoma patients is 40 Gy in 15 fraction radiotherapy with temozolomide (TMZ). However, this regimen has a lower biologic equivalent dose (BED) compared to the Stupp regimen of 60 Gy in 30 fractions. We hypothesize that accelerated hypofractionated radiation of 52.5 Gy in 15 fractions (BED equivalent to Stupp) will have superior survival compared to 40 Gy in 15 fractions. METHODS Elderly patients (≥ 65 years old) who received hypofractionated radiation with TMZ from 2010 to 2020 were included in this analysis. Overall survival (OS) and progression free survival were defined as the time elapsed between surgery/biopsy and death from any cause or progression. Baseline characteristics were compared between patients who received 40 and 52.5 Gy. Univariable and multivariable analyses were performed. RESULTS Sixty-six newly diagnosed patients were eligible for analysis. Thirty-nine patients were treated with 40 Gy in 15 fractions while twenty-seven were treated with 52.5 Gy in 15 fractions. Patients had no significant differences in age, sex, methylation status, or performance status. OS was superior in the 52.5 Gy group (14.1 months) when compared to the 40 Gy group (7.9 months, p = 0.011). Isoeffective dosing to 52.5 Gy was shown to be an independent prognostic factor for improved OS on multivariable analysis. CONCLUSIONS Isoeffective dosing to 52.5 Gy in 15 fractions was associated with superior OS compared to standard of care 40 Gy in 15 fractions. These hypothesis generating data support accelerated hypofractionation in future prospective trials.
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Affiliation(s)
- Haley K Perlow
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, 460 W. 10th Avenue43210, USA
| | - Alexander Yaney
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, 460 W. 10th Avenue43210, USA
| | - Michael Yang
- Ohio State University School of Medicine, Columbus, OH, USA
| | - Brett Klamer
- Center for Biostatistics, The Ohio State University, Columbus, OH, USA
| | | | - Raju R Raval
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, 460 W. 10th Avenue43210, USA
| | - Dukagjin M Blakaj
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, 460 W. 10th Avenue43210, USA
| | - Andrea Arnett
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, 460 W. 10th Avenue43210, USA
| | - Sasha Beyer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, 460 W. 10th Avenue43210, USA
| | - James B Elder
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mario Ammirati
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Russell Lonser
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Douglas Hardesty
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Shirley Ong
- Department of Neuro-Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Pierre Giglio
- Department of Neuro-Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Clement Pillainayagam
- Department of Neuro-Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Justin Goranovich
- Department of Neuro-Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - John Grecula
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, 460 W. 10th Avenue43210, USA
| | - Arnab Chakravarti
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, 460 W. 10th Avenue43210, USA
| | - Vinai Gondi
- Northwestern Medicine Cancer Center Warrenville, Northwestern Medicine Proton Center, Warrenville, IL, USA
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Cinic, Rochester, MN, USA
| | - Joshua D Palmer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, 460 W. 10th Avenue43210, USA.
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23
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Fernandez LG, Oyon DE, Gondi V, Grimm S, Khan OH. Secondary CNS myeloma with remission after systemic CNS-penetrating agents. Neurooncol Adv 2022; 4:vdac106. [PMID: 35892045 PMCID: PMC9307102 DOI: 10.1093/noajnl/vdac106] [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] [Indexed: 11/30/2022] Open
Abstract
Background CNS myeloma is a rare manifestation of multiple myeloma and is often associated with a dismal prognosis; however, cases are increasing in frequency as overall survival improves for MM. There is currently no standardized treatment for CNS myeloma; however, different chemotherapy and radiotherapy regimens have been described. Methods We had previously reported on the efficacy of proton-based craniospinal irradiation in a patient with CNS myeloma; here we present a patient with a history of extramedullary plasmacytoma, 10 years in remission status post standard systemic chemotherapy, with biopsy-proven CNS myeloma successfully treated with systemic chemotherapy as a first-line treatment. Results The patient achieved clinical and radiographic remission on 2 separate occasions with systemic chemotherapy alone. Conclusions This case demonstrates that systemically administered agents may have activity in CNS myeloma. Further investigations are necessary to establish the optimal combination of agents and treatment schedules.
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Affiliation(s)
- Luis G Fernandez
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University , Chicago, Illinois , USA
| | - Daniel Eduardo Oyon
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University , Chicago, Illinois , USA
| | - Vinai Gondi
- Northwestern Medicine Proton Center , Warrenville, Illinois , USA
| | - Sean Grimm
- Rush University Medical Center, Department of Neurological Sciences, Section of Neuro-Oncology, Rush Medical College , Chicago, Illinois , USA
| | - Osaama H Khan
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University , Chicago, Illinois , USA
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24
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Vogelbaum MA, Brown PD, Messersmith H, Brastianos PK, Burri S, Cahill D, Dunn IF, Gaspar LE, Gatson NTN, Gondi V, Jordan JT, Lassman AB, Maues J, Mohile N, Redjal N, Stevens G, Sulman E, van den Bent M, Wallace HJ, Weinberg JS, Zadeh G, Schiff D. Treatment for Brain Metastases: ASCO-SNO-ASTRO Guideline. J Clin Oncol 2021; 40:492-516. [PMID: 34932393 DOI: 10.1200/jco.21.02314] [Citation(s) in RCA: 220] [Impact Index Per Article: 73.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To provide guidance to clinicians regarding therapy for patients with brain metastases from solid tumors. METHODS ASCO convened an Expert Panel and conducted a systematic review of the literature. RESULTS Thirty-two randomized trials published in 2008 or later met eligibility criteria and form the primary evidentiary base. RECOMMENDATIONS Surgery is a reasonable option for patients with brain metastases. Patients with large tumors with mass effect are more likely to benefit than those with multiple brain metastases and/or uncontrolled systemic disease. Patients with symptomatic brain metastases should receive local therapy regardless of the systemic therapy used. For patients with asymptomatic brain metastases, local therapy should not be deferred unless deferral is specifically recommended in this guideline. The decision to defer local therapy should be based on a multidisciplinary discussion of the potential benefits and harms that the patient may experience. Several regimens were recommended for non-small-cell lung cancer, breast cancer, and melanoma. For patients with asymptomatic brain metastases and no systemic therapy options, stereotactic radiosurgery (SRS) alone should be offered to patients with one to four unresected brain metastases, excluding small-cell lung carcinoma. SRS alone to the surgical cavity should be offered to patients with one to two resected brain metastases. SRS, whole brain radiation therapy, or their combination are reasonable options for other patients. Memantine and hippocampal avoidance should be offered to patients who receive whole brain radiation therapy and have no hippocampal lesions and 4 months or more expected survival. Patients with asymptomatic brain metastases with either Karnofsky Performance Status ≤ 50 or Karnofsky Performance Status < 70 with no systemic therapy options do not derive benefit from radiation therapy.Additional information is available at www.asco.org/neurooncology-guidelines.
