A Comparison of Grade 4 Lymphopenia With Proton Versus Photon Radiation Therapy for Esophageal Cancer

David M. Routman, Aurelie Garant, Scott C. Lester, Courtney N. Day, William S. Harmsen, Cristobal T. Sanheuza, Harry H. Yoon, Michelle A. Neben-Wittich, James A. Martenson, Michael G. Haddock, Christopher L. Hallemeier, Kenneth W. Merrell

Research output: Contribution to journalArticle

2 Citations (Scopus)

Abstract

Purpose: Grade 4 lymphopenia (G4L) during radiation therapy (RT) is associated with higher rates of distant metastasis and decreased overall survival in a number of malignancies, including esophageal cancer (EC). Through a reduction in integral radiation dose, proton RT (PRT) may reduce G4L relative to photon RT (XRT). The purpose of this study was to compare G4L in patients with EC undergoing PRT versus XRT. Methods and materials: Patients receiving curative-intent RT and concurrent chemotherapy for EC were identified. Lymphocyte nadir was defined as the lowest lymphocyte count during RT. G4L was defined as absolute lymphocyte count <200/mm 3 . Univariate and multivariable logistic regression analyses (MVA) were performed to assess patient and treatment factors associated with lymphopenia. A propensity-matched (PM) cohort was created using logistic regression, including baseline covariates. Results: A total of 144 patients met the inclusion criteria. The median age was 66 years (range, 32-85 years). Of these patients, 79 received XRT (27% 3-dimensional chemo-RT and 73% intensity modulated RT) and 65 received PRT (100% pencil-beam scanning). Chemotherapy consisted of weekly carboplatin and paclitaxel (99%). There were no significant differences in baseline characteristics between the groups, except for age (median 4 years older in the PRT cohort). G4L was significantly higher in patients who received XRT versus those who received PRT (56% vs 22%; P <.01). On MVA, XRT (odds ratio [OR]: 5.13; 95% confidence interval [CI], 2.35-11.18; P <.001) and stage III/IV (OR: 4.54; 95% CI, 1.87-11.00; P <.001) were associated with G4L. PM resulted in 50 PRT and 50 XRT patients. In the PM cohort, G4L occurred in 60% of patients who received XRT versus 24% of patients who received PRT. On MVA, XRT (OR: 5.28; 95% CI, 2.14-12.99; P <.001) and stage III/IV (OR: 3.77; 95% CI, 1.26-11.30; P =.02) were associated with G4L. Conclusions: XRT was associated with a significantly higher risk of G4L in comparison with PRT. Further work is needed to evaluate a potential association between RT modality and antitumor immunity as well as long-term outcomes.

Original languageEnglish (US)
Pages (from-to)63-69
Number of pages7
JournalAdvances in Radiation Oncology
Volume4
Issue number1
DOIs
StatePublished - Jan 1 2019
Externally publishedYes

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Lymphopenia
Esophageal Neoplasms
Photons
Protons
Radiotherapy
Odds Ratio
Confidence Intervals
Lymphocyte Count
Logistic Models
Proton Therapy
Drug Therapy
Carboplatin
Paclitaxel
Immunity
Age Groups
Regression Analysis
Lymphocytes
Radiation
Neoplasm Metastasis

ASJC Scopus subject areas

  • Oncology
  • Radiology Nuclear Medicine and imaging

Cite this

A Comparison of Grade 4 Lymphopenia With Proton Versus Photon Radiation Therapy for Esophageal Cancer. / Routman, David M.; Garant, Aurelie; Lester, Scott C.; Day, Courtney N.; Harmsen, William S.; Sanheuza, Cristobal T.; Yoon, Harry H.; Neben-Wittich, Michelle A.; Martenson, James A.; Haddock, Michael G.; Hallemeier, Christopher L.; Merrell, Kenneth W.

In: Advances in Radiation Oncology, Vol. 4, No. 1, 01.01.2019, p. 63-69.

