Proton Therapy for Unresectable and Medically Inoperable Locally Advanced Pancreatic Cancer: Results From a Multi-Institutional Prospective Registry.

Purpose: Compared with photon-based techniques, proton beam radiation therapy (PBT) may improve the therapeutic ratio of radiation therapy (RT) for locally advanced pancreatic cancer (LAPC), but available data have been limited to single-institutional experiences. This study examined the toxicity, survival, and disease control rates among patients enrolled in a multi-institutional prospective registry study and treated with PBT for LAPC. Methods and Materials: Between March 2013 and November 2019, 19 patients with inoperable disease across 7 institutions underwent PBT with definitive intent for LAPC. Patients received a median radiation dose/fractionation of 54 Gy/30 fractions (range, 50.4-60.0 Gy/19-33 fractions). Most received prior (68.4%) or concurrent (78.9%) chemotherapy. Patients were assessed prospectively for toxicities using National Cancer Institute Common Terminology Criteria for Adverse Events, version 4.0. Kaplan-Meier analysis was used to analyze overall survival, locoregional recurrence-free survival, time to locoregional recurrence, distant metastasis-free survival, and time to new progression or metastasis for the adenocarcinoma cohort (17 patients). Results: No patients experienced grade ≥3 acute or chronic treatment-related adverse events. Grade 1 and 2 adverse events occurred in 78.7% and 21.3% of patients, respectively. Median overall survival, locoregional recurrence-free survival, distant metastasis-free survival, and time to new progression or metastasis were 14.6, 11.0, 11.0, and 13.9 months, respectively. Freedom from locoregional recurrence at 2 years was 81.7%. All patients completed treatment with one requiring a RT break for stent placement. Conclusions: Proton beam RT for LAPC offered excellent tolerability while still maintaining disease control and survival rates comparable with dose-escalated photon-based RT. These findings are consistent with the known physical and dosimetric advantages offered by proton therapy, but the conclusions are limited owing to the patient sample size. Further clinical studies incorporating dose-escalated PBT are warranted to evaluate whether these dosimetric advantages translate into clinically meaningful benefits.

Hypofractionated proton beam radiotherapy in patients with unresectable liver tumors: multi-institutional prospective results from the Proton Collaborative Group.

BACKGROUND: Recent advances in radiotherapy techniques have allowed ablative doses to be safely delivered to inoperable liver tumors. In this setting, proton beam radiotherapy (PBT) provides the means to escalate radiation dose to the target volume while sparing the uninvolved liver. This study evaluated the safety and efficacy of hypofractionated PBT for liver tumors, predominantly hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC). METHODS: We evaluated the prospective registry of the Proton Collaborative Group for patients undergoing definitive PBT for liver tumors. Demographic, clinicopathologic, toxicity, and dosimetry information were compiled. RESULTS: To date, 63 patients have been treated at 9 institutions between 2013 and 2019. Thirty (48%) had HCC and 25 (40%) had ICC. The median dose and biological equivalent dose (BED) delivered was 58.05 GyE (range 32.5-75) and 80.5 GyE (range 53.6-100), respectively. The median mean liver BED was 13.9 GyE. Three (4.8%) patients experienced at least one grade ≥ 3 toxicity. With median follow-up of 5.1 months (range 0.1-40.8), the local control (LC) rate at 1 year was 91.2% for HCC and 90.9% for ICC. The 1-year LC was significantly higher (95.7%) for patients receiving BED greater than 75.2 GyE than for patients receiving BED of 75.2 GyE or lower (84.6%, p = 0.029). The overall survival rate at 1 year was 65.6% for HCC and 81.8% for ICC. CONCLUSIONS: Hypofractionated PBT results in excellent LC, sparing of the uninvolved liver, and low toxicity, even in the setting of dose-escalation. Higher dose correlates with improved LC, highlighting the importance of PBT especially in patients with recurrent or bulky disease.

Comparison of stereotactic body radiation therapy for biopsy-proven versus radiographically diagnosed early-stage non-small lung cancer: a single-institution experience.

INTRODUCTION: Histological confirmation of non-small cell lung cancer (NSCLC) is often required before patients are offered stereotactic body radiation therapy (SBRT) as a treatment option. Many patients, however, are unsuitable to undergo a biopsy procedure because of comorbidity. Our objective is to compare the outcomes of patients with biopsy-proven (BxPr) or clinically/radiographically diagnosed (RadDx) early-stage NSCLC treated with SBRT. METHODS: Records of 88 patients treated with SBRT at a single institution were reviewed. Sixty-five patients had BxPr early-stage NSCLC. Twenty-three patients were RadDx with early-stage NSCLC based on an FDG-avid chest nodule on PET scan, serial sequential CT-findings compatible with NSCLC, and consensus of a multidisciplinary team. Outcomes of patients with BxPr and RadDx NSCLC were evaluated in regard to local control, regional lymph node metastasis-free and distant metastasis-free rates, and overall survival using Kaplan-Meier survival curves. RESULTS: Median follow-up for all patients was 29 months (range, 4-82 months). Cumulative local progression-free rate after 3 years for the BxPr group was 93.1% (95% confidence interval [CI], 85.2%-97.6%) and 94.10% (95% CI, 73.2%-97.6%) for the RadDx group (p = 0.98). No differences regarding regional lymph node metastasis-free and distant metastasis-free rates by subgroup were observed. The overall 3-year survival rate for the BxPr group was 59.9% (95% CI, 44.8%-68.2%) and 58.9% (95% CI, 40.1%-77.8%) for the RadDx group (p = 0.46). CONCLUSIONS: SBRT is a practical treatment modality for patients with RadDx early-stage NSCLC. Outcomes of patients RadDx with NSCLC mirror the results of patients treated with BxPr disease.

