Association of survival with stereotactic body radiation therapy following induction chemotherapy for unresected locally advanced pancreatic cancer.

Background: Induction chemotherapy (iC) followed by concurrent chemoradiation has been shown to improve overall survival (OS) for locally advanced pancreatic cancer (LAPC). However, the survival benefit of stereotactic body radiation therapy (SBRT) versus conventionally fractionated radiation therapy (CFRT) following iC remains unclear. Methods: The National Cancer Database (NCDB) was queried for primary stage III, cT4N0-1M0 LAPC (2004-2015). Kaplan-Meier analysis, Cox proportional hazards method, and propensity score matching were used. Results: Among 872 patients, 738 patients underwent CFRT and 134 patients received SBRT. Median follow-up was 24.3 months and 22.9 months for the CFRT and SBRT cohorts, respectively. The use of SBRT showed improved survival in both the multivariate analysis (HR 0.78, p=0.025) and 120 propensity-matched pairs (median OS 18.1 vs 15.9 months, p=0.004) compared to the CFRT. Conclusion: This NCDB analysis suggests survival benefit with the use of SBRT versus CFRT following iC for the LAPC.

Radiofrequency Ablation and Radiation Therapy Improve Local Control in Spinal Metastases Compared to Radiofrequency Ablation Alone.

PURPOSE:: The spinal column is the most common location for osseous metastases and is associated with pain and decreased quality of life. This study evaluated combined radiofrequency ablation (RFA) with radiation therapy (RT) compared to RFA alone for improving pain and local control. METHODS:: This was a single-institution retrospective review of patients who underwent RFA of spinal metastases between 2016 and 2017, with or without RT to the same vertebral level. Pain was measured with visual analog scale at initial presentation and at 3 and 12 weeks of follow-up. Local failure (LF), distant failure, and overall survival (OS) were compared and Kaplan-Meier statistics were calculated. RESULTS:: Twenty-six patients with 28 spinal metastases were treated with RFA. Ten patients with 11 metastases were treated with RFA + RT. More patients with lung primaries were treated with RFA alone and more patients with breast primaries were treated with combination RFA+RT. There was no significant difference in pain scores between groups ( P = .96). At a median follow-up of 8.2 months, LF was noted in 8 of 17 metastases treated with RFA alone compared to 1 of 11 metastases treated with RFA+RT ( P = .049). There was a significant benefit in time to LF favoring RFA+RT ( P = .02) and a significant benefit in OS ( P = .0045). CONCLUSION:: This study demonstrates a benefit in local control with RFA+RT versus RFA alone. Palliation of pain was effective using both regimens. This study was limited by a nearly unequal distribution of primary tumor histologies between groups. Literature regarding combined treatment of RFA and RT for spinal metastases is scarce and prospective protocols are warranted.

Adjuvant chemotherapy followed by concurrent chemoradiation is associated with improved survival for resected stage I-II pancreatic cancer.

BACKGROUND: This National Cancer Database (NCDB) analysis evaluates the clinical outcomes of postoperative chemotherapy followed by concurrent chemoradiation (C + CRT) compared to concurrent chemoradiation (CRT) alone or adjuvant chemotherapy alone (C) for resected pancreatic cancer. METHODS: The NCDB was queried for primary stage I-II, cT1-3N0-1M0, resected pancreatic adenocarcinoma treated with adjuvant C, CRT, or C + CRT (2004-2015). Patients treated with C + CRT were compared with those treated with C (cohort C) and CRT (cohort CRT). Baseline patient, tumor, and treatment characteristics were examined. Kaplan-Meier analysis, multivariable Cox proportional hazards method, forest plot, and propensity score matching were used. RESULTS: Among 5667 patients, median follow-up was 34.7, 45.2, and 39.7 months for the C, CRT, and C + CRT cohorts, respectively. By multivariable analysis for all patients, C and CRT had worse OS compared to C + CRT. Treatment interactions were seen among pathologically node-positive disease. C + CRT was favored in 1-3 and 4+ positive lymph node diseases when compared to C or CRT alone, but none of the treatment options were significantly favored in node negative disease. Using propensity score matching, 2152 patients for cohort C and 1774 patients for cohort CRT were matched. C + CRT remained significant for improved OS for both cohort C (median OS 23.3 vs 20.0 months) and cohort CRT (median OS 23.4 vs 20.8 months). CONCLUSION: This NCDB study using propensity score matched analysis suggests an OS benefit for C + CRT compared to C or CRT alone following surgical resection of pancreatic cancer, particularly for patients with pathologically positive lymph nodes.

Stereotactic body radiation therapy for non-small cell lung cancer: A review.

