Concurrent whole brain radiotherapy and bortezomib for brain metastasis

Abstract Background Survival of patients with brain metastasis particularly from historically more radio-resistant malignancies remains dismal. A phase I study of concurrent bortezomib and whole brain radiotherapy was conducted to determine the tolerance and safety of this approach in patients with previously untreated brain metastasis. Methods A phase I dose escalation study evaluated the safety of bortezomib (0.9, 1.1, 1.3, 1.5, and 1.7 mg/m2) given on days 1, 4, 8 and 11 of whole brain radiotherapy. Patients with confirmed brain metastasis were recruited for participation. The primary endpoint was the dose-limiting toxicity, defined as any ≥ grade 3 non-hematologic toxicity or grade ≥ 4 hematologic toxicity from the start of treatment to one month post irradiation. Time-to-Event Continual Reassessment Method (TITE-CRM) was used to determine dose escalation. A companion study of brain diffusion tensor imaging MRI was conducted on a subset of patients to assess changes in the brain that might predict delayed cognitive effects. Results Twenty-four patients were recruited and completed the planned therapy. Patients with melanoma accounted for 83% of all participants. The bortezomib dose was escalated as planned to the highest dose of 1.7 mg/m2/dose. No grade 4/5 toxicities related to treatment were observed. Two patients had grade 3 dose-limiting toxicities (hyponatremia and encephalopathy). A partial or minor response was observed in 38% of patients. Bortezomib showed greater demyelination in hippocampus-associated white matter structures on MRI one month after radiotherapy compared to patients not treated with bortezomib (increase in radial diffusivity +16.8% versus 4.8%; p = 0.0023). Conclusions Concurrent bortezomib and whole brain irradiation for brain metastasis is well tolerated at one month follow-up, but MRI changes that have been shown to predict delayed cognitive function can be detected within one month of treatment.http://deepblue.lib.umich.edu/bitstream/2027.42/112849/1/13014_2013_Article_928.pd

Predictors of multidomain decline in health‐related quality of life after stereotactic body radiation therapy (SBRT) for prostate cancer

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/136687/1/cncr30519_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/136687/2/cncr30519.pd

Design and Rationale of the Fontan Udenafil Exercise Longitudinal (FUEL) Trial

The Fontan operation creates a circulation characterized by elevated central venous pressure and low cardiac output. Over time, these characteristics result in a predictable and persistent decline in exercise performance that is associated with an increase in morbidity and mortality. A medical therapy that targets the abnormalities of the Fontan circulation might, therefore, be associated with improved outcomes. Udenafil, a phosphodiesterase type 5 inhibitor, has undergone phase I/II testing in adolescents who have had the Fontan operation and has been shown to be safe and well tolerated in the short-term. However, there are no data regarding the long-term efficacy of udenafil in this population. The Fontan Udenafil Exercise Longitudinal (FUEL) Trial is a randomized, double blind, placebo controlled phase III clinical trial being conducted by the Pediatric Heart Network in collaboration with Mezzion Pharma Co., Ltd. This trial is designed to test the hypothesis that treatment with udenafil will lead to an improvement in exercise capacity in adolescents who have undergone the Fontan operation. A safety extension trial, the FUEL Open-Label Extension Trial (FUEL OLE), offers the opportunity for all FUEL subjects to obtain open-label udenafil for an additional 12 months following completion of FUEL, and evaluates the long-term safety and tolerability of this medication. This manuscript describes the rationale and study design for FUEL and FUEL OLE. Together, these trials provide an opportunity to better understand the role of medical management in the care of those who have undergone the Fontan operation

Defining a standard set of patient-centered outcomes for men with localized prostate cancer

Background Value-based health care has been proposed as a unifying force to drive improved outcomes and cost containment. Objective To develop a standard set of multidimensional patient-centered health outcomes for tracking, comparing, and improving localized prostate cancer (PCa) treatment value. Design, setting, and participants We convened an international working group of patients, registry experts, urologists, and radiation oncologists to review existing data and practices. Outcome measurements and statistical analysis The group defined a recommended standard set representing who should be tracked, what should be measured and at what time points, and what data are necessary to make meaningful comparisons. Using a modified Delphi method over a series of teleconferences, the group reached consensus for the Standard Set. Results and limitations We recommend that the Standard Set apply to men with newly diagnosed localized PCa treated with active surveillance, surgery, radiation, or other methods. The Standard Set includes acute toxicities occurring within 6 mo of treatment as well as patient-reported outcomes tracked regularly out to 10 yr. Patient-reported domains of urinary incontinence and irritation, bowel symptoms, sexual symptoms, and hormonal symptoms are included, and the recommended measurement tool is the Expanded Prostate Cancer Index Composite Short Form. Disease control outcomes include overall, cause-specific, metastasis-free, and biochemical relapse-free survival. Baseline clinical, pathologic, and comorbidity information is included to improve the interpretability of comparisons. Conclusions We have defined a simple, easily implemented set of outcomes that we believe should be measured in all men with localized PCa as a crucial first step in improving the value of care. Patient summary Measuring, reporting, and comparing identical outcomes across treatments and treatment centers will provide patients and providers with information to make informed treatment decisions. We defined a set of outcomes that we recommend being tracked for every man being treated for localized prostate cancer