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Affiliation(s)
| | | | | | | | - Stuart Burri
- Levine Cancer Institute at Atrium Health, Charlotte, NC
| | - Dan Cahill
- Massachusetts General Hospital, Boston, MA
| | - Ian F Dunn
- Stephenson Cancer Center at the University of Oklahoma, Oklahoma City, OK
| | - Laurie E Gaspar
- University of Colorado School of Medicine, Aurora, CO.,University of Texas MD Anderson Cancer Center Northern Colorado, Greeley, CO
| | - Na Tosha N Gatson
- Banner MD Anderson Cancer Center, Phoenix, AZ.,Geisinger Neuroscience Institute. Danville, PA
| | - Vinai Gondi
- Northwestern Medicine Cancer Center Warrenville and Proton Center, Warrenville, IL
| | | | | | - Julia Maues
- Georgetown Breast Cancer Advocates, Washington, DC
| | - Nimish Mohile
- University of Rochester Medical Center, Rochester, NY
| | - Navid Redjal
- Capital Health Medical Center - Hopewell Campus, Princeton, NJ
| | | | | | - Martin van den Bent
- Brain Tumor Center at Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | | | | | | | - David Schiff
- University of Virginia Medical Center, Charlottesville, VA
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25
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Abraham CD, Pugh SL, Bovi JA, Gondi V, Mehta MP, Benzinger T, Owen CJ, Lo SS, Kundapur V, Brown PD, Sun AY, Howard SP, DeNittis AS, Robinson CG, Kachnic LA. Association of Pretreatment Hippocampal Volume With Neurocognitive Function in Patients Treated With Hippocampal Avoidance Whole Brain Radiation Therapy for Brain Metastases: Secondary Analysis of NRG Oncology/RTOG 0933. Adv Radiat Oncol 2021; 7:100859. [PMID: 36420209 PMCID: PMC9677217 DOI: 10.1016/j.adro.2021.100859] [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: 06/22/2020] [Accepted: 11/05/2021] [Indexed: 12/30/2022] Open
Abstract
Purpose Hippocampal volume (HV) is an established predicting factor for neurocognitive function (NCF) in neurodegenerative disease. Whether the same phenomenon exists with hippocampal-avoidant whole brain radiation therapy is not known; therefore, we assessed the association of baseline HV with NCF among patients enrolled on RTOG 0933. Methods and Materials Hippocampal volume and total brain volume were calculated from the radiation therapy plan. Hippocampal volume was correlated with baseline and 4-month NCF scores (Hopkins Verbal Learning Test-Revised [HVLT-R] Total Recall [TR], Immediate Recognition, and Delayed Recall [DR]) using Pearson correlation. Deterioration in NCF was defined per the primary endpoint of RTOG 0933(mean 4-month relative decline in HVLT-R DR). Comparisons between patients with deteriorated and nondeteriorated NCF were made using the Wilcoxon test. Results Forty-two patients were evaluable. The median age was 56.5 years (range, 28-83 years), and 81% had a class II recursive partitioning analysis. The median total, right, and left HVs were 5.4 cm3 (range, 1.9-7.4 cm3), 2.8 cm3 (range, 0.9-4.0 cm3), and 2.7 cm3 (range, 1.0-3.7 cm3), respectively. The median total brain volume was 1343 cm3 (range, 1120.5-1738.8 cm3). For all measures of corrected HV, increasing HV was associated with higher baseline HVLT-R TR and DR scores (ρ: range, 0.35-0.40; P-value range, .009-.024) and 4-month TR and DR scores (ρ: range, 0.29-0.40; P-value range, .009-.04), with the exception of right HV and 4-month DR scores (ρ: 0.29; P = .059). There was no significant association between HV and NCF change between baseline and 4 months. Fourteen patients (33.3%) developed NCF deterioration per the primary endpoint of RTOG 0933. There was no significant difference in HV between patients with deteriorated and nondeteriorated NCF, although in all instances, patients with deteriorated NCF had numerically lower HV. Conclusions Larger HV was positively associated with improved performance on baseline and 4-month HVLT-R TR and DR scores in patients with brain metastases undergoing hippocampal-avoidant whole brain radiation therapy but was not associated with a change in NCF.
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Affiliation(s)
- Christopher D. Abraham
- Washington University School of Medicine, Saint Louis, Missouri,Barnes-Jewish Hospital, Saint Louis, Missouri,Corresponding author: Christopher D. Abraham, MD
| | - Stephanie L. Pugh
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | - Joseph A. Bovi
- Froedtert and the Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Vinai Gondi
- Northwestern Medicine Cancer, Warrenville, Illinois
| | | | | | | | - Simon S. Lo
- University of Washington Medical Center, Seattle, Washington
| | | | | | - Alexander Y. Sun
- University Health Network–Princess Margaret Hospital, Toronto, Ontario, Canada
| | - Steven P. Howard
- University of Wisconsin Hospital and Clinics, Madison, Wisconsin
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Lukas R, Sachdev S, Kumthekar P, Dixit K, Grimm S, Gondi V, Sharp L, Lezon R, James D, Lesniak M, Stupp R, Wainwright D. CTIM-12. A PHASE 1 TRIAL OF IMMUNORADIOTHERAPY WITH THE IDO ENZYME INHIBITOR (BMS-986205) AND NIVOLUMAB IN PATIENTS WITH NEWLY DIAGNOSED MGMT PROMOTER UNMETHYLATED IDHwt GLIOBLASTOMA. Neuro Oncol 2021. [DOI: 10.1093/neuonc/noab196.204] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
IDHwt glioblastoma with unmethylated MGMT gene promoter carries a poor prognosis. Preclinical studies have shown that combination of radiotherapy and dual immunotherapy with nivolumab and IDO inhibition significantly prolongs survival of mice with an orthotopic glioblastoma [Ladomersky, et al. CCR 2018;24(11):2559-2573]. In a clinical trial in patients with newly diagnosed glioblastoma with unmethylated MGMT we substituted temozolomide for dual immunotherapy combination.
METHODS
Phase 1 trial [NCT04047706] using a 3 + 3 dose-escalation design. All received standard radiotherapy (30 x 2 Gy) with addition of once daily oral BMS-986205 and intravenous nivolumab (240mg every 2 weeks) begining on day 1 of radiotherapy and continuing until disease progression or intolerance. BMS-986205 dosing was increased from 50 mg to 100 mg. DLT period encompasses 6 weeks of radiotherapy and the 4 subsequent weeks. Immunocorrelatives being conducted before and after treatment include mass spectrometry for tryptophan and kynurenine levels, immunohistochemistry of resected tumor, and RNA-sequencing and flow cytometric analysis of PBMCs.
RESULTS
Twelve patients were treated on 2 dose levels of BMS-986205 (50, 100 mg). Treatment-emergent toxicity was as expected for this population. Three (25%) treatment-related SAEs were reported. Dose limiting toxicity of grade 3 transaminase elevation was observed in 2 patients at the 100 mg dose level, while at lower doses of BMS-986205 no substantial alterations of liver enzymes was observed. No other relevant treatment related toxicity occured. Ongoing immunocorrelative profiling and preliminary outcome data (all patients minimal follow-up >12 months) will be available at the time of the meeting.
CONCLUSIONS
Dose limiting toxicity of BMS-986205 in combination with nivolumab and radiotherapy is hepatic (reversible) transaminitis. The recommended dose for further investigation is 50 mg. Accrual is ongoing for the MGMT promoter methylated cohort using the same regimen without withholding temozolomide. A randomized phase 2/3 trial is approved within the NRG network.
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Affiliation(s)
- Rimas Lukas
- Northwestern Medicine Lou and Jean Malnati Brain Tumor Institute, Chicago, IL, USA
| | | | - Priya Kumthekar
- Northwestern Medicine; Feinberg School of Medicine, Chicago, IL, USA
| | - Karan Dixit
- Northwestern Medicine Lou and Jean Malnati Brain Tumor Institute, Chicago, IL, USA
| | - Sean Grimm
- Northwestern University, Chicago, IL, USA
| | - Vinai Gondi
- Northwestern University, Warrenville, IL, USA
| | | | - Ray Lezon
- Northwestern University, Chicago, IL, USA
| | | | | | - Roger Stupp
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Thorpe C, DeWees T, Bhangoo R, Petersen M, Chang J, Hartsell W, Sinesi C, Rwigema J, Keole S, Gondi V, Vargas C. Randomized Phase III Study of Moderately Hypofractionated Radiation Therapy With or Without Androgen Suppression for Intermediate Risk Adenocarcinoma of the Prostate: Analysis of Quality of Life and Toxicity, PCG GU 003. Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
As novel systemic therapies yield improved survival in metastatic cancer patients, the frequency of brain metastases continues to increase. Over the years, management strategies have continued to evolve. Historically, stereotactic radiosurgery has been used as a boost to whole-brain radiotherapy (WBRT) but is increasingly being used as a replacement for WBRT. Given its capacity to treat both macro- and micro-metastases in the brain, WBRT has been an important management strategy for years, and recent research has identified technologic and pharmacologic approaches to delivering WBRT more safely. In this review, we outline the current landscape of radiotherapeutic treatment options and discuss approaches to integrating radiotherapy advances in the contemporary management of brain metastases.