Stereotactic body radiation therapy (SBRT) is the treatment of choice for medically inoperable patients with early stage non-small cell lung cancer (NSCLC). A literature search primarily based on PubMed electronic databases was completed in July 2018. Inclusion and exclusion criteria were determined prior to the search, and only prospective clinical trials were included. Nineteen trials from 2005 to 2018 met the inclusion criteria, reporting the outcomes of 1434 patients with central and peripheral early stage NSCLC. Patient eligibility, prescription dose and delivery, and follow up duration varied widely. Three-years overall survival ranged from 43% to 95% with loco-regional control of up to 98% at 3 years. Up to 33% of patients failed distantly after SBRT at 3 years. SBRT was generally well tolerated with 10%-30% grade 3-4 toxicities and a few treatment-related deaths. No differences in outcomes were observed between conventionally fractionated radiation therapy and SBRT, central and peripheral lung tumors, or inoperable and operable patients. SBRT remains a reasonable treatment option for medically inoperable and select operable patients with early stage NSCLC. SBRT has shown excellent local and regional control with toxicity rates equivalent to surgery. Decreasing fractionation schedules have been consistently shown to be both safe and effective. Distant failure is common, and chemotherapy may be considered for select patients. However, the survival benefit of additional interventions, such as chemotherapy, for early stage NSCLC treated with SBRT remains unclear.

Duration of chemotherapy prior to chemoradiation affects survival outcomes for resected stage I-II or unresected stage III pancreatic cancer.

BACKGROUND: For resected early stage pancreatic cancer, RTOG 9704 evaluated the outcome of 3 weeks of postoperative chemotherapy (C) followed by chemoradiation (CRT) and further C. For unresectable locally advanced pancreatic cancer, a recent literature review of prospective studies showed that the duration of induction C prior to CRT can impact survival. However, the ideal duration of C prior to CRT remains unclear for these patient cohorts. This National Cancer Database (NCDB) study was performed to compare the outcome of various durations of C prior to CRT. METHODS: The NCDB was queried for resected primary stage I-II, cT1-3N0-1M0, and unresected stage III, cT4N0-1M0 pancreatic adenocarcinoma treated with C + CRT (2004-2015). Cohorts I-II and III included stage I-II and stage III cases, respectively. Patients were stratified by short (short C) and long duration (long C) of chemotherapy based on their median durations. Baseline patient, tumor, and treatment characteristics were examined. The primary endpoint was overall survival (OS). Kaplan-Meier analysis, multivariable Cox proportional hazards method, and propensity score matching were used. RESULTS: Among 1577 patients, cohort I-II had 839 patients and cohort III had 738 patients. The longer duration of chemotherapy prior to CRT showed improved OS in the multivariate analysis in both cohort I-II (hazards ratio [HR] 0.72, P < 0.001) and cohort III (HR 0.83, P = 0.03). Using 1:1 propensity score matching, 610 patients for cohort I-II and 542 patients for cohort III were matched. After matching, long C remained statistically significant for improved OS compared with short C in both cohort I-II (median OS 26.1 vs 21.9 months; P = 0.003) and cohort III (median OS 16.7 vs 14.2; P = 0.02). CONCLUSION: Our NCDB study using propensity score-matched analysis showed a survival benefit for using the longer duration of chemotherapy compared to the shorter duration for both resected stage I-II and unresected stage III pancreatic cancer.

Dose escalation of radiation therapy with or without induction chemotherapy for unresectable locally advanced pancreatic cancer.

BACKGROUND: Dose escalation of conventionally fractionated radiation therapy (CFRT) above 45-54 Gy has an unclear survival benefit. Prior National Cancer Database (NCDB) analyses have shown improved overall survival with induction chemotherapy (iC) prior to concurrent chemoradiation (CRT) in locally advanced pancreatic cancer. Our study compared dose-escalated CFRT with and without iC. METHODS: The NCDB was queried for primary stage III, cT4 N0-1 M0 LAPC treated with CRT with or without iC (2004-2015). CFRT was stratified by < 55 Gy and ≥ 55 Gy. Cohort iC + CRT and CRT included those with and without iC, respectively. The primary endpoint was overall survival (OS). Kaplan-Meier analysis, Cox proportional hazards method, and propensity score matching were used. RESULTS: Among 2029 patients, cohort iC + CRT had 738 patients (n = 601 for 45-55 Gy and n = 137 for ≥55 Gy) and cohort CRT had 1291 patients (n = 1066 for 45-55 Gy and n = 225 for ≥55 Gy). Median follow-up was 24.3 months and 24.6 months for cohorts iC + CRT and CRT, respectively. Dose escalation showed improved survival in the multivariable analysis in cohort iC + CRT (HR 0.77, p = 0.013) but not in cohort CRT (HR 0.91, p = 0.19). Using 2:1 propensity score matching, a total of 387 patients for cohort iC + CRT and 549 patients for cohort CRT were matched. After matching, dose escalation remained significant for improved overall survival in cohort iC + CRT (median OS 16.2 vs 15.2 months; 2-yr OS 33.4% vs 25.4%; p = 0.022) but not in cohort CRT (median OS 11.8 vs 10.6 months; 2-yr OS 13.3% vs 10.1%; p = 0.16). CONCLUSIONS: Patients with locally advanced pancreatic cancer who undergo iC have improved survival with radiation dose escalation above 55 Gy. For patients without iC, there is no clear association between radiation dose escalation and survival.