Helical image-guided stereotactic body radiotherapy (SBRT) for the treatment of early-stage lung cancer: a single-institution experience at the Willis-Knighton Cancer Center.

AIMS AND BACKGROUND: Our aim is to report on the clinical methods and outcomes of helical intensity-modulated stereotactic body radiotherapy (SBRT) for the treatment of early-stage non-small cell lung cancer (NSCLC). METHODS AND STUDY DESIGN: Seventy-nine patients with stage I NSCLC underwent helical SBRT with 48 Gy in 4 fractions or 60 Gy in 5 fractions. All patients underwent 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) or FDG-PET/computed tomography (CT) scanning in the immobilized treatment position for planned fusion with a separate kilovoltage (KV) CT simulation prior to treatment. Megavoltage CT images were obtained on the treatment unit prior to therapy and repeated at mid-fraction with comparison and fusion to the KV CT simulation planning images to assure setup accuracy. Serial follow-up with FDG-PET or FDG-PET/CT was performed at 3-4 months and every 6 months thereafter. RESULTS: Median follow-up was 27 months (range, 4-82 months). Overall local control rate (LCR) was 93.6% (95% confidence interval [CI], 86.0-97.3%) and 3-year overall survival (OS) was 58.4% (95% CI, 47.2-69.5%). For patients with T1N0M0 disease (n = 59) the LCR was 94.9% (95% CI, 86.1-98.3%) and the 3-year OS was 62.8% (95% CI, 49.9-73.9%). Patients treated with 60 Gy had longer 3-year OS than patients treated with 48 Gy (65.2% vs 37.5%; P = 0.044). SBRT-related toxicity was modest, with 10 patients developing grade 1/2 chest wall toxicity based on the Common Terminology Criteria for Adverse Events (CTCAE). CONCLUSION: Image-guided SBRT with helical IMRT delivered in 4 or 5 fractions of 12 Gy with rigid immobilization, FDG-PET-assisted targeting, and repeat mid-fraction CT scan is an effective treatment for early NSCLC.

Influence of patient characteristics on survival following treatment with helical stereotactic body radiotherapy (SBRT) in stage I non-small-cell lung cancer.

BACKGROUND: To determine the influence of patient and tumor characteristics on clinical outcomes in patients with early-stage non-small cell lung cancer (NSCLC) treated with helical intensity modulated stereotactic body radiotherapy (SBRT). METHODS: From March 2005 to August 2010 a total of 62 patients with biopsy proven Stage I NSCLC underwent helical SBRT with 48 Gy in 4 fractions or 60 Gy in 5 fractions. Patient and tumor characteristics including tumor stage, age, sex, tumor histology, maximal tumor diameter, and smoking history, were evaluated in regard to local control and overall survival using Kaplan-Meier survival curves and the Cox proportional hazard method. Treatment related toxicity in the patient subgroups was evaluated. RESULTS: The median follow-up was 28 months. Total cohort local control was 93.55% and 3-year overall survival (OS) was 53.4%. Those patients with Stage IA disease had a 3-year OS of 64.4% versus 32.1% for Stage IB disease (P = 0.042). Tumors classified as T1a (≤20 mm) and T1b (20-30 mm) had significantly increased overall survival compared to T2 (>30 mm) tumors (P = 0.046). There was a slight survival advantage in those patients with adenocarcinoma. No correlation between age, gender or smoking history, and overall survival was found. Nine patients had radiation related toxicity, which was increasingly more common with advancing age. CONCLUSION: Helical SBRT is an effective method to treat NSCLC and the most significant prognostic factors were tumor stage and size. There was no correlation between age, gender, and smoking history.

Cardiac angiosarcoma treated with resection and adjuvant radiation therapy.

Primary cardiac angiosarcoma is a rare and aggressive tumor with a remarkably high rate of metastasis. Due to the high rate of metastasis, surgical resection is often limited and survival expectations modest. This report describes the case of a 35-year-old African-American woman with initially non-metastatic primary right atrial angiosarcoma who was treated with surgical resection of the primary tumor, reconstruction of the right atrium, and patch repair of the atrial septum via Gore-Tex patch. She underwent post-operative radiation therapy to the atrial bed with curative intent. However, after eight months of symptom-free survival, she presented with extensive metastases within bone and the right retroperitoneum without local recurrence. Palliative radiation treatment commenced for the metastases in the retroperitoneum and cervical spine.