Research output: Contribution to journalArticle

Routman, DM, Garant, A, Lester, SC, Day, CN, Harmsen, WS, Sanheuza, CT, Yoon, HH, Neben-Wittich, MA, Martenson, JA, Haddock, MG, Hallemeier, CL & Merrell, KW 2019, 'A Comparison of Grade 4 Lymphopenia With Proton Versus Photon Radiation Therapy for Esophageal Cancer', Advances in Radiation Oncology, vol. 4, no. 1, pp. 63-69. https://doi.org/10.1016/j.adro.2018.09.004
Routman, David M. ; Garant, Aurelie ; Lester, Scott C. ; Day, Courtney N. ; Harmsen, William S. ; Sanheuza, Cristobal T. ; Yoon, Harry H. ; Neben-Wittich, Michelle A. ; Martenson, James A. ; Haddock, Michael G. ; Hallemeier, Christopher L. ; Merrell, Kenneth W. / A Comparison of Grade 4 Lymphopenia With Proton Versus Photon Radiation Therapy for Esophageal Cancer. In: Advances in Radiation Oncology. 2019 ; Vol. 4, No. 1. pp. 63-69.
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title = "A Comparison of Grade 4 Lymphopenia With Proton Versus Photon Radiation Therapy for Esophageal Cancer",
abstract = "Purpose: Grade 4 lymphopenia (G4L) during radiation therapy (RT) is associated with higher rates of distant metastasis and decreased overall survival in a number of malignancies, including esophageal cancer (EC). Through a reduction in integral radiation dose, proton RT (PRT) may reduce G4L relative to photon RT (XRT). The purpose of this study was to compare G4L in patients with EC undergoing PRT versus XRT. Methods and materials: Patients receiving curative-intent RT and concurrent chemotherapy for EC were identified. Lymphocyte nadir was defined as the lowest lymphocyte count during RT. G4L was defined as absolute lymphocyte count <200/mm 3 . Univariate and multivariable logistic regression analyses (MVA) were performed to assess patient and treatment factors associated with lymphopenia. A propensity-matched (PM) cohort was created using logistic regression, including baseline covariates. Results: A total of 144 patients met the inclusion criteria. The median age was 66 years (range, 32-85 years). Of these patients, 79 received XRT (27{\%} 3-dimensional chemo-RT and 73{\%} intensity modulated RT) and 65 received PRT (100{\%} pencil-beam scanning). Chemotherapy consisted of weekly carboplatin and paclitaxel (99{\%}). There were no significant differences in baseline characteristics between the groups, except for age (median 4 years older in the PRT cohort). G4L was significantly higher in patients who received XRT versus those who received PRT (56{\%} vs 22{\%}; P <.01). On MVA, XRT (odds ratio [OR]: 5.13; 95{\%} confidence interval [CI], 2.35-11.18; P <.001) and stage III/IV (OR: 4.54; 95{\%} CI, 1.87-11.00; P <.001) were associated with G4L. PM resulted in 50 PRT and 50 XRT patients. In the PM cohort, G4L occurred in 60{\%} of patients who received XRT versus 24{\%} of patients who received PRT. On MVA, XRT (OR: 5.28; 95{\%} CI, 2.14-12.99; P <.001) and stage III/IV (OR: 3.77; 95{\%} CI, 1.26-11.30; P =.02) were associated with G4L. Conclusions: XRT was associated with a significantly higher risk of G4L in comparison with PRT. Further work is needed to evaluate a potential association between RT modality and antitumor immunity as well as long-term outcomes.",
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T1 - A Comparison of Grade 4 Lymphopenia With Proton Versus Photon Radiation Therapy for Esophageal Cancer

AU - Routman, David M.

AU - Garant, Aurelie

AU - Lester, Scott C.

AU - Day, Courtney N.

AU - Harmsen, William S.

AU - Sanheuza, Cristobal T.

AU - Yoon, Harry H.

AU - Neben-Wittich, Michelle A.

AU - Martenson, James A.

AU - Haddock, Michael G.

AU - Hallemeier, Christopher L.

AU - Merrell, Kenneth W.