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Affiliation(s)
- Vinai Gondi
- Northwestern Medicine Cancer Center Warrenville and Proton Center, Warrenville, Illinois, USA
| | | | - Helen A Shih
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
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Bhangoo R, DeWees T, Thorpe C, Petersen M, Hartsell W, Chang J, Sinesi C, Mishra M, Mohammed N, McGee L, Keole S, Sweeney P, Gondi V, Vargas C. Updated Toxicity and Quality-of-Life Outcomes From a Randomized Phase III Trial of Extreme Hypofractionated vs. Standard Fractionated Proton Therapy for Low-Risk Prostate Cancer. Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.870] [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: 11/27/2022]
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Brown PD, Parsons MW, Rusthoven CG, Gondi V. Hippocampal Avoidance Prophylactic Cranial Irradiation: A New Standard of Care? J Clin Oncol 2021; 39:3093-3096. [PMID: 34379456 DOI: 10.1200/jco.21.01632] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Michael W Parsons
- Pappas Center for Neuro-Oncology and Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO
| | - Vinai Gondi
- Department of Radiation Oncology, Northwestern Medicine Cancer Center Warrenville and Northwestern Medicine Proton Center, Warrenville, IL
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Gondi V. Radiotherapy intensification for glioblastoma: enhancing the backbone of treatment. Chin Clin Oncol 2021; 10:39. [PMID: 34496598 DOI: 10.21037/cco-21-109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 08/13/2021] [Indexed: 11/06/2022]
Abstract
Given the impact of radiotherapy on survival outcomes for patients with glioblastoma (GBM), intensification of radiotherapy through dose-escalation and/or dose-per-fraction escalation has been an important area of ongoing investigation. Prior to the introduction of temozolomide, radiotherapy intensification beyond 60-Gy conventionally fractionated radiotherapy did not yield a survival benefit. With the emergence of temozolomide and its radio-sensitizing properties, as well as greater understanding of the patterns of first progression after 60-Gy radiotherapy, hypotheses regarding the impact of radiotherapy intensification have arisen. This article will discuss ongoing and future investigations of radiotherapy intensification in the modern temozolomide era of GBM management. These efforts have focused on better radiotherapy delivery techniques and/or improved tumor imaging to identify high-risk regions of progression.
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Affiliation(s)
- Vinai Gondi
- Brain & Spine Tumor Center, Northwestern Medicine Cancer Center Warrenville and Northwestern Medicine Proton Center, Warrenville, IL, USA
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Mladkova N, Lo S, Brown PD, Gondi V, Palmer JD. Hippocampal Avoidance Prophylactic Cranial Irradiation: Interpreting the Evidence. J Thorac Oncol 2021; 16:e60-e63. [PMID: 34304857 DOI: 10.1016/j.jtho.2021.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 04/19/2021] [Accepted: 04/20/2021] [Indexed: 01/28/2023]
Affiliation(s)
- Nikol Mladkova
- Department of Radiation Oncology, The Ohio State University, Columbus, Ohio
| | - Simon Lo
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Vinai Gondi
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Joshua D Palmer
- Department of Radiation Oncology, The Ohio State University, Columbus, Ohio.
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Affiliation(s)
- Amit K Chowdhry
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York.
| | - Vinai Gondi
- Northwestern Medicine Cancer Center Warrenville and Northwestern Medicine Proton Center, Warrenville, Illinois
| | - Stephanie L Pugh
- NRG Oncology Statistical and Data Management Center, American College of Radiology, Philadelphia, Pennsylvania
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Mohiuddin S, Maraka S, Usman Baig M, Gupta S, Muzzafar T, Valyi-Nagy T, Lindsay H, Moody K, Razvi S, Paulino A, Slavin K, Gondi V, McCutcheon I, Zaky W, Khatua S. Case series of diffuse extraneural metastasis in H3F3A mutant high-grade gliomas: Clinical, molecular phenotype and literature review. J Clin Neurosci 2021; 89:405-411. [PMID: 34053821 DOI: 10.1016/j.jocn.2021.05.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 12/16/2020] [Revised: 05/16/2021] [Accepted: 05/17/2021] [Indexed: 11/19/2022]
Abstract
H3K27M and H3.3G34R/V mutations have been identified in pediatric high-grade gliomas (pHGG), though extraneural metastases are rarely reported and poorly characterized. Three pHGG patients from two institutions were identified with extraneural metastasis, harboring histone mutations. Their clinical, imaging and molecular characteristics are reported here. A 17-year old female presented with supratentorial H3.3G34R-mutant glioma with metastatic osseous lesions in the spine, pelvis, bone marrow, pleural effusion and soft tissue of pelvis. Bone marrow biopsy and soft tissue of pelvis biopsy showed neoplastic cells positive for P53. A 20-year old female was diagnosed with H3F3A H3K27M-mutant thalamic glioma. She developed diffuse sclerotic osseous lesions. Biopsy of an osseous lesion was non-diagnostic. A 17-year old female presented with a H3F3A H3K27M-mutant diffuse midline glioma with diffuse spinal cord metastasis. She further developed multifocal chest lymphadenopathy, pleural effusions, and a soft tissue mass in the abdominal wall. The latter was positive for H3K27M mutation. We present the first case series of pHGG with H3F3A mutation and diffuse extraneural dissemination, describing their clinical and molecular profile.
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Affiliation(s)
- Sana Mohiuddin
- Department of Pediatrics Patient Care, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Stefania Maraka
- Department of Neurology and Rehabilitation, University of Illinois at Chicago, Chicago, IL, USA; Department of Neuro-oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Muhammad Usman Baig
- Department of Pediatrics Patient Care, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sumit Gupta
- Department of Pediatrics Patient Care, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tariq Muzzafar
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tibor Valyi-Nagy
- Department of Pathology, University of Illinois at Chicago, Chicago, IL, USA
| | - Holly Lindsay
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine, Houston, TX, USA
| | - Karen Moody
- Department of Pediatrics Patient Care, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shehla Razvi
- Department of Pediatrics Patient Care, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Arnold Paulino
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Konstantin Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Vinai Gondi
- Northwestern Medicine Chicago Proton Center, Warrenville, IL, USA
| | - Ian McCutcheon
- Department of Neurosurgery, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Wafik Zaky
- Department of Pediatrics Patient Care, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Soumen Khatua
- Department of Hematology-Oncology, Mayo Clinic, Rochester, MN.