Validation of the Combination Gleason Score as an Independent Favorable Prognostic Factor in Prostate Cancer Treated With Dose-Escalated Radiotherapy

Purpose/Objective(s): Prognostic factors that alter prostate cancer effect include TNM stage, pre-treatment PSA, Gleason score, and Gleason grade group (2). Of these, Gleason score yields the largest impact on cause-specific survival (CSS) (5). While Gleason score is crucial to predicting outcomes, disparity between biopsy and prostatectomy sample scores is often seen. This can result in Gleason score upgrading (GSU) and downgrading (GSD) at the time of surgery. Phillips et al. explored this phenomenon through combining the lowest and highest Gleason scores at biopsy (ComboGS) and examining how such a factor would impact GSU and prostate cancer specific survival (PCSM). This study aims to validate the Phillips et al. findings via an independent cohort of prostate cancer patients treated with definitive dose-escalated radiation therapy (DE-RT) at a single institution. Materials/Methods: DE-RT was administered to 2,539 men; 687 men had a ComboGS. We utilized univariate and multivariable analysis to evaluate relapse rates and clinical outcomes. To further ascertain the ComboGS prognostic impact, we employed the Cancer of the Prostate Risk Assessment Score (CAPRA) and the modified CAPRA (mCAPRA). Rates of biochemical event-free survival (bEFS) and distant metastasis-free survival (DMFS) were compared across CAPRA scores, with and without modification, and the prognostic value of the CAPRA scores were compared using Harrel\u27s concordance index (C-index) (12). Results: ComboGS presence in Gleason 7-10 prostate cancer patients generated improved 10-year biochemical event-free survival (bEFS) from 76.6% to 82.4% (HR 0.75, CI 0.59-0.96, P = 0.021), 10-year distant metastasis-free survival (DMFS) from 89.3% to 93.2% (HR 0.57, CI 0.39-0.85, P = 0.005), 10-year PCSM from 93.9% to 97.4% (HR 0.39, CI 0.21-0.7, P = 0.001) and 10-year overall survival (OS) from 65.7% to 75.6% (HR 0.69, CI 0.57-0.83, P \u3c 0.001). Multivariable analysis also supported that ComboGS is protective for biochemical failure (HR 0.64, CI 0.50-0.83, P \u3c 0.001), distant metastasis (HR 0.42, CI 0.28-0.63, P \u3c 0.001), death from prostate cancer (HR 0.32, CI 0.17-0.58, P \u3c 0.001), and overall mortality (HR 0.65, CI 0.54-0.79, P \u3c 0.001). Additionally, adjusting the CAPRA score for ComboGS decreased the risk of biochemical failure (BF) by nearly 30% (HR = 0.70 [95% CI, 0.55-0.88], P = 0.003) and by 50% (HR = 0.54 [95% CI, 0.37-0.80], P = 0.002) for distant metastasis. Conclusion: ComboGS is a useful and readily available independent prognostic factor for all clinical endpoints (biochemical failure, distant metastasis, cancer-specific survival and overall survival). Moreover, the ComboGS can be used in conjunction with the extensively validated CAPRA scoring, to better risk stratify patients being treated with definitive DE-RT and possibly de-escalate therapy for some men with ComboGS 7 disease