PY - 2019/1/1

Y1 - 2019/1/1

N2 - Purpose: Grade 4 lymphopenia (G4L) during radiation therapy (RT) is associated with higher rates of distant metastasis and decreased overall survival in a number of malignancies, including esophageal cancer (EC). Through a reduction in integral radiation dose, proton RT (PRT) may reduce G4L relative to photon RT (XRT). The purpose of this study was to compare G4L in patients with EC undergoing PRT versus XRT. Methods and materials: Patients receiving curative-intent RT and concurrent chemotherapy for EC were identified. Lymphocyte nadir was defined as the lowest lymphocyte count during RT. G4L was defined as absolute lymphocyte count <200/mm 3 . Univariate and multivariable logistic regression analyses (MVA) were performed to assess patient and treatment factors associated with lymphopenia. A propensity-matched (PM) cohort was created using logistic regression, including baseline covariates. Results: A total of 144 patients met the inclusion criteria. The median age was 66 years (range, 32-85 years). Of these patients, 79 received XRT (27% 3-dimensional chemo-RT and 73% intensity modulated RT) and 65 received PRT (100% pencil-beam scanning). Chemotherapy consisted of weekly carboplatin and paclitaxel (99%). There were no significant differences in baseline characteristics between the groups, except for age (median 4 years older in the PRT cohort). G4L was significantly higher in patients who received XRT versus those who received PRT (56% vs 22%; P <.01). On MVA, XRT (odds ratio [OR]: 5.13; 95% confidence interval [CI], 2.35-11.18; P <.001) and stage III/IV (OR: 4.54; 95% CI, 1.87-11.00; P <.001) were associated with G4L. PM resulted in 50 PRT and 50 XRT patients. In the PM cohort, G4L occurred in 60% of patients who received XRT versus 24% of patients who received PRT. On MVA, XRT (OR: 5.28; 95% CI, 2.14-12.99; P <.001) and stage III/IV (OR: 3.77; 95% CI, 1.26-11.30; P =.02) were associated with G4L. Conclusions: XRT was associated with a significantly higher risk of G4L in comparison with PRT. Further work is needed to evaluate a potential association between RT modality and antitumor immunity as well as long-term outcomes.

AB - Purpose: Grade 4 lymphopenia (G4L) during radiation therapy (RT) is associated with higher rates of distant metastasis and decreased overall survival in a number of malignancies, including esophageal cancer (EC). Through a reduction in integral radiation dose, proton RT (PRT) may reduce G4L relative to photon RT (XRT). The purpose of this study was to compare G4L in patients with EC undergoing PRT versus XRT. Methods and materials: Patients receiving curative-intent RT and concurrent chemotherapy for EC were identified. Lymphocyte nadir was defined as the lowest lymphocyte count during RT. G4L was defined as absolute lymphocyte count <200/mm 3 . Univariate and multivariable logistic regression analyses (MVA) were performed to assess patient and treatment factors associated with lymphopenia. A propensity-matched (PM) cohort was created using logistic regression, including baseline covariates. Results: A total of 144 patients met the inclusion criteria. The median age was 66 years (range, 32-85 years). Of these patients, 79 received XRT (27% 3-dimensional chemo-RT and 73% intensity modulated RT) and 65 received PRT (100% pencil-beam scanning). Chemotherapy consisted of weekly carboplatin and paclitaxel (99%). There were no significant differences in baseline characteristics between the groups, except for age (median 4 years older in the PRT cohort). G4L was significantly higher in patients who received XRT versus those who received PRT (56% vs 22%; P <.01). On MVA, XRT (odds ratio [OR]: 5.13; 95% confidence interval [CI], 2.35-11.18; P <.001) and stage III/IV (OR: 4.54; 95% CI, 1.87-11.00; P <.001) were associated with G4L. PM resulted in 50 PRT and 50 XRT patients. In the PM cohort, G4L occurred in 60% of patients who received XRT versus 24% of patients who received PRT. On MVA, XRT (OR: 5.28; 95% CI, 2.14-12.99; P <.001) and stage III/IV (OR: 3.77; 95% CI, 1.26-11.30; P =.02) were associated with G4L. Conclusions: XRT was associated with a significantly higher risk of G4L in comparison with PRT. Further work is needed to evaluate a potential association between RT modality and antitumor immunity as well as long-term outcomes.

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