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Singh R, Lehrer EJ, Wang M, Perlow HK, Zaorsky NG, Trifiletti DM, Bovi J, Navarria P, Scoccianti S, Gondi V, Brown PD, Palmer JD. Dose Escalated Radiation Therapy for Glioblastoma Multiforme: An International Systematic Review and Meta-Analysis of 22 Prospective Trials. Int J Radiat Oncol Biol Phys 2021; 111:371-384. [PMID: 33991621 DOI: 10.1016/j.ijrobp.2021.05.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 04/06/2021] [Accepted: 05/01/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE Limited evidence is available on the utility of dose-escalated radiation therapy (DE-RT) with or without temozolomide (TMZ) versus standard-of-care radiation therapy (SoC-RT) for patients with newly diagnosed glioblastoma multiforme. We performed a systematic review/meta-analysis to compare overall survival (OS) and progression-free survival (PFS) between DE-RT and SoC-RT. METHODS AND MATERIALS We used a Population, Intervention, Control, Outcomes, Study Design/Preferred Reporting Items for Systematic Reviews and Meta-analyses/Meta-analysis of Observational Studies in Epidemiology selection criterion to identify studies. The primary and secondary outcomes were 1-year OS and 1-year PFS, respectively. Outcomes and comparisons were subdivided based on receipt of TMZ and MGMT status. DE-RT was defined based on equivalent dose calculations. Random effects meta-analyses using the Knapp-Hartung correction, arcsine transformation, and restricted maximum likelihood method were conducted. Meta-regression was used to compare therapeutic (eg, DE-RT or TMZ) and pathologic characteristics (eg, MGMT methylation status) using the Wald-type test. RESULTS Across 22 published studies, 2198 patients with glioblastoma multiforme were included; 507 received DE-RT. One-year OS after DE-RT alone was higher than SoC-RT alone (46.3% vs 23.4%; P = .02) as was 1-year PFS (17.9% vs 5.3%; P = .02). No significant difference in 1-year OS (73.2% vs 64.4%; P = .23) or 1-year PFS (44.5% vs 44.3%; P = .33) between DE-RT + TMZ and SoC-RT + TMZ was noted. No difference in 1-year OS was noted between DE-RT + TMZ and SoC-RT + TMZ in either MGMT methylated (83.2% vs 73.2%; P = .23) or MGMT unmethylated (72.6% vs 50.6%; P = .16) patients. CONCLUSIONS DE-RT alone resulted in superior PFS and OS versus SoC-RT alone. DE-RT + TMZ did not lead to improved outcomes versus SoC-RT + TMZ. No differential benefit based on MGMT status was found. Future studies are warranted to define which subgroups benefit most from DE-RT.
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Affiliation(s)
- Raj Singh
- Department of Radiation Oncology, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ming Wang
- Department of Public Health Sciences, Penn State University, Hershey, Pennsylvania
| | - Haley K Perlow
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Nicholas G Zaorsky
- Department of Public Health Sciences, Penn State University, Hershey, Pennsylvania; Department of Radiation Oncology, Penn State Cancer Institute, Hershey, Pennsylvania
| | | | - Joseph Bovi
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Pierina Navarria
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Hospital-IRCCS, Rozzano (MI), Italy
| | - Silvia Scoccianti
- Radiation Oncology Unit, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
| | - Vinai Gondi
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Joshua D Palmer
- Department of Radiation Oncology and Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio; Department of Radiation Oncology, Virginia Commonwealth University Health System, Richmond, Virginia.
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36
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Brodin NP, Kabarriti R, Schechter CB, Pankuch M, Gondi V, Kalnicki S, Garg MK, Tomé WA. Individualized quality of life benefit and cost-effectiveness estimates of proton therapy for patients with oropharyngeal cancer. Radiat Oncol 2021; 16:19. [PMID: 33478544 PMCID: PMC7819210 DOI: 10.1186/s13014-021-01745-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 01/02/2021] [Indexed: 11/16/2022] Open
Abstract
Background Proton therapy is a promising advancement in radiation oncology especially in terms of reducing normal tissue toxicity, although it is currently expensive and of limited availability. Here we estimated the individual quality of life benefit and cost-effectiveness of proton therapy in patients with oropharyngeal cancer treated with definitive radiation therapy (RT), as a decision-making tool for treatment individualization.
Methods and materials Normal tissue complication probability models were used to estimate the risk of dysphagia, esophagitis, hypothyroidism, xerostomia and oral mucositis for 33 patients, comparing delivered photon intensity-modulated RT (IMRT) plans to intensity-modulated proton therapy (IMPT) plans. Quality-adjusted life years (QALYs) lost were calculated for each complication while accounting for patient-specific conditional survival probability and assigning quality-adjustment factors based on complication severity. Cost-effectiveness was modeled based on upfront costs of IMPT and IMRT, and the cost of acute and/or long-term management of treatment complications. Uncertainties in all model parameters and sensitivity analyses were included through Monte Carlo sampling.
Results The incremental cost-effectiveness ratios (ICERs) showed considerable variability in the cost of QALYs spared between patients, with median $361,405/QALY for all patients, varying from $54,477/QALY to $1,508,845/QALY between individual patients. Proton therapy was more likely to be cost-effective for patients with p16-positive tumors ($234,201/QALY), compared to p16-negative tumors ($516,297/QALY). For patients with p16-positive tumors treated with comprehensive nodal irradiation, proton therapy is estimated to be cost-effective in ≥ 50% of sampled cases for 8/9 patients at $500,000/QALY, compared to 6/24 patients who either have p16-negative tumors or receive unilateral neck irradiation. Conclusions Proton therapy cost-effectiveness varies greatly among oropharyngeal cancer patients, and highlights the importance of individualized decision-making. Although the upfront cost, societal willingness to pay and healthcare administration can vary greatly among different countries, identifying patients for whom proton therapy will have the greatest benefit can optimize resource allocation and inform prospective clinical trial design.
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Affiliation(s)
- N Patrik Brodin
- Institute for Onco-Physics, Albert Einstein College of Medicine, Bronx, NY, 10461, USA. .,Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, 10461, USA.
| | - Rafi Kabarriti
- Institute for Onco-Physics, Albert Einstein College of Medicine, Bronx, NY, 10461, USA.,Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, 10461, USA
| | - Clyde B Schechter
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY, 10461, USA
| | - Mark Pankuch
- Northwestern Medicine Chicago Proton Center, Warrenville, IL, 60555, USA
| | - Vinai Gondi
- Northwestern Medicine Chicago Proton Center, Warrenville, IL, 60555, USA
| | - Shalom Kalnicki
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, 10461, USA.,Department of Urology, Montefiore Medical Center, Bronx, NY, 10461, USA
| | - Madhur K Garg
- Institute for Onco-Physics, Albert Einstein College of Medicine, Bronx, NY, 10461, USA.,Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, 10461, USA.,Department of Otorhinolaryngology - Head and Neck Surgery, Montefiore Medical Center, Bronx, NY, 10461, USA.,Department of Urology, Montefiore Medical Center, Bronx, NY, 10461, USA
| | - Wolfgang A Tomé
- Institute for Onco-Physics, Albert Einstein College of Medicine, Bronx, NY, 10461, USA. .,Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, 10461, USA. .,Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, 10461, USA.
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Gondi V, Mehta MP. Radiotherapy innovations to optimize brain metastases control. Neuro Oncol 2020; 22:1715-1717. [PMID: 33089325 PMCID: PMC7746921 DOI: 10.1093/neuonc/noaa244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2024] Open
Affiliation(s)
- Vinai Gondi
- Northwestern Medicine Cancer Center Warrenville, Northwestern Medicine Proton Center, Warrenville, Illinois
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38
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Mehta M, Gondi V, Brown P, Ahluwalia M. RTID-01. RADIOSURGERY FOLLOWED BY TUMOR TREATING FIELDS FOR BRAIN METASTASES (1-10) FROM NSCLC IN THE PHASE 3 METIS TRIAL. Neuro Oncol 2020. [DOI: 10.1093/neuonc/noaa215.807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Tumor Treating Fields (TTFields) are non-invasive, loco-regional, anti-mitotic treatment modality comprising alternating electric fields. TTFields have demonstrated efficacy in preclinical non-small cell lung cancer (NSCLC) models. TTFields treatment to the brain was safe and extended overall survival in newly-diagnosed glioblastoma. The objective of the METIS study [NCT02831959] is evaluation of the efficacy and safety of TTFields in NSCLC patients with brain metastases.