Gemcitabine-Mediated Radiosensitization of Human Soft Tissue Sarcoma1

Background/Purpose: Local and systemic control of soft tissue sarcoma (STS) remains a clinical challenge, particularly for retroperitoneal, deep truncal, or advanced extremity disease. 2′,2′-Difluoro-2′-deoxycytidine (gemcitabine) is a potent radiosensitizer in many tumor types, but it has not been studied in human STS. The purpose of this study was to determine the radiosensitizing potential of gemcitabine in preclinical models of human STS. Materials and Methods: The in vitro radiosensitizing activity of gemcitabine was assessed with clonogenic survival assay on three human STS cell lines: SK-LMS-1 (leiomyosarcoma), SW-872 (liposarcoma), and HT-1080 (fibrosarcoma). Cell cycle distribution was determined using dual-channel flow cytometry. The in vivo radiosensitizing activity of gemcitabine was assessed with subcutaneous SK-LMS-1 nude mice xenografts. Tumor-bearing mice were treated with concurrent weekly gemcitabine and fractionated daily radiotherapy (RT) (2 Gy daily) for 3 weeks (a total dose of 30 Gy). Results: The 50% inhibitory concentration (IC50) of gemcitabine for the human STS cell lines ranged from 10 to 1000 nM. Significant in vitro radiosensitization was demonstrated in all three human STS cell lines using gemcitabine concentrations at and below the IC50. Maximal radiosensitization was associated with accumulation of cells in early S-phase. SK-LMS-1 xenografts displayed significant tumor growth delay with combined gemcitabine and RT compared to either treatment alone. Treatment related toxicity was greatest in the gemcitabine plus RT arm, but remained at an acceptable level. Conclusions: Gemcitabine is a potent radiosensitizer in preclinical models of human STS. Clinical trials combining gemcitabine and RT in human STS are warranted

Diffusion Magnetic Resonance Imaging: An Imaging Treatment Response Biomarker to Chemoradiotherapy in a Mouse Model of Squamous Cell Cancer of the Head and Neck1

For the treatment of squamous cell cancer of the head and neck (SCCHN), the assessment of treatment response is traditionally accomplished by volumetric measurements and has been suggested to be prognostic for an eventual response to treatment. An early evaluation response during the course of radiation therapy could provide an opportunity to tailor treatment to individual patients. Diffusion magnetic resonance imaging (MRI) allows for the quantification of tissue water diffusion values, thus treatment-induced loss of tumor cells will result in the increase in water mobility at the microscopic level, which can be detected as an increase in tumor diffusion values before any volumetric changes occur. We evaluated the use of diffusion MRI as an imaging biomarker of treatment response in an orthotopic mouse model of SCCHN. Mice with murine squamous cells expressing the yeast transgene cytosine deaminase were treated with 5-fluorocytosine (5FC), ionizing radiation, and combined therapy and were compared with control animals both during and after treatment for changes in tumor volumes, diffusion values, and survival. Radiation therapy had minimal effect on volumetric growth rate, diffusion, or survival. Although 5FC and combination treatment resulted in similar reductions in tumor volumes, the combination treatment elicited a much greater increase in tumor diffusion values, which correlated with improved survival. Thus, diffusion MRI as an imaging biomarker has a potential for early evaluation of the response to chemoradiation treatment in SCCHN

Imaging of Proteolytic Activity Using a Conditional Cell Surface Receptor

Programmed cell death (apoptosis) is a ubiquitous means utilized by multicellular organisms for elimination of unwanted cells during development and homeostasis. Dysregulated apoptosis is implicated in an array of clinical disorders including cancer, autoimmune diseases, neurodegenerative disorders, and ischemia. During programmed cell death, a series of proteases, known as caspases, with different specificities play crucial roles in the apoptotic process. Caspase-3, a group II cysteine aspartate protease, recognizes and cleaves substrates harboring the amino acid sequence aspartic acid–glutamic acid–valine–aspartic acid (DEVD), and it plays an important role in the terminal phase of apoptosis. Here we report the development of a novel imaging platform for sensing the activation of cellular proteases. A recombinant chimeric protein was constructed, composed of a cell-surface-targeted single-chain antibody (sFv) fused to a Golgi retention signal. The DEVD tetrapeptide sequence was included between the single-chain antibody and the Golgi retention signal as a caspase-3 protease cleavage site. When expressed in cultured cells this fusion protein was localized to Golgi bodies and was not detected on the cell surface. Induction of apoptosis resulted in cleavage of the fusion protein releasing the single-chain antibody from the Golgi retention signal in a caspase-dependent manner. As a result, in cells undergoing apoptosis the single-chain antibody was visualized at the cell surface by immunofluorescence microscopy. The expression of sFv on the surface of cells in a protease-dependent manner provides a unique opportunity for real-time imaging through the use of targeted nanoparticles. This methodology may provide for a multimodal noninvasive real-time imaging of apoptosis and a new opportunity for high-throughput screening of cell-death-modulating therapeutic agents