METHODS
NSCLC patients (N=270) with 1-10 brain metastases were randomized 1:1 to stereotactic radio surgery (SRS) followed by continuous TTFields ((150 kHz, > 18 hours/day) within 7 days of SRS or supportive care. The portable device delivered TTFields to the brain using 4 transducer arrays, while patients received the best standard-of-care for systemic disease. Patients were followed every two months until second intracranial progression. Key inclusion criteria: KPS ≥70, new diagnosis of 1 inoperable or 2–10 supra- and/or infratentorial brain metastases from NSCLC amenable to SRS; and optimal therapy for extracranial disease. Prior WBRT, surgical resection of metastases, or recurrent brain metastases were exclusionary. Primary endpoint was time to 1st intracranial progression. Secondary endpoints included time to neurocognitive failure (HVLT, COWAT and TMT), overall survival, radiological response rate (RANO-BM and RECIST V1.1); quality-of-life; adverse events; time to first/second intracranial progression for patients with 1–4 and 5–10 brain metastases; bi-monthly intracranial progression rate from 2–12 months; and time to second intracranial and distant progression. The sample size (N=270) was calculated using a log-rank test (Lakatos 1988 and 2002) with 80% power at two sided alpha of 0.05 to detect a hazard ratio of 0.57. On September, 2019, an independent Data Monitoring Committee (DMC) reviewed METIS trial data collected to that point. The DMC concluded that no unexpected safety issues had emerged and recommended continuation of the METIS study as planned.
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Affiliation(s)
| | - Vinai Gondi
- Northwestern Medicine Cancer Center, Warrenville, IL, USA
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Wefel JS, DeMora L, Gondi V, Tsien C, Chenevert T, Gilbert M, Omuro A, Cao Y, Srinivasan A, Rogers L, Shi W, Nedzi L, Chan M, Suh J, Battiste J, Mishra M, Shivnani A, Movsas B, Mehta M. CTNI-50. NEUROCOGNITIVE FUNCTION (NCF) OF THE PHOTON COHORT IN NRG-BN001. Neuro Oncol 2020. [DOI: 10.1093/neuonc/noaa215.216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
NRG BN001 is an ongoing randomized phase II trial of dose-intense (DI-RT) versus standard dose photon-based radiation therapy (SD-RT) with temozolomide (TMZ) for newly diagnosed glioblastoma. We report preliminary results of Group 1, DI-RT delivered with IMRT while SD-RT could be 3DCRT or IMRT. Group 2, DI-RT delivered with proton therapy, continues to accrue. From 10/2014 to 7/2018, 229 patients were eligible and randomized. Differences in overall survival following DI-RT versus SD-RT were not significant. Patients were scheduled to complete NCF testing at baseline, cycle 3 (within 7 days of cycle 4), and cycle 12 (day 22–28 of cycle 12, or 60 weeks from completion of chemoradiation). At baseline, 93–94% of eligible patients completed NCF testing. Compliance for evaluable patients at cycle 3 and cycle 12 was 66–68% and 51–54%, respectively, across the battery of NCF tests. The most common reasons for missing data were patient refusal (cycle 3: 14%, cycle 12: 22–23%) and institutional error (cycle 3: 9–10%, cycle 12: 14–15%). A prespecified secondary endpoint analysis was conducted to evaluate differences in NCF between SD-RT and DI-RT based on the Clinical Trial Battery Composite (CTB COMP), which is the mean of the standardized scores from the NCF test battery (HVLT-R, TMT, COWA). There was no statistically significant between arm difference in change from baseline on the CTB COMP at cycle 3 (DI-RT vs SD-RT mean/SD, 0.0 +/- 1.3 vs -0.3 +/- 1.5, p=0.370, Cohen’s d=0.22) or cycle 12 (DI-RT vs SD-RT mean/SD, 0.2 +/- 1.7 vs 0.2 +/- 1.1, p=0.977, Cohen’s d=0.01). A mixed effects longitudinal model of the CTB COMP yielded a non-significant time by treatment effect interaction (p=0.216). There were no significant differences in change scores between arms on any NCF test at cycles 3 or 12. NCF outcomes were similar for photon-based SD-RT and DI-RT.
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Affiliation(s)
| | | | - Vinai Gondi
- Northwestern Medicine Cancer Center Warrenville, Warrenville, IL, USA
| | - Christina Tsien
- Johns Hopkins University/Sidney Kimmel Cancer Center, Baltimore, MD, USA
| | | | | | | | - Yue Cao
- University of Michigan, Ann Arbor, MI, USA
| | | | | | - Wenyin Shi
- Jefferson University Hospital, Philadelphia, PA, USA
| | - Lucien Nedzi
- UT Southwestern/Simmons Cancer Center-Dallas, Dallas, TX, USA
| | - Michael Chan
- Wake Forest University Health Sciences, Winston-Salem, NC, USA
| | - John Suh
- Cleveland Clinic, Cleveland, OH, USA
| | - James Battiste
- Stephenson Cancer Center at the University of Oklahoma, Oklahoma City, OK, USA
| | - Mark Mishra
- University of Maryland / Greenebaum Cancer Center, Baltimore, MD, USA
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Bovi J, Pugh S, Brown P, Gondi V, Wefel JS, Tome WA, Gilbert M, Robinson C, Benzinger TLS, Sabsevitz D, Lee K, Paulson E, Kundapur V, Roberge D, Kaufman I, Shah SA, Usuki KY, Stea BD, Yoon HA, DeMora L, Mehta M, Kachnik L. NCOG-04. PRETREATMENT VOLUME OF MR-DETERMINED WHITE MATTER INJURY (WMI) PREDICTS NEUROCOGNITIVE DECLINE AFTER HIPPOCAMPAL AVOIDANT (HA) WBRT+MEMANTINE FOR BRAIN METASTASES: SECONDARY ANALYSIS OF NRG ONCOLOGYCC001. Neuro Oncol 2020. [DOI: 10.1093/neuonc/noaa215.543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
PURPOSE
Previous secondary analysis of NRG/RTOG 0933 provided hypothesis-generating data supporting a relationship between larger volumes of MR-determined pre-treatment WMI and developing neurocognitive decline following HA-WBRT. The current study examines the relationship between pre-treatment WMI and neurocognitive function (NCF) following WBRT+memantine +/-HA in a substantially larger cohort.
METHODS
NCF testing was performed at baseline,2,4,6,and 12 months post-WBRT, and included Hopkins Verbal Learning Test–Revised (HVLT-R), Trail Making Test (TMT) Parts A and B, and Controlled Oral Word Association (COWA). Pre-treatment WMI was measured by FLAIR volume corrected for whole brain volume and corrected for the FLAIR volume associated with metastases (FLAIR/(whole brain volume – metastasis FLAIR volume). Pearson correlation coefficients were used to assess association between pre-treatment WMI and change from baseline for each standardized NCF score.
RESULTS
Of 518 randomized patients, 442 (217,WBRT+Memantine; 225,HA-WBRT+Memantine) had WMI data and were included. In the entire cohort, mean FLAIR volume was 9.3cc (0.1-68.2cc), mean metastases FLAIR volume was 61.5cc (0-423.5cc), mean Whole Brain volume was 1336.4cc (949.4-2397.8cc). At 2 months, there were no significant correlations between neurocognitive test change scores and pre-treatment WMI volume. However, at 4 months, both HVLT-R Total Recall and TMT Part B change score and pre-treatment WMI volume were significantly negatively correlated on the HA-WBRT+Memantine arm (ρ=-0.22 p=0.042 and ρ=-0.27, p=0.013). At 12 months, both TMT Part A and TMT Part B change scores and pre-treatment WMI volume were significantly negatively correlated on the HA-WBRT+Memantine arm (ρ=-0.30, p=0.046 and ρ=-0.53, p< 0.001).
CONCLUSIONS
Pre-treatment WMI volume was a significant imaging-biomarker predictor of post-treatment neurocognitive decline at 4-and 12-months following HA-WBRT+Memantine. This suggests patients with greater pre-treatment WMI were more susceptible to neurocognitive decline, specifically when undergoing HA-WBRT, but not following standard WBRT. Dose heterogeneity inherent to HA-WBRT delivery may contribute to these findings and are hypothesis generating.
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Affiliation(s)
- Joseph Bovi
- Dept. Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Stephanie Pugh
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA, USA
| | | | - Vinai Gondi
- Northwestern Medicine Cancer Center, Warrenville, IL, USA
| | | | | | | | | | | | | | - Karen Lee
- Medical College of Wisconsin, Milwaukee, WI, USA
| | - Eric Paulson
- Medical College of Wisconsin, Milwaukee, WI, USA
| | | | | | | | - Sunjay A Shah
- Delaware/ Christiana Care NCI Community Oncology Research Program, Wilmington, DE, USA
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Palmer J, Ostrom Q, Cioffi G, Patil N, Kruchko C, Zaorsky N, Trifiletti D, Gondi V, Brown P, Chakravarti A, Barnholtz-Sloan J. Association Of Radon And High Particulate Pollution With Incidence Of Brain Tumors In The United States. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.165] [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: 11/24/2022]
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42
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Redmond K, Grimm J, Robinson C, Gondi V, Gui C, Kundapur V, Whitton A, DeNittis A, Dominello M, Nguyen T, Shi W, Wendland M, Shah S, Pugh S, Mehta M, Kachnic L. Steep Dose-response Relationship between Maximum Hippocampal Dose and Memory Deficits following Hippocampal Avoidance Whole Brain Radiation Therapy (HA-WBRT) for Brain Metastases: A Secondary Analysis of NRG/RTOG 0933. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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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43
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Affiliation(s)
- Vinai Gondi
- Vinai Gondi, MD, Northwestern Medicine Cancer Center Warrenville and Northwestern Medicine Proton Center, Warrenville, IL; and Paul D. Brown, MD, Mayo Clinic, Rochester, MN
| | - Paul D Brown
- Vinai Gondi, MD, Northwestern Medicine Cancer Center Warrenville and Northwestern Medicine Proton Center, Warrenville, IL; and Paul D. Brown, MD, Mayo Clinic, Rochester, MN
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44
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Gross JP, Powell S, Zelko F, Hartsell W, Goldman S, Fangusaro J, Lulla RR, Smiley NP, Chang JHC, Gondi V. Improved neuropsychological outcomes following proton therapy relative to X-ray therapy for pediatric brain tumor patients. Neuro Oncol 2020; 21:934-943. [PMID: 30997512 DOI: 10.1093/neuonc/noz070] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Survivors of pediatric brain tumors are at risk for impaired development in multiple neuropsychological domains. The purpose of this study was to compare neuropsychological outcomes of pediatric brain tumor patients who underwent X-ray radiotherapy (XRT) versus proton radiotherapy (PRT). METHODS Pediatric patients who underwent either XRT or PRT and received posttreatment age-appropriate neuropsychological evaluation-including measures of intelligence (IQ), attention, memory, visuographic skills, academic skills, and parent-reported adaptive functioning-were identified. Multivariate analyses were performed to assess differences in neuropsychological outcomes and included tests for interaction between treatment cohort and follow-up time. RESULTS Between 1998 and 2017, 125 patients with tumors located in the supratentorial (17.6%), midline (28.8%), or posterior fossa (53.6%) compartments received radiation and had posttreatment neuropsychological evaluation. Median age at treatment was 7.4 years. The PRT patient cohort had higher estimated SES and shorter median time from radiotherapy completion to last neuropsychological evaluation (6.7 vs 2.6 y, P < 0.001). On multivariable analysis, PRT was associated with higher full-scale IQ (β = 10.6, P = 0.048) and processing speed (β = 14.4, P = 0.007) relative to XRT, with trend toward higher verbal IQ (β = 9.9, P = 0.06) and general adaptive functioning (β = 11.4, P = 0.07). Planned sensitivity analyses truncating follow-up interval in the XRT cohort re-demonstrated higher verbal IQ (P = 0.01) and IQ (P = 0.04) following PRT, with trend toward improved processing speed (P = 0.09). CONCLUSIONS PRT is associated with favorable outcomes for intelligence and processing speed. Combined with other strategies for treatment de-intensification, PRT may further reduce neuropsychological morbidity of brain tumor treatment.
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Affiliation(s)
- Jeffrey P Gross
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Stephanie Powell
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Frank Zelko
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - William Hartsell
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Radiation Oncology Consultants LLC, Chicago, Illinois.,Northwestern Medicine Chicago Proton Center, Warrenville, Illinois
| | - Stewart Goldman
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jason Fangusaro
- Department of Pediatrics, Emory University School of Medicine and the Aflac Cancer Center, Atlanta, Georgia
| | - Rishi R Lulla
- Department of Pediatrics, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Natasha Pillay Smiley
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - John Han-Chih Chang
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Vinai Gondi
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Radiation Oncology Consultants LLC, Chicago, Illinois.,Northwestern Medicine Chicago Proton Center, Warrenville, Illinois
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45
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Mehta MP, Gondi V, Brown P, Ahluwalia M. 30. RADIOSURGERY FOLLOWED BY TUMOR TREATING FIELDS FOR BRAIN METASTASES (1–10) FROM NSCLC IN THE PHASE 3 METIS TRIAL. Neurooncol Adv 2020. [PMCID: PMC7401333 DOI: 10.1093/noajnl/vdaa073.018] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Tumor Treating Fields (TTFields) are non-invasive, loco-regional, anti-mitotic treatment modality comprising alternating electric fields. TTFields have demonstrated efficacy in preclinical non-small cell lung cancer (NSCLC) models. TTFields treatment to the brain was safe and extended overall survival in newly-diagnosed glioblastoma. The objective of the METIS study [NCT02831959] is evaluation of the efficacy and safety of TTFields in NSCLC patients with brain metastases. METHODS NSCLC patients (N=270) with 1–10 brain metastases were randomized 1:1 to stereotactic radio surgery (SRS) followed by continuous TTFields ((150 kHz, > 18 hours/day) within 7 days of SRS or supportive care. The portable device delivered TTFields to the brain using 4 transducer arrays, while patients received the best standard-of-care for systemic disease. Patients were followed every two months until second intracranial progression. Key inclusion criteria: KPS ≥70, new diagnosis of 1 inoperable or 2–10 supra- and/or infratentorial brain metastases from NSCLC amenable to SRS; and optimal therapy for extracranial disease. Prior WBRT, surgical resection of metastases, or recurrent brain metastases were exclusionary. Primary endpoint was time to 1st intracranial progression. Secondary endpoints included time to neurocognitive failure (HVLT, COWAT and TMT), overall survival, radiological response rate (RANO-BM and RECIST V1.1); quality-of-life; adverse events; time to first/second intracranial progression for patients with 1–4 and 5–10 brain metastases; bi-monthly intracranial progression rate from 2–12 months; and time to second intracranial and distant progression. The sample size (N=270) was calculated using a log-rank test (Lakatos 1988 and 2002) with 80% power at two sided alpha of 0.05 to detect a hazard ratio of 0.57. On September, 2019, an independent Data Monitoring Committee (DMC) reviewed METIS trial data collected to that point. The DMC concluded that no unexpected safety issues had emerged and recommended continuation of the METIS study as planned.
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Affiliation(s)
| | - Vinai Gondi
- Northwestern Medicine Cancer Center, Warrenville, IL, USA
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Brown PD, Gondi V, Pugh S, Tome WA, Wefel JS, Armstrong TS, Bovi JA, Robinson C, Konski A, Khuntia D, Grosshans D, Benzinger TLS, Bruner D, Gilbert MR, Roberge D, Kundapur V, Devisetty K, Shah S, Usuki K, Anderson BM, Stea B, Yoon H, Li J, Laack NN, Kruser TJ, Chmura SJ, Shi W, Deshmukh S, Mehta MP, Kachnic LA. Hippocampal Avoidance During Whole-Brain Radiotherapy Plus Memantine for Patients With Brain Metastases: Phase III Trial NRG Oncology CC001. J Clin Oncol 2020; 38:1019-1029. [PMID: 32058845 PMCID: PMC7106984 DOI: 10.1200/jco.19.02767] [Citation(s) in RCA: 413] [Impact Index Per Article: 103.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2020] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Radiation dose to the neuroregenerative zone of the hippocampus has been found to be associated with cognitive toxicity. Hippocampal avoidance (HA) using intensity-modulated radiotherapy during whole-brain radiotherapy (WBRT) is hypothesized to preserve cognition. METHODS This phase III trial enrolled adult patients with brain metastases to HA-WBRT plus memantine or WBRT plus memantine. The primary end point was time to cognitive function failure, defined as decline using the reliable change index on at least one of the cognitive tests. Secondary end points included overall survival (OS), intracranial progression-free survival (PFS), toxicity, and patient-reported symptom burden. RESULTS Between July 2015 and March 2018, 518 patients were randomly assigned. Median follow-up for alive patients was 7.9 months. Risk of cognitive failure was significantly lower after HA-WBRT plus memantine versus WBRT plus memantine (adjusted hazard ratio, 0.74; 95% CI, 0.58 to 0.95; P = .02). This difference was attributable to less deterioration in executive function at 4 months (23.3% v 40.4%; P = .01) and learning and memory at 6 months (11.5% v 24.7% [P = .049] and 16.4% v 33.3% [P = .02], respectively). Treatment arms did not differ significantly in OS, intracranial PFS, or toxicity. At 6 months, using all data, patients who received HA-WBRT plus memantine reported less fatigue (P = .04), less difficulty with remembering things (P = .01), and less difficulty with speaking (P = .049) and using imputed data, less interference of neurologic symptoms in daily activities (P = .008) and fewer cognitive symptoms (P = .01). CONCLUSION HA-WBRT plus memantine better preserves cognitive function and patient-reported symptoms, with no difference in intracranial PFS and OS, and should be considered a standard of care for patients with good performance status who plan to receive WBRT for brain metastases with no metastases in the HA region.
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Affiliation(s)
| | - Vinai Gondi
- Northwestern Medicine Cancer Center Warrenville and Northwestern Medicine Proton Center, Warrenville, IL
| | - Stephanie Pugh
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA
| | - Wolfgang A. Tome
- Montefiore Medical Center, Albert Einstein College of Medicine, The Bronx, NY
| | | | | | - Joseph A. Bovi
- Froedtert & the Medical College of Wisconsin, Milwaukee, WI
| | | | | | - Deepak Khuntia
- East Bay Radiation Oncology Center, Eden Medical Center, Castro Valley, CA
| | - David Grosshans
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Deborah Bruner
- Winship Cancer Institute of Emory University, Atlanta, GA
| | - Mark R. Gilbert
- National Cancer Institute Center for Cancer Research, Bethesda, MD
| | - David Roberge
- CHUM-Hôtel-Dieu de Montréal, Montreal, Quebec, Canada
| | | | - Kiran Devisetty
- Wayne State University, Karmanos Cancer Institute, Detroit, MI
| | - Sunjay Shah
- ChristianaCare National Cancer Institute Community Oncology Research Program, Newark, DE
| | | | | | - Baldassarre Stea
- University of Arizona Medical Center-University Campus, Tucson, AZ
| | - Harold Yoon
- Heartland Cancer Research National Cancer Institute Community Oncology Research Program, Decatur, IL
| | - Jing Li
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | - Steven J. Chmura
- The University of Chicago Comprehensive Cancer Center, Chicago, IL
| | - Wenyin Shi
- Thomas Jefferson University Hospital, Philadelphia, PA
| | - Snehal Deshmukh
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA
| | | | - Lisa A. Kachnic
- Vanderbilt University Medical Center, Ingram Cancer Center, Nashville, TN
| | - for NRG Oncology
- Mayo Clinic, Rochester, MN
- Northwestern Medicine Cancer Center Warrenville and Northwestern Medicine Proton Center, Warrenville, IL
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA
- Montefiore Medical Center, Albert Einstein College of Medicine, The Bronx, NY
- The University of Texas MD Anderson Cancer Center, Houston, TX
- National Cancer Institute Center for Cancer Research, Bethesda, MD
- Froedtert & the Medical College of Wisconsin, Milwaukee, WI
- Washington University in St Louis, St Louis, MO
- Chester County Hospital, West Chester, PA
- East Bay Radiation Oncology Center, Eden Medical Center, Castro Valley, CA
- Winship Cancer Institute of Emory University, Atlanta, GA
- CHUM-Hôtel-Dieu de Montréal, Montreal, Quebec, Canada
- Saskatoon Cancer Center, Saskatoon, Saskatchewan, Canada
- Wayne State University, Karmanos Cancer Institute, Detroit, MI
- ChristianaCare National Cancer Institute Community Oncology Research Program, Newark, DE
- University of Rochester, Rochester, NY
- University of Wisconsin Hospitals and Clinics, Madison, WI
- University of Arizona Medical Center-University Campus, Tucson, AZ
- Heartland Cancer Research National Cancer Institute Community Oncology Research Program, Decatur, IL
- Northwestern Memorial Hospital, Chicago, IL
- The University of Chicago Comprehensive Cancer Center, Chicago, IL
- Thomas Jefferson University Hospital, Philadelphia, PA
- Miami Cancer Institute, Miami, FL
- Vanderbilt University Medical Center, Ingram Cancer Center, Nashville, TN
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Palmer JD, Trifiletti DM, Gondi V, Chan M, Minniti G, Rusthoven CG, Schild SE, Mishra MV, Bovi J, Williams N, Lustberg M, Brown PD, Rao G, Roberge D. Multidisciplinary patient-centered management of brain metastases and future directions. Neurooncol Adv 2020; 2:vdaa034. [PMID: 32793882 PMCID: PMC7415255 DOI: 10.1093/noajnl/vdaa034] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [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] [Indexed: 12/18/2022] Open
Abstract
The incidence of brain metastasis is increasing as improvements in systemic therapy lead to increased survival. This provides new and challenging clinical decisions for patients who are trying to balance the risk of recurrence or progression with treatment-related side effects, and it requires appropriate management strategies from multidisciplinary teams. Improvements in prognostic assessment and systemic therapy with increasing activity in the brain allow for individualized care to better guide the use of local therapies and/or systemic therapy. Here, we review the current landscape of brain-directed therapy for the treatment of brain metastasis in the context of recent improved systemic treatment options. We also discuss emerging treatment strategies including targeted therapies for patients with actionable mutations, immunotherapy, modern whole-brain radiation therapy, radiosurgery, surgery, and clinical trials.
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Affiliation(s)
- Joshua D Palmer
- Department of Radiation Oncology, The James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Department of Neurosurgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Daniel M Trifiletti
- Departments of Radiation Oncology and Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Vinai Gondi
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Radiation Oncology Consultants LLC, Chicago, Illinois, USA
- Northwestern Medicine Chicago Proton Center Warrenville, Chicago, Illinois, USA
| | - Michael Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Giuseppe Minniti
- Radiation Oncology Unit, UPMC Hillman Cancer Center, San Pietro Hospital FBF, Rome, Italy
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic Scottsdale, Phoenix, Arizona, USA
| | - Mark V Mishra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Joseph Bovi
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Nicole Williams
- Department of Medical Oncology, The James Cancer Hospital and Solove Research Institute at The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Maryam Lustberg
- Department of Medical Oncology, The James Cancer Hospital and Solove Research Institute at The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ganesh Rao
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David Roberge
- Department of Radiation Oncology, Centre Hospitalier de l’ Université de Montreal, Montreal, Quebec, Canada
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48
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Kam KL, Snuderl M, Khan O, Wolinsky JP, Gondi V, Grimm S, Horbinski C. Using methylation profiling to diagnose systemic metastases of pleomorphic xanthoastrocytoma. Neurooncol Adv 2019; 2:vdz057. [PMID: 32002518 PMCID: PMC6978194 DOI: 10.1093/noajnl/vdz057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Indexed: 01/02/2023] Open
Affiliation(s)
- Kwok-Ling Kam
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Matija Snuderl
- Department of Pathology, NYU Langone Health, New York University, New York
| | - Osaama Khan
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Jean-Paul Wolinsky
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Vinai Gondi
- Department of Radiation Oncology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Sean Grimm
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Craig Horbinski
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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49
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Armstrong T, Deshmukh S, Brown P, Gondi V, Benzinger T, Gilbert M, Tome W, Wefel J, Bruner D, Roberge D, Kundapur V, Devisetty K, Shah S, Usuki K, Baschnagel A, Stea B, Yoon H, Li J, Laack N, Mehta M, Kachnic L. ACTR-50. PRESERVATION OF NEUROCOGNITIVE FUNCTION & PATIENT-REPORTED SYMPTOMS WITH HIPPOCAMPAL AVOIDANCE (HA) DURING WHOLE-BRAIN RADIOTHERAPY (WBRT) FOR BRAIN METASTASES: LONG-TERM RESULTS OF NRG ONCOLOGY CC001. Neuro Oncol 2019. [DOI: 10.1093/neuonc/noz175.092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
NRG-CC001 sought to evaluate the neuro-protective effects of avoiding the peri-hippocampal stem cell niche using intensity-modulated radiotherapy during WBRT.
METHODS
Patients with brain metastasis were stratified by RPA class and prior radiosurgery/surgery and randomized to WBRT+M or HA-WBRT+ Memantine (M) (30Gy in 10 fractions). Standardized NCF tests and the M.D. Anderson Symptom Inventory Brain Tumor (MDASI-BT) were obtained at baseline, 2, 4, 6, and 12 months (mos). The primary endpoint was NCF failure defined using the reliable change index. Pre-specified secondary endpoints included patient-reported symptoms using the MDASI-BT. Time to NCF was reported as cumulative incidence (with death without NCF failure as a competing risk); between-arms differences were tested using Gray’s test. Deterioration at discrete time-points were tested using chi-square tests. MDASI-BT symptom burden, interference, and cognitive and neurologic burden were analyzed using mixed effects models and t-tests within the model using Hochberg’s multiplicity adjustment.
RESULTS
A total of 518 patients were randomized from 7/2016 to 3/2018. Median follow-up for alive patients was 12.1 mos, with no difference between arms in terms of toxicity, overall survival or intracranial progression-free survival. HA-WBRT+M was associated with lower risk of NCF failure (adjusted HR=0.739, 95% CI: 0.577–0.945, p=0.0.016), with differences first noted at 4 mos in Trail Making Test Part-B (23.3% vs. 40.4% deteriorated, p=0.012). Age did not dilute treatment effect. HA-WBRT+M was associated with reduced cognitive symptom burden in an imputed model (estimate=-0.29, p=0.0425), and also reduced overall symptom burden (p< 0.0001) and interference (p< 0.0016) at 6 mos.
CONCLUSIONS
The addition of HA to WBRT+M preserved NCF and reduced patient reported cognitive symptom burden, overall symptom burden and symptom interference and should be considered standard of care for any patient fit enough to have WBRT. Supported by grants UG1CA189867 (NCORP), U10CA180868 (NRG Oncology Operations), DCP from the National Cancer Institute.
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Affiliation(s)
- Terri Armstrong
- Neuro-Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | | | | | - Vinai Gondi
- Northwestern Medical Cancer Center, Chicago, IL, USA
| | - Tammy Benzinger
- Washington University School of Medicine, St. Louis, MO, USA
| | - Mark Gilbert
- Neuro-Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | | | | | - Deborah Bruner
- Emory University/Winship Cancer Center, Atlanta, GA, USA
| | - David Roberge
- CHUM - Centre Hospitalier de l’Universite de Montreal, Montreal, QC, Canada
| | | | - Kiran Devisetty
- Wayne State University/Karmanos Cancer Institute, Detroit, MI, USA
| | - Sunjay Shah
- McLaren Cancer Institute - Flint (ACCRUALS UNDER Delaware/Christiana Care NCI Community Oncology Research Program), Mclaran, USA
| | | | | | | | - Harold Yoon
- Heartland Cancer Research NCORP, Springfield, USA
| | - Jing Li
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nadia Laack
- Mayo Clinic/Accruals for Rochester Methodist Hospital (NCCTG), Rochester, MN, USA
| | | | - Lisa Kachnic
- Vanderbilt - Ingram Cancer Center, Nashville, TN, USA
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50
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Mehta M, Gondi V, Ahluwalia M, Brown P. RBTT-02. RADIOSURGERY FOLLOWED BY TUMOR TREATING FIELDS FOR BRAIN METASTASES (1–10) FROM NSCLC IN THE PHASE 3 METIS TRIAL. Neuro Oncol 2019. [DOI: 10.1093/neuonc/noz175.914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND: Tumor Treating Fields (TTFields) are non-invasive, loco-regional, anti-mitotic treatment modality comprising alternating electric fields. TTFields have demonstrated efficacy in preclinical non-small cell lung cancer (NSCLC) models. TTFields treatment to the brain was safe and extended overall survival in newly-diagnosed glioblastoma. The METIS study [NCT02831959] investigates the efficacy and safety of TTFields in NSCLC patients with brain metastases. Study Design: NSCLC patients (N=270) with 1–10 brain metastases are randomized 1:1 to stereotactic radio surgery (SRS) followed by continuous TTFields ((150 kHz, > 18 hours/day) within 7 days of SRS or supportive care. The portable device delivers TTFields to the brain using 4 transducer arrays, while patients receive the best standard-of-care for systemic disease. Patients are followed every two months until second intracranial progression. Key inclusion criteria: KPS ≥70, new diagnosis of 1 inoperable or 2–10 supra- and/or infratentorial brain metastases from NSCLC amenable to SRS; and optimal therapy for extracranial disease. Prior WBRT or surgical resection of metastases, a single resectable lesion or recurrent brain metastases were exclusionary. Primary endpoint was time to 1st intracranial progression. Secondary endpoints included time to neurocognitive failure (HVLT, COWAT and TMT), overall survival, radiological response rate (RANO-BM and RECIST V1.1); quality-of-life; adverse events; time to first/second intracranial progression for patients with 1–4 and 5–10 brain metastases; bi-monthly intracranial progression rate from 2–12 months; and time to second intracranial and distant progression. The sample size (N=270) was calculated using a log-rank test (Lakatos 1988 and 2002) with 80% power at two sided alpha of 0.05 to detect a hazard ratio of 0.57. In August 2018, an independent Data Monitoring Committee (DMC) performed a review of the METIS trial data collected to that point. The DMC concluded that no unexpected safety issues had emerged and recommended continuation of the METIS study as planned.
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Affiliation(s)
| | - Vinai Gondi
- Northwestern Medicine Cancer Center Warrenville, IL, USA
| | - Manmeet Ahluwalia